Critical care of severe bronchiolitis during shortage of ICU resources

Abstract

Large seasonal outbreaks of bronchiolitis put pressure on healthcare systems and particularly on intensive care units (ICUs). ICU admission is necessary to provide respiratory support to the severest cases, otherwise bronchiolitis can result in substantial mortality. ICU resources are often insufficient and there is scant evidence to guide the ICU clinical management. Most available studies do not cover the ICU-admitted cases and do not consider the associated public health issues. We review this topic through a multidisciplinary approach from both the clinical and public health perspectives, with an analysis based on pathophysiology and cost-effectiveness. We suggest ways to optimise respiratory care, minimise ICU stay, "protect" ICU beds and, whenever possible, make them available for other critically ill children. We also provide guidance on how to prepare ICUs to work under stressful conditions due to outbreaks and to reduce the risk of nosocomial cross-contamination, particularly in ICUs caring for high-risk children.

Funding: None.

Keywords: Infant; NICU; Outbreak; PICU; RSV; Respiratory failure.

Fig. 1

Estimation of burden of care induced by bronchiolitis on ICUs. These should be considered illustrative estimations of the situation encountered in several high-income countries. Numbers represent the ratio between the annual cases of bronchiolitis needing ICU admission and the available beds in ICUs (paediatric, neonatal or mixed). Numbers have been obtained using local registries or personal communications from local colleagues (see acknowledgements). They represent estimations, as during the outbreaks the ICU beds might be temporarily increased by reducing elective surgical activities or changing the criteria for ICU admission of other patients, or admitting cases to neonatal ICUs that usually were not accepting infants with bronchiolitis. Abbreviation: ICU: intensive care unit.

Fig. 2

Flow chart of critical steps to prepare an ICU for the management of a bronchiolitis outbreak. The isolation area and instruments to be used in it should be prepared beforehand: images A and B show an isolation room (red circle) which is located at the end of an ICU and equipped with negative pressure ventilation, filter and personal protective equipment (blue square), as well as single door through which patients are admitted and discharged (red dual arrow) without entering other zones of the ICU (pictures from the “A. Béclère” Hospital, APHP-Paris Saclay University); image C shows a ventilator equipped with a HEPA filter on the expiratory limb (red arrow). A protocol for clinical management should then be prepared and shared between the wards concerned. Specific training and simulation should be performed, and this is particularly important for those neonatal ICUs that are versed only in managing neonates with different types of respiratory failure. Specific criteria for ICU admission/discharge and continuous communication between wards should be enforced to guarantee an optimised patient flow. Finally, containment to reduce the risk of cross-contamination should be enforced and ICU stay should be kept as short as possible. Abbreviations. ED: emergency department; HEPA: high-efficiency particulate absorption; ICU: intensive care unit.

Fig. 3

Suggested protocol for the clinical management of infants with severe bronchiolitis needing ICU admission. Isolation and cohorting should be enforced during the whole ICU stay. ∗Multiplex PCR might be performed upon ICU admission (if not performed earlier). Other tests may be performed upon ICU admission or later depending on clinical severity or if secondary infections are suspected. Standard vital monitoring (i.e. peripheral haemoglobin saturation, heart and respiratory rate) as well as calculation of a dyspnoea and a comfort score should also be performed upon admission and serially during the ICU stay. ^•Quantitative lung ultrasound and capillary or transcutaneous blood gas analysis should be done upon ICU admission based on clinical evaluation. ^#CPAP generator (continuous or variable flow or other) and interface (nasal masks/prongs, facial mask or helmet) should be chosen depending on team expertise and patient comfort. ^†Enteral and intravenous hydration should be given using nasogastric tubes and isotonic solutions, respectively. ^‡Ventilatory parameters should be adjusted depending on chest expansion, blood gases, synchrony and comfort. Colours depict increasing clinical severity. Non-pharmacological sedation is performed with parental presence, installation, feeding, pacifiers with sucrose solutions; pharmacological sedation in non-invasively supported infants can be provided with mild sedative drugs (hydroxyzine, midazolam, chloral hydrate or dexmetomidine). The (light blue) arrow illustrates the frequency of tests and monitoring to be repeated during the ICU stay depending on clinical severity; capillary blood gas analysis allows measurement of blood sodium and indicates whether its supplementation is needed. HHHFNC are not included in the protocol as there is no evidence for their use in ICU, they can fail significantly more often compared to CPAP and prolong ICU stay. More details in the text. Abbreviations: BGA: blood gas analysis; CPAP: continuous positive airway pressure; CRP: C-reactive protein; Edi: electronic diaphragmatic activity; HEPA: high-efficiency particulate absorbing; HHHFNC: heated humidified high flow nasal cannula; ICU: intensive care unit; IV: intravenous; NARDS: neonatal acute respiratory distress syndrome; NIPPV: non-invasive positive pressure ventilation; NIV-NAVA: non-invasive ventilation with neurally assisted ventilation adjust; NP: non-pharmacological; P: pharmacological; PARDS: paediatric acute respiratory distress syndrome; PCR: polymerase chain reaction; PCT: procalcitonin; qLUS: quantitative lung ultrasound; QID: quater in die (i.e. every 6 h); TC: transcutaneous; TID: tris in die (i.e. every 8 h).