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Objectives: To assess the potential effect of two guideline discharge oxygen saturation (SpO(2)) recommendations (≥90% and ≥94%) in recovering bronchiolitis., Methods and Patients: Infants aged up to 18 months requiring therapeutic oxygen for SpO(2) (≤93%) had SpO(2) assessed in air every 2 h. Time from admission to re-establish feeding (>75% normal) and for SpO(2) to become stable for at least 4 h at ≥90% and ≥94% were noted., Results: 68 infants, median age 14 weeks, were included. Feeding problems resolved at a median of 11 h (inter-quartile range, IQR 0-47). SpO(2) became stable for at least 4 h at 17 h (IQR 0-49) for ≥90% and 63 h (IQR 34-105) for ≥94%. Time for infants to achieve a stable SpO(2)≥90% and resolve feeding difficulties was a median of 22 h (IQR 7-39 h) sooner than the equivalent for stable SpO(2)≥94%., Conclusions: Accepting lower SpO(2) at discharge could significantly reduce length of stay, but require the clinical and safety effects to be studied.

In 127 infants admitted to intensive care for RSV bronchiolitis, concomitant bacterial sepsis was a rare event. However, in the subgroup of intubated patients the incidence of bacterial pneumonia was 43.9% (95% CI 31.0-56.8%), half community acquired and half nosocomial. As clinical signs are not helpful in identifying these patients, tracheal aspirates have to be investigated microbiologically on a routine basis in order to start antibiotics in time.

Background: Acute otitis media (AOM) is the most common bacterial co-infection of viral bronchiolitis., Aims: To evaluate the influence of AOM on the clinical course of bronchiolitis., Subjects: 150 children younger than 24 months old, diagnosed with bronchiolitis, hospitalised between December 1997 and May 1999., Methods: Body temperature, respiratory rate, oxygen saturation, and the need for oxygen supplementation were recorded on admission and daily throughout hospitalisation. Complete blood count, erythrocyte sedimentation rate, and assay for respiratory syncytial virus were performed on admission. All children were examined daily for the appearance of AOM. The clinical course of children with bronchiolitis and AOM was compared to those without AOM., Results: AOM was diagnosed in 79/150 (53%) children with bronchiolitis. Most were diagnosed within the first two days of hospitalisation. No significant difference was found in the clinical and laboratory findings on admission and on daily follow up between children with and without AOM., Conclusions: This 2.5 year prospective study showed no difference in the course of bronchiolitis, whether an ear infection was present or not.

Little attention has been given to the relation between fever and the severity of bronchiolitis. Therefore, the relation between fever and the clinical course of 90 infants (59 boys, 31 girls) hospitalised during one season with bronchiolitis was studied prospectively. Fever (defined as a single recording > 38.0 degrees C or two successive recording > 37.8 degrees C) was present in 28 infants. These infants were older (mean age, 5.3 v 4.0 months), had a longer mean hospital stay (4.2 v 2.7 days), and a more severe clinical course (71.0% v 29.0%) than those infants without fever. Radiological abnormalities (collapse/consolidation) were found in 60. 7% of the febrile group compared with 14.8% of the afebrile infants. These results suggest that monitoring of body temperature is important in bronchiolitis and that fever is likely to be associated with a more severe clinical course and radiological abnormalities.

Background: Previous studies suggest that recurrent episodes of coughing and wheezing occur in up to 75% of infants after acute viral bronchiolitis., Aim: To assess the efficacy of budesonide given by means of a metered dose inhaler, spacer, and face mask in reducing the incidence of coughing and wheezing episodes up to 12 months after acute viral bronchiolitis., Methods: Children under the age of 12 months admitted to hospital with acute viral bronchiolitis were randomised to receive either budesonide or placebo (200 microg or one puff twice daily) for the next eight weeks. Parents kept a diary card record of all episodes of coughing and wheezing over the next 12 months., Results: Full follow up data were collected for 49 infants. There were no significant differences between the two study groups for the number of infants with symptom episodes up to six months after hospital discharge. At 12 months, 21 infants in the budesonide group had symptom episodes compared with 12 of 24 in the placebo group. The median number of symptom episodes was 2 (range, 0-13) in those who received budesonide and 1 (range, 0-11) in those who received placebo. Because there is no pharmacological explanation for these results, they are likely to be caused by a type 1 error, possibly exacerbated by there being more boys in the treatment group., Conclusion: Routine administration of budesonide by means of a metered dose inhaler, spacer, and face mask system immediately after acute viral bronchiolitis cannot be recommended.

As part of a long term prospective study, 73 children who had been admitted to hospital with viral bronchiolitis as infants, were reviewed 5.5 years later and compared with a carefully matched control group. In the postbronchiolitis group, there was a highly significant increase in respiratory symptoms including wheezing (42.5% v 15.0%, relative risk = 2.8). Although atopy in the family was not significantly increased in the index group, personal atopy was more prevalent. However, personal atopy was not significantly more prevalent in the symptomatic postbronchiolitis, compared with those who were symptom free, and so did not account for the high prevalence of postbronchiolitis wheezing in this cohort. In addition, in a stepwise logistic regressional model, bronchiolitis remained a significant predictor of wheezing after adjusting for potential confounding variables, including atopy. Bronchial responsiveness to histamine was significantly increased in the index group. However, no significant relationship of positive tests to wheezing could be demonstrated, and a high rate of positive responses was noted in the controls.

