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Bronchiolitis, the annual winter endemic of acute viral lower respiratory tract illness in infants, is challenging for hospitals with overfull paediatric wards, for general practitioners worried about not spotting the infant at risk and for sleep-deprived parents looking after a sick child. The National Institute for Health and Care Excellence (NICE) Bronchiolitis guideline, published in 2015,1 highlights ‘red flags’ and lists ineffective treatments which ‘should not be used’, citing abundant clinical trials. In this journal, Carande and colleagues2 gauge the effect of the guideline publication on management in general practice. There were some shifts towards better practice in the (self-selected) general practitioner (GP) respondents, though improvement was incremental rather than transformational, as is common to new guidelines.3 Nearly three-quarters of respondents routinely used oximetry for the assessment of a child with acute bronchiolitis. Measuring oxygen saturation with an age-appropriate device has been widely promoted as essential in the assessment of patients of any age with acute lower …

Background Our group has been analysing routine operational data on A and E and UCC attendances with a focus on “frequent flyers” – those who attend 4 or more times per year. Aims To test the hypothesis that those who repeatedly attend fall into two main groups: chronic long standing illness (CLSI) and those who decide to attend A&E out of choice or preference. To describe the clinical characteristics of a subgroup attending very frequently. Method Retrospective analysis conducted on routine operational data collected for a large DGH. The data set included collated paediatric attendances to the Urgent care centre and paediatric A+E at the Hospital over a one-year period (01/10/13–30/09/14). A sub-group of those attending nine or more times was analysed. Results 10641 patients under 5 attended A&E in the time period, 753 attended 4 or more times, 33 attended 9 or more times (over a total of 337 attendances). Of these, 23% required admission and 77% and were discharged. Of the top 33 attenders 15 (45%) had a CLSI, (6, 18% multiple e.g ex-prem, Intraventricular haemorrhage and Chronic lung disease, 9, 27% single e.g. cleft palate). More than half 18 (55%) had no underlying chronic illness. In patients with chronic disease background admission risk was significantly higher Table 1. (Chi Sq 22.7, p = 0.00002) The most common diagnosis in the top 33 attenders was upper respiratory tract infection, followed by unspecified viral infection, acute bronchiolitis and intestinal infection. The top three diagnoses for the different patient groups are shown in Table 2. Conclusion Frequent attenders can be characterised into two different groups, those with chronic underlying conditions and those without. We are exploring options to reduce repeat A&E/UCC attendance by those with chronic illnesses with additional community specialist nurse support and in both groups with parental and GP education particularly targeting the management of respiratory illness.

Background: A study was undertaken to evaluate the efficacy of dexamethasone in patients mechanically ventilated for lower respiratory infection caused by respiratory syncytial virus (RSV-LRTI). Methods: In a multicentre randomised controlled trial patients were randomised to receive either intravenous dexamethasone (0.15 mg/kg 6 hourly for 48 hours) or placebo. End points were the duration of mechanical ventilation, length of stay (LOS) in the pediatric intensive care unit (PICU) and in hospital, and the duration of supplemental oxygen administration. Results: Thirty seven patients received dexamethasone and 45 received placebo. There was no significant difference in any of the end points between the two groups. In a post hoc analysis patients were stratified into those with mild gas exchange anomalies ( PaO2/FiO(2) > 200 mm Hg and/or mean airway pressure 10 cm H2O, pneumonia group). In the 39 patients with bronchiolitis the duration of mechanical ventilation was 4.3 days shorter in the dexamethasone group than in the placebo group (4.9 v 9.2 days, 95% CI - 7.8 to - 0.8, p= 0.02) and the duration of supplemental oxygen was 3.6 days shorter (7.7 v 11.3 days, 95% CI - 8.0 to - 0.1, p= 0.048). No differences in end points were found in the pneumonia group. Conclusions: Dexamethasone had no beneficial effect in patients mechanically ventilated for RSV-LRTI but was found to have a beneficial effect in patients with bronchiolitis

A prospective randomised controlled pilot study was performed comparing home oxygen therapy with traditional inpatient hospitalisation for children with acute bronchiolitis. Children aged 3-24 months with acute bronchiolitis, still requiring oxygen supplementation 24 h after admission to hospital, were randomly assigned to receive oxygen supplementation at home with support from "hospital in the home" (HiTH) or to continue oxygen supplementation in hospital. 44 children (26 male, mean age 9.2 months) were recruited (HiTH n = 22) between 1 August and 30 November 2007. Only one child from each group was readmitted to hospital and there were no serious complications. Children in the HiTH group spent almost 2 days less in a hospital bed than those managed as traditional inpatients: HiTH 55.2 h (interquartile range (IQR) 40.3-88.9) versus in hospital 96.9 h (IQR 71.2-147.2) p = 0.001. Home oxygen therapy appears to be a feasible alternative to traditional hospital oxygen therapy in selected children with acute bronchiolitis.

