A retrospective study, led by Akron Children’s pediatric intensivist Dr. Jonathan Pelletier, may lead to further review of various respiratory support options used in treating for infants and toddlers for bronchiolitis.
Bronchiolitis, usually caused by RSV, is the most common reason for children under age two to be hospitalized and drove a three-fold increase in pediatric intensive care (PICU) admissions between 2013 and 2022.
Dr. Pelletier and his colleagues looked at the use of non-invasive means of offering respiratory support to patients with bronchiolitis in the PICU, such as the use of high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV). The use of these treatments increased nearly five and sixfold, respectively, during the ten-year study period and yet there was no reduction in the use of invasive mechanical ventilation (IMV).
The study, published in JAMA Network Open, American Academy of Pediatrics and Medpage Today, suggests