Risk Factors Associated with Mechanical Ventilation in Critical Bronchiolitis

Abstract

The American Academy of Pediatrics (AAP) recommends supportive care for the management of bronchiolitis. However, patients admitted to the intensive care unit with severe (critical) bronchiolitis define a unique group with varying needs for both non-invasive and invasive respiratory support. Currently, no guidance exists to help clinicians discern who will progress to invasive mechanical support. Here, we sought to identify key clinical features that distinguish pediatric patients with critical bronchiolitis requiring invasive mechanical ventilation from those that did not. We conducted a retrospective cohort study at a tertiary pediatric medical center. Children ≤2 years old admitted to the pediatric intensive care unit (PICU) from January 2015 to December 2019 with acute bronchiolitis were studied. Patients were divided into non-invasive respiratory support (NRS) and invasive mechanical ventilation (IMV) groups; the IMV group was further subdivided depending on timing of intubation relative to PICU admission. Of the 573 qualifying patients, 133 (23%) required invasive mechanical ventilation. Median age and weight were lower in the IMV group, while incidence of prematurity and pre-existing neurologic or genetic conditions were higher compared to the NRS group. Multi-microbial pneumonias were diagnosed more commonly in the IMV group, in turn associated with higher severity of illness scores, longer PICU lengths of stay, and more antibiotic usage. Within the IMV group, those intubated earlier had a shorter duration of mechanical ventilation and PICU length of stay, associated with lower pathogen load and, in turn, shorter antibiotic duration. Taken together, our data reveal that critically ill patients with bronchiolitis who require mechanical ventilation possess high risk features, including younger age, history of prematurity, neurologic or genetic co-morbidities, and a propensity for multi-microbial infections.

Children born preterm admitted to paediatric intensive care for bronchiolitis: a systematic review and meta-analysis

“…Characteristics of included studies are summarised in Table 1 . There was considerable heterogeneity in study settings, ranging from single centres [ 9 ] to national datasets, [ 28 , 29 , 31 , 34 ] and units ranged in size from a 7-bed PICU [ 9 ] to a 32-bed mixed cardiac/medical PICU [ 30 ]. Generally sample sizes were small: 17 studies (57%) included under 200 children, only 2 included over 1,000 [ 29 , 34 ].…”

“…Figure 2 shows a summary of the risk of bias assessments for the 31 studies, of which 26 (84%) had a high risk of bias, four (13%) had an unclear risk of bias [ 17 , 30 , 34 , 36 ], and one (3%) had a low risk of bias [ 28 ]. No studies compared confounding factors such as comorbidities between preterm and term-born groups, so all were assigned a high risk of bias in this domain.…”

“…The pooled percentage of PICU admissions born extremely preterm (reported in five studies [ 7 , 18 , 30 , 31 , 33 ]) was 5.0% (range: 1.3% to 11.0%, 95%CI: 2.0% to 8.1%) [see Additional File for forest plot], with significant heterogeneity between studies (I 2 = 83%). There was no clear relationship between the study period and the proportion of children born extremely preterm.…”

Antibiotic use in nonintubated children with bronchiolitis in the intensive care unit

“…Despite these guidelines, antibiotic use remains high in the ICU 5 and children requiring ICU admission may represent a population in which the current guidelines do not apply. The incidence of bacterial co‐infection in intubated patients has been reported to be between 17% and 70% and children with co‐infections are intubated for longer and have longer hospital stays 6–8 . In a study utilizing a large multi‐centered database of children's hospitals, 94% of intubated patients received at least 2 days of antibiotics at some point during their ICU stay.…”

“…The incidence of bacterial co-infection in intubated patients has been reported to be between 17% and 70% and children with co-infections are intubated for longer and have longer hospital stays. [6][7][8] In a study utilizing a large multicentered database of children's hospitals, 94% of intubated patients received at least 2 days of antibiotics at some point during their ICU stay. Patients who received antibiotics during the first 2 days of mechanical ventilation had a shorter duration of intubation and shorter hospital length of stay.…”