Commentary on : Zhang L, Mendoza-Sassi RA, Klassen TP, et al. Nebulized hypertonic saline for acute bronchiolitis: a systematic review. Pediatrics 2015;136:687–701.[OpenUrl][1][Abstract/FREE Full Text][2] Acute bronchiolitis is the most common cause of hospitalisation of infants. There is no specific therapy that provides consistent benefit. Nebulised hypertonic saline (HS) may be theoretically effective by improving mucociliary clearance, and reducing airway oedema and mucus viscosity. HS has been investigated as a therapeutic intervention in multiple studies, with inconsistent results. A 2013 Cochrane meta-analysis concluded that HS is a safe and effective treatment for acute bronchiolitis.1 This analysis of 11 randomised controlled trials (RCTs) (1090 infants) found a 1.15 days (95% CI 0.82 to 1.49) shorter mean hospital length of stay (LOS) in those treated with HS compared with normal saline (NS). Although initially promising, subsequent RCTs have shown that HS may not be as effective as … [1]: {openurl}?query=rft.jtitle%253DPediatrics%26rft_id%253Dinfo%253Adoi%252F10.1542%252Fpeds.2015-1914%26rft_id%253Dinfo%253Apmid%252F26416925%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=pediatrics&resid=136/4/687&atom=%2Febmed%2F21%2F4%2F143.atom

Aims The utilisation of blood gas analysis (BGA) in acute bronchiolitis is common with wide variation between hospitals. Guidelines recommend its use only in those with severe respiratory distress and who are tiring but evidence for such practice is sparse. This study investigated clinical indicators that demarcate clinically important rise in carbon dioxide (CO2). Methods We undertook a prospective observational study of children admitted from the emergency department (ED) to a tertiary care university hospital with a diagnosis of bronchiolitis (October 2014–January 2015). Data was obtained from hospital charts and electronic patient information and analysed using STATA/IC 12.1 for Mac. Univariate analysis examined the correlation between blood gas CO2 and oxygen requirement, SpO2 in air, vital signs, feeding support requirement, gender, age, co-morbidities and history of prematurity. Statistically significant variables were entered into a logistic regression model. Results 220 patients with bronchiolitis were admitted (mean age of 0.57 years (95% CI:0.05,0.64)). 113 (51%) had at least one BGA done. Those with more than three BGAs (32/113 (28%)) were significantly younger and more likely to be premature. 14% (30/220) were admitted to intensive/high dependency care (ITU/HDU). In ED a CO2 >7kPA was associated with an admission to HDU/ITU (OR 3.75(95% CI:1.13,12.47), p = 0.031); prematurity and young age also independently predicted ITU/HDU (IRR1.53(95% CI:1.21,1.93), p 7kPa in ED were 7kPa in the regression model (OR 2.46(95% CI:1.42,4.26), p = 0.001 and OR 0.08(95% CI:0.03,0.17), p Conclusion Age under 3 months, history of prematurity and CO2 >7kPa done in ED identify those with prolonged LOS and/or HDU/ITU admission. Significantly raised CO2 is not seen in bronchiolitis without oxygen requirement. Further work will look to elucidate when BGA may be helpful in the management of bronchiolitis.

