Trends in Bronchiolitis ICU Admissions and Ventilation Practices: 2010–2019

Abstract

OBJECTIVES:To determine the changes in ICU admissions, ventilatory support, length of stay, and cost for patients with bronchiolitis in the United States. METHODS:Retrospective cross-sectional study of the Pediatric Health Information Systems database. All patients age ,2 years admitted with bronchiolitis and discharged between January 1, 2010 and December 31, 2019, were included. Outcomes included proportions of annual ICU admissions, invasive mechanical ventilation (IMV), noninvasive ventilation (NIV), and cost.RESULTS: Of 203 859 admissions for bronchiolitis, 39 442 (19.3%) were admitted to an ICU, 6751 (3.3%) received IMV, and 9983 (4.9%) received NIV. ICU admissions for bronchiolitis doubled from 11.7% in 2010 to 24.5% in 2019 (P , .001 for trend), whereas ICU admissions for all children in Pediatric Health Information Systems ,2 years of age increased from 16.0% to 21.1% during the same period (P , .001 for trend). Use of NIV increased sevenfold from 1.2% in 2010 to 9.5% in 2019 (P , .001 for trend). Use of IMV did not significantly change (3.3% in 2010 to 2.8% in 2019, P = .414 for trend). In mixed-effects multivariable logistic regression, discharge year was a significant predictor of NIV (odds ratio: 1.24; 95% confidence interval [CI]: 1.23-1.24) and ICU admission (odds ratio: 1.09; 95% CI: 1.09-1.09) but not IMV (odds ratio: 1.00; 95% CI: 1.00-1.00). CONCLUSIONS:The proportions of children with bronchiolitis admitted to an ICU and receiving NIV have substantially increased, whereas the proportion receiving IMV is unchanged over the past decade. Further study is needed to better understand the factors underlying these temporal patterns.WHAT'S KNOWN ON THIS SUBJECT: In the early part of the last decade, trends toward rising ICU admission proportion and noninvasive ventilation use were noted in patients with bronchiolitis. These trends were temporally associated with increased cost.WHAT THIS STUDY ADDS: In this national database analysis, the ICU admission proportion in bronchiolitis doubled between 2010 and 2019, coupled with a sevenfold increase in the use of noninvasive ventilation. These changes were not associated with changes in the proportion of invasive mechanical ventilation.

Prevalence and risk factors of discomfort in infants with severe bronchiolitis

“…Ventilatory support is commonly used in patients with bronchiolitis admitted in PICU, especially noninvasive ventilation 2 . High‐flow nasal cannula (HFNC), continuous positive airway pressure (CPAP) and bilevel positive airway pressure ventilation (BiPAP) are increasingly used in patients with severe acute bronchiolitis 3 . In acute settings, noninvasive ventilation (including HFNC, CPAP and BiPAP) aimed to improve gas exchange, decrease work of breathing and improve patients' comfort 4 .…”

“…2 Highflow nasal cannula (HFNC), continuous positive airway pressure (CPAP) and bilevel positive airway pressure ventilation (BiPAP) are increasingly used in patients with severe acute bronchiolitis. 3 In acute settings, noninvasive ventilation (including HFNC, CPAP and BiPAP) aimed to improve gas exchange, decrease work of breathing and improve patients' comfort. 4 Its benefits have been demonstrated in both physiological 5 and clinical 6 studies.…”

Trends in Hospital Costs and Levels of Services Provided for Children With Bronchiolitis Treated in Children’s Hospitals

“… 1 , 4 These findings conflict with a recent analysis of the Pediatric Health Information Systems (PHIS) database, which found that costs per hospitalization were stable despite higher rates of noninvasive ventilation (NIV) and intensive care unit (ICU) use over time. 5 …”

“… 9 , 10 , 11 Second, the trends in hospital costs observed in the PHIS database were sensitive to the strategy used to identify patients, specifically including patients with bronchiolitis only in the primary diagnosis position compared with including patients with bronchiolitis in any position. 5 Finally, as value-based payment models are increasingly adopted, children’s hospitals are focusing on an accurate case-mix adjustment, and changes in diagnostic coding practices are likely ocurring. 12 Therefore, it is unclear to what extent apparent trends in resource use are associated with patient-level factors as opposed to coding practices.…”

Changes in Ventilation Practices for Bronchiolitis in the Hospital Ward and Need for ICU Transfer over the Last Decade

“…The overall survival rate was 99.95%. Moreover, the percentage of bronchiolitis admissions transferred to ICU grew from 11.7% in 2010 to 24.5% in 2019 [ 12 ], and the application of mechanical ventilation kept constant over time (≈3%). The paradoxical tendency to increase ICU utilisation after the adoption of a ward-based protocol had already been described [ 13 ].…”