During the last 4 years we have seen 13 children with a severe bronchiolitis. The children have had prolonged respiratory illnesses waxing and waning over many months, often requiring oxygen therapy for long periods. The diagnosis is based on a clinical picture similar to acute bronchiolitis, but persisting for months, frequently associated with failure to thrive, coupled with lung function evidence of hyperinflation and airways obstruction but normal static compliance. Confusion with other chronic lung conditions can be clarified by straightforward observations and investigations. We believe that chronic bronchiolitis is fairly common and often misdiagnosed. The short- and medium-term prognosis appears good although small airways disease may persist into adult life.

The clinical and respiratory function characteristics of 200 children 7 years after their admission to hospital with acute lower respiratory tract infection in infancy have been presented. Results were subsequently analysed according to disease category (bronchitis, bronchiolitis, or pneumonia) at initial presentation. Within each diagnostic category recurrent cough and wheeze, a tendency for colds 'to go to the chest', medication, absence from school, and family doctor consultations were significantly increased. Ventilatory function was diminished and bronchial reactivity increased when compared with matched controls. Studies of a different design are required to elucidate the mechanisms whereby symptoms are increased, ventilatory function impaired, and bronchial reactivity increased after severe lower respiratory infection in infancy.

We reviewed the clinical progress of 81 children as part of a prospective study three and a half years after admission to hospital with acute viral bronchiolitis in infancy. Fifty six (69%) reported episodes of lower respiratory symptoms continuing over the preceding year, 25 (31%) had symptoms lasting for longer than two weeks on two or more occasions, 14 (17%) had symptoms for more than 100 days, and six (7%) required readmission to hospital with acute respiratory illness. Two years previously, these percentages had been 82%, 36%, 33%, and 13% respectively. Forty six (57%) children were said to be improving or to have become asymptomatic, but eight (10%) were deteriorating. There was no difference in the personal or family history of atopy, nor in the rate of skin test positivity between those with and without continuing symptoms, suggesting that atopy does not play an important role in the persistence of symptoms. Less than half the symptomatic children had received bronchodilator treatment during the preceding 12 months.

A retrospective review of children who needed mechanical ventilation for severe bronchiolitis identified 62 cases over a 10 year period. The mean age at initiation of ventilation was 73 days (range: 14-201). Compared with a group of 150 children in hospital for bronchiolitis but not transferred to the intensive care unit, these 62 cases were significantly younger (73.0 compared with 166.3 days), and smaller (4.5 compared with 6.8 kg), and significantly more had been born prematurely (40% compared with 16%). Taken independently, age, weight, and prematurity were significantly associated with the need for artificial ventilation, weight being the most important factor. Using stepwise logistic regression, prematurity in itself added to the quality of the prediction but age did not. The mean duration of mechanical ventilation was 105 hours (range 2-381). Duration of ventilation was significantly longer in children with a low gestational age at birth and a positive familial history of atopy. There were no deaths, and no patient developed pneumothorax or pneumomediastinum. Mechanical ventilation is well tolerated and safe in acute bronchiolitis.

Three- to 4-hour polygraphic sleep studies were carried out in 16 infants aged between 1 and 6 months during and after recovery from acute bronchiolitis. During bronchiolitis 35% of total sleep time was active sleep compared with 31% after recovery. Respiration rate was increased during bronchiolitis and was higher in active sleep and quiet sleep irrespective of the stage of the illness. Apnoeic pauses were invariably shorter than 15 seconds, the mean duration for active sleep and quiet sleep being similar during infection and after recovery. Apnoeic episodes were central in type and generally initiated by a sign or body movements. Preapnoea heart rate was significantly higher than during or after apnoea. Apnoea index (the percentage of time the baby spends apnoeic), apnoea attack rate (the number of episodes of apnoea per unit time), and apnoea percentage (the distribution of episodes of apnoea while in a given sleep state) were increased significantly in quiet sleep during the index illness. Transcutaneous oxygen tension was significantly reduced during the course of infection, but comparable values were obtained in active sleep and quiet sleep during initial and recovery periods. These results show that the main changes in respiration pattern during the course of acute bronchiolitis occur in quiet sleep.

Four infants in whom excessive secretion of antidiuretic hormone was associated with pulmonary infections are reported. Severe hyponatraemia was noted in 3 of them; in the fourth, fluid restriction may have prevented this complication.

We assessed the clinical progress of 55 children 2 years after admission to hospital with acute bronchiolitis and performed lung function tests on 40. During the 2 year follow up period 75% of the children had wheezed, 36% had 2 or more lower respiratory symptoms lasting more than 2 weeks, 33% had more than 100 days of lower respiratory symptoms, and 13% were readmitted to hospital with acute respiratory disease. In addition 60% of the children were hyperinflated on lung function tests. Many of the children with hyperinflation at the 2 year assessment had not been hyperinflated 1 year earlier, suggesting variable airways obstruction. Reversibility of airways obstruction was also assessed by response to nebulised salbutamol. Nine children had a fall greater than 15% in airways resistance after salbutamol and these children had the highest baseline airways resistances. Airways resistance was higher in the children with a family history of atopy.

We performed 211 lung function measurements on 93 children in the first year after they had been admitted with acute bronchiolitis. During the convalescent phase of the illness, 77% of the infants were hyperinflated with a thoracic gas volume greater than 40 ml/kg and 3 months later 43% were hyperinflated. Twelve months after the initial illness, 17% still had lung function abnormalities and most of these children have had lower respiratory tract symptoms. For the group as a whole about 60% have had at least one episode of wheezing. Specific conductances were significantly lower in children from atopic families, indicating worse lung function, but the significance of this finding is unclear.