Nebulised hypertonic saline is attractive as a therapy for acute viral bronchiolitis. Thick and sticky secretions in oedematous airways induce breathlessness and poor feeding as a hallmark of the disease. Loosening secretions with this simple therapy could prevent admission to hospital, or speed recovery and discharge. In a condition with no current acute therapeutic options, this would be welcome indeed.1 ,2 Hypertonic saline changes mucous rheology, and when used in cystic fibrosis, has good—if modest—effect.3 In bronchiolitis, hypertonic saline has had a promising start. Early trials demonstrated appealing benefits with reduction in length of stay by up to 25%.4 A Cochrane review, last updated in 2013, concludes with a recommendation to use hypertonic saline in bronchiolitis to reduce length of stay in hospitalised patients.5 Hypertonic Saline in acute Bronchiolitis RCT and Economic evaluation (SABRE), printed in this issue,6 is the largest reported study for the use of nebulised hypertonic saline infants hospitalised with bronchiolitis. Importantly, the study protocol challenges head on the difficulties with using a placebo control when testing a nebulised intervention. As it cannot be assumed that nebulised normal saline (0.9%) will have no clinical effect, the non-intervention arm in SABRE was the current standard of care in the UK— i.e., no regular use of epinephrine, salbutamol or 0.9% saline that were nebulised in all previous studies testing hypertonic saline in bronchiolitis. By necessity, that made the trial open label, which leaves a study open to criticism of potential confounding bias. In this case, however, the weight of evidence to date in favour of hypertonic saline and the desperate need for something to work in bronchiolitis, might suggest any anticipated bias would have been in favour of the intervention. Yet, the open label design did not favour the intervention: nebulised hypertonic saline …

Inhaled sympathomimetic agents are often used in bronchiolitis with little objective evidence of benefit. The arterial oxygen saturation (SaO2) reflects the adequacy of ventilation-perfusion balance. The aim of the current study was to determine the effect of inhaled salbutamol on SaO2. In a randomised, double blind study, 21 infants, admitted with bronchiolitis positive for respiratory syncytial virus, had continuous SaO2 measurements made before and after nebulised salbutamol or placebo. SaO2 was recorded over 30 minutes for a baseline, then during the 10 minutes of first nebulisation with either salbutamol or saline, then over 30 minutes after nebulisation, the 10 minutes of second nebulisation with the alternate regime, and another 30 minutes after this second nebulisation. Desaturation occurred after salbutamol and saline nebulisation. The fall in SaO2 with salbutamol was seen whether infants received it as the first or second nebulisation. The fall in SaO2 after saline was seen when given first, but not when given after salbutamol. The decrease in SaO2 was greater and more prolonged with salbutamol than with saline. Routine nebulised aerosol sympathomimetic treatment during acute bronchiolitis cannot be recommended.

Commentary on : Everard ML, Hind D, Ugonna K, et al. SABRE: a multicenter randomized control trial of nebulised hypertonic saline in infants hospitalised with acute bronchiolitis. Thorax 2014;69:1105–12[OpenUrl][1][Abstract/FREE Full Text][2]. Acute bronchiolitis is the most frequent lower respiratory infection in infancy, yet no therapy has shown consistent benefit.1 Although initially promising, there is now conflicting evidence regarding the efficacy of nebulised 3% hypertonic saline (HS). In 2013, a Cochrane meta-analysis concluded that HS may significantly reduce the hospital length of stay among infants hospitalised with mild-to-moderate bronchiolitis and also improve clinical severity scores.2 Other studies suggest that HS has no effect on length of stay.3 ,4 This study was a multicentre, parallel-group, open-label randomised trial comparing 4 mL of nebulised HS administered every 6 h to standard supportive care in infants aged

Background Respiratory syncytial virus (RSV) infections can be prevented by good hygiene and prophylactic palivizumab, a monoclonal antibody against the fusion protein of VRS. The criteria for selecting patients for palivizumab prescription in our hospital are: Purpose To describe the use of palivizumab in the vaccination campaign in our hospital, evaluating the appropriateness of its use by the established criteria and its effectiveness. Material and methods We performed a retrospective observational study. All patients who received palivizumab between 01/10/2013 and 31/03/2014 were included. The data collected using the clinical records were: sex, gestational age, selection criteria, and number of hospitalizations due to acute bronchiolitis between 01/10/2013 and 30/09/2014. RSV was analysed in these patients by Polymerase Chain Reaction (PCR). Results Palivizumab was administered to 68 patients (48.5% female) with a median gestational age of 209 days (176–287). 24 patients (35.3%) fulfilled criterion 2, 14 (20.6%) criterion 1, 10 (14.7%) criterion 4, 5 (7.3%) criteria 1 and 3, 4 (5.9%) criteria 2 and 4, 3 (4.4%) criterion 3, 2 (2.9%) criteria 3 and 4. 4 patients did not meet any criteria and 2 had no data. Only 6 patients who received palivizumab were hospitalised with a diagnosis of acute bronchiolitis and their RSV PCRs were negative. Conclusion Palivizumab is used under the established criteria in our hospital. The study data show that immunising these at-risk patients with the palivizumab vaccine was an effective strategy for at least one year. Although the study period was 1 year, it would be desirable to measure effectiveness over a longer period. References and/or Acknowledgements No conflict of interest.

Low vitamin D status have been found to be associated with the risk of acute upper and lower respiratory tract infections. The deficiency of vitamin D was the significant risk factors contributed to the post-bronchiolitis wheezing in children. We aimed to investigate the association between vitamin D status and occurrence of recurrent acute bronchiolitiThe children with acute bronchiolitis who aged 2 months to 2 years were hospitalized between December 2008 and April 2009 in the Ankara Training and Research Hospital, Ankara, Turkey were included in the analysis. This study was prospective and case-control study. We used a questionnaire addressing demographic factors, exposure to sunlight and vitamin use. We defined children with recurrent wheeze as = 3 wheezing attacks. In total, 56 cases and 30 controls were enrolled. The mean age of all children was 12±7.2 months (2 months- 2 years). The mean of serum 25-OHD3 was 138±56.7 nmol/L in total patients, 134.3±55.6 nmol/L in cases and 145±59.2nmol/L in control group. There was not any significant difference between cases and controls in 25-OHD3 levels (p>0.05). The mean of serum 25-OHD3 was 132.4±58 (10–263) nmol/L in group 1 (n=42) and 140±49 (75–208) nmol/L in group 2 (n=14), the difference was not statistically significant (p>0.05). There was no significant correlation between the number of wheezing attacks (p>0.05). No correlation between vitamin D levels and acute bronchiolitis was found but this may be the result of few numbers of patients that we studied with.

Commentary on: K Al-Ansari, M Sakran, BL Davidson, et al.. Nebulized 5% or 3% hypertonic or 0.9% saline for treating acute bronchiolitis in infants.J Pediatr2010;157:630–4, 634.e1.

Background and aims Most of clinical scales used in the assessment of acute bronchiolitis are not validated or are partial validated. The objective of this study is the validation of a clinical scale in the assessment of acute bronchiolitis (AB). Material and methods Validation of a clinical severity scale in the context of a randomised, double-blind, clinical trial. 148 infants hospitalised with moderate acute bronchiolitis for 2 epidemics (2011–2013) were included. Demographics and clinical data were recorded. Different observers assessed all patients at admission and three times daily until discharge with Wood-Downes modifies by Ferres (WDF) scale. Mild bronchiolitis and those with severity risk factors were excluded. The primary outcome was the difference in the numeric rating scale since admission until were discharged from hospital or admitted to PICU. The collected variables were analysed using non-parametric tests. In all cases it was considered a significance level of 95%. Results Mean age and range interquartilico [IQR] 1.5 months (1–3), 50% were male. The WDF scale in patients admitted to PICU was significantly higher (6 (4–8) vs 5 (4–8), p = 0.026). The WDF scale decreased an average of 3.87 points (95% CI, 2.5–6.5) from admission to the time of discharge. Conclusions Our results suggest that the WDF scale is related to the severity and outcome of patients with acute bronchiolitis at admission and at discharge. It´s change from admission to discharge, which show a clear decrease adequately, reflect good clinical evolution necessary for discharge home.

Background and aims Nebulised 3% hypertonic saline (3%HSS) decreases length of hospitalisation and rate of admission in infants with moderate bronchiolitis. To describe whether treatment with nebulised 3%HSS, with or without bronchodilators in acute moderate bronchiolitis, decreases the rate of admission to PICU compared to nebulised saline (FSS) with bronchodilators. Material and methods 389 patients with moderate acute bronchiolitis were admitted, 181 were collected retrospectively (group 0: October 2008 to May 2010) and 208 prospectively (group 1: October 2011 to May 2013 patients). Group 0 received treatment with FSS and group 1 received 3%HSS. The PICU admission rate was recorded as the main variable. Secondary variables: overall hospital length of stay (LOS), stay at PICU, need for mechanical ventilation (MV) and its duration. The collected variables were analysed using Chi – square and nonparametric tests. Results Demographic data and clinical data were similar in both groups (p > 0.05): mean age, gender male, RSV positive, corticosteroids or antibiotics use. LOS was longer in group 0 (p = 0.020). PICU admission was 17.8% vs 12.5%, p = 0.146, stay PICU: 5.91 days vs 3.76 days, p = 0.859), VM rate in PICU was 25% vs 24%, p = 0.931 and VM duration of PICU was 7.63 days vs 7.17 days. Conclusions Patients treated with 3%SSH showed the same PICU admission rate and stay. The nebulised 3%SSH does not decrease the PICU admission. Overall hospital LOS was longer in FSS group.

Background and aims The use of nebulized adrenaline in the treatment of infants with acute bronchiolitis, has been related to increased cardiac rate. On the other hand, bronchoconstriction episodes requiring bronchodilators have been reported with the use of nebulized 3% hypertonic saline solution (3%SSH) without bronchodilators. We aimed to analyse the safety of nebulized adrenaline and nebulized 3% HSS in the management of infants hospitalised for acute moderate bronchiolitis. Methods Randomised, double-blind, controlled trial. 185 hospitalised infants (2.11 ± 2.23 months (mean ± SD) received nebulized 3%HSS (7ml) either with 3 mg of adrenaline (group SSH3%+A; n = 94) or 3 ml of placebo (group SSH3%+P; n = 91), in addition to routine therapy. Nebulizations were initially administered every four hours and adjusted thereafter according to clinical response. The principal outcomes measures were cardiac rate (CR) and frequency rate (FR) up to the median of stay, nebulization requirements and need of transfer to the PICU. Results There was not statistically significant differences in the cardiac frequency (p = 0.76, 0.48 and 0.73, respectively) and frequency rate (p = 0.88, 0.07 and 0.24, respectively) in 3 days of median of stay, nebulizations rates (p = 0.89), PICU’s admission (p = 1). No other adverse events were reported. Conclusion In acute bronchiolitis for moderately ill hospitalised infants, nebulized adrenaline and nebulized 3%HSS are safe.

Backgrounds and aims Wood Downes’s modified by Ferres score (WDF) was not designed for the bronchiolitis, but its use has been generalised to evaluate the severity. Our aim is to relate the length of stay and the bronchiolitis´s severity at admission, by WDF. Patient and methods We included the acute bronchiolitis hospitalised during two epidemics (2011–2013). They were classified in mild (MiB; WDF 7) according to the scale WDF realised at admission. The mild ones and to the patients without WDF at admission were excluded. The main variable was the length of stay. We registered: age, RSV, sex, previous and during treatment and UCIP’s need. Analysis with SPSS 17.0. Results 208 hospitalised infants were included (mean age of 72,9 days (5–373). Positive RSV in 67,8%. 90,5% were MB and 9,5% SB. Both groups were homogeneous in demographics data and previous admission treatment (p > 0.05). The mean WDF at admission was 5,42 (4–10). During the hospitalisation, they received nebulised bronchodilator in 3% hypertonic saline solution (3%SSH) (65%) or 3%SSH (35%). 22% received corticoids and 8,2% antibiotics. Length of stay: 5,3 days (0–46). The MB had an mean length of stay of 4,8 days and the SB of 13,44 (p = 0.0001). Conclusions WDF’s scale has demonstrated, in our sample, to be a good predictor of the length of stay in moderate and severe bronchiolitis. The SB had a statistically significant more length of stay than MB.

Background and aims To evaluate the use of antibiotics and its relation to the length of stay (LOS) in patients hospitalised with acute bronchiolitis (AB). Patients and Method In a context of a randomised, controlled, double-blind clinical trial, 177 infants hospitalised with AB in two epidemics (2011–2013) were included. They were classified according to the scale of Wood- Downes modified by Ferres (WDF), in mild (MiB), moderate (MB) or severe (SB). The primary outcome was LOS. We evaluated the antibiotic used and CRP. Data were analysed with SPSS17. Results There were 7.9% MiB, 83.6% MB and 8.5% SB. Of them, 21.4% of MiB, 14.2% of MB and 66.7% of the SB received antibiotic therapy. The most commonly used antibiotics were amoxicillin-clavulanate, cefotaxime and azithromycin. The most frequent reasons were clinical worsening measured by WDF scale, increased CRP and fever. The mean LOS for acute bronchiolitis without antibiotics was 4.51 days and with antibiotics 7.84 days (p = 0.001). The use of antibiotics in SB was significantly higher than in MB (p = 0.001). In the group of MB, the mean LOS was 4.44 days (no antibiotics) vs 7.29 (antibiotics), p = 0.001. In the group of BG, the mean LOS was 9.4 days vs. 13.5 days, p = 0.53. There were statistically significant differences in elevated CRP and the use of antibiotics (p = 0.005). Conclusions The AB who received antibiotics had significantly more LOS. There were statistically significant differences to received antibiotics in MB, but not in SB, perhaps because the LOS of this group is high.

A 7-month old girl with the complaints of crying, cyanosis and breathing rapidly was brought to a hospital by her family. After taking nebulised salbutamol, the symptoms relieved. However, the symptoms reoccurred despite appropriate acute bronchiolitis treatment. She was hospitalized due to massive right thoracic infiltration in the chest x-ray. During evaluation, thoracal ultrasound showed a suspicious solid mass at the posterior mediastinum. Thorax computerised tomography revealed a right hemithoracal and posterior mediastinal gross solid mass. As the staging procedure, bone marrow aspirations were done which resulted in normal findings. The trucut biopsy of the thoracal mass resulted as small round blue malignant tumor cells consistent with peripheral neuroectodermal tumor/ewing sarcoma which was very rare in this age group.

Introduction SIGN recommends rapid virological testing for RSV. There was a perception that in the absence of laboratory confirmation, infants were being increasingly investigated and treated to cover for bacterial pneumonia. Method A cost analysis comparing two periods when NPA was routinely done and when it was not done was undertaken. A retrospective audit comparing patients diagnosed with bronchiolitis in December 2001 when NPA testing was routinely done and December 2010 when it could only be requested by senior clinicians. This decision was meant to cut costs as it was felt that a positive NPA did not change management. Results In 2001, 15 patients (75%) were diagnosed with bronchiolitis using NPA techniques compared to two patients (5.9%) in the 2010 cohort. In 2010, 10 patients (29.4%) received chest radiographs compared to 6 patients (30.0%) in 2001. A total of 3 patients (15.0%) received the 9 blood investigations in the 2001 cohort group compared to 10 patients (29.41%) who received the 43 investigations in the 2010 cohort. The combined cost of all investigations during inpatient stay per patient was £24.95 in the 2001 cohort group compared to £10.10 in the 2010 cohort group. NPA tests are considerably more expensive, specifically 1.5 times the cost of chest radiographs and more than 8 times the cost of any blood investigation. The mean length of inpatient stay was similar in both cohorts: 2.9 days in 2001 and 2.7 days in 2010 Conclusion NPA testing may not be a cost-effective matter-of-course investigation. Notably, bronchiolitis requires a predominately clinical diagnosis. The cost of NPA testing, appreciably higher than for any investigation, accounted for almost 75% of the investigation spend in 2001, yet only 14.5% in 2010. However, as the other investigations are not interchangeable with NPAs, there must be a presumption that other legitimate rationales dictated their requirement.

Inhaled adrenaline shows promise in outpatients, but treatment for inpatients remains unclear

Background Bronchiolitis is the commonest respiratory viral illness in infants with the potential for significant morbidity. There is growing evidence for the use of continuous positive airway pressure (CPAP) non-invasive ventilation in the most seriously affected of these children. Despite the increasing literature regarding the use of CPAP there are currently no studies which identify clinical predictors of requirement for CPAP using the UK bronchiolitis age limit of 12 months, leaving the decision to clinical judgement alone. Objective To identify clinical factors in infants with bronchiolitis at the time of presentation to the emergency department, which might predict a requirement for CPAP following admission. Methods Retrospective review of paediatric emergency department case notes was conducted on all bronchiolitis admissions to one tertiary paediatric emergency department in a 12-month period (April 2009–March 2010). Inclusion criteria consisted of a clinical diagnosis of bronchiolitis in those 12 months of age or under. Potential clinical predictors were identified through an extensive literature review. Data extraction of these predetermined potential clinical predictors was carried out and recorded for each case. Logistic regression was then conducted for each variable to identify statistically significant independent predictors of CPAP requirment. Results During the study period 163 infants were admitted with acute bronchiolitis. Of the 163 infants admitted 28 (17%) received CPAP. The most significant predictors of CPAP requirement in those admitted were as follows: lower oxygen saturation (mean 92.7% vs 97.1%, p Conclusion We have identified a number of clinical variables which may be assessed within the emergency department, each independently predictive of CPAP requirement in those who are admitted with bronchiolitis. These findings are of particular importance as an aid to clinical assessment of bronchiolitis severity. They are also likely to have a useful role in logistical management decisions, allowing early planning for non-invasive ventilation.

Introduction Bronchiolitis is a significant cause of acute morbidity in the first 12 months of life. A proportion of infants will be admitted to hospital and currently the decision to admit is based on clinical judgement alone. Research evidence identifying indicators for admission is scarce, there have been no studies assessing clinical predictors of admission in infants with bronchiolitis under the age of 12 months. Aim To determine which clinical features in the emergency department are able to predict the need for hospital admission in infants with acute bronchiolitis. Methods All infants presenting with acute bronchiolitis to one tertiary paediatric emergency department from April 2009 to March 2010 were included in this study. Inclusion criteria were a clinical diagnosis of bronchiolitis in an infant aged Results 449 infants presented with acute bronchiolitis during the study period (298 (66%) male, mean age 23±14.5 weeks). 163 (36%) infants were admitted to hospital. The main clinical features predictive of admission (mean for admitted group vs discharged group respectively) included: younger age at presentation (mean 17.9 weeks vs 26.4 weeks, p Conclusion We have identified seven objective clinical parameters which can be used in the emergency department to predict which infants with bronchiolitis require admission to hospital. These data have been assimilated into a simple clinical risk score; further work is required to validate this scoring system and to assess its utility in supporting clinical decisions.

Although the track record for successful treatment interventions for acute bronchiolitis has so far been unimpressive,1 a recent trial …

▴ Wainwright C, Altamirano L, Cheney M, et al . A multicenter, randomized, double-blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med2003;349:27–35 [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] The evidence that oxygen is the only effective treatment in viral bronchiolitis continues to mount. The largest double blind, randomised, placebo controlled trial to date of nebulised adrenaline (epinephrine) showed no improvement in duration of hospital stay/time until ready for discharge with adrenaline compared with placebo. Indeed, in … [1]: {openurl}?query=rft.jtitle%253DNew%2BEngland%2BJournal%2Bof%2BMedicine%26rft.stitle%253DNEJM%26rft.issn%253D0028-4793%26rft.aulast%253DWainwright%26rft.auinit1%253DC.%26rft.volume%253D349%26rft.issue%253D1%26rft.spage%253D27%26rft.epage%253D35%26rft.atitle%253DA%2BMulticenter%252C%2BRandomized%252C%2BDouble-Blind%252C%2BControlled%2BTrial%2Bof%2BNebulized%2BEpinephrine%2Bin%2BInfants%2Bwith%2BAcute%2BBronchiolitis%26rft_id%253Dinfo%253Adoi%252F10.1056%252FNEJMoa022226%26rft_id%253Dinfo%253Apmid%252F12840089%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1056/NEJMoa022226&link_type=DOI [3]: /lookup/external-ref?access_num=12840089&link_type=MED&atom=%2Fthoraxjnl%2F58%2F10%2F871.atom [4]: /lookup/external-ref?access_num=000183896100005&link_type=ISI

Source Citation Schuh S, Coates AL, Binnie R, et al. Efficacy of oral dexamethasone in outpatients with acute bronchiolitis. J Pediatr. 2002 Jan;140:27-32. 11815760

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.

Thirty-one infants admitted to hospital with acute bronchiolitis during an epidemic of respiratory syncytial virus were compared with a control group of 32 infants to establish whether the two groups differed in atopic background. Past history of respiratory illness, eczema, and present reactions to skin testing differed significantly between the two groups. Thus, infants with acute bronchiolitis had a significantly higher atopic predisposition than the controls.

In a double blind randomised trial, we found no evidence that nebulised ipratropium bromide was of clinical benefit in acute bronchiolitis.

Forty four children with acute bronchiolitis were given twice daily chest physiotherapy in addition to standard supportive measures and were compared with 46 controls who were not given physiotherapy. There was no clinically discernable benefit on the course of their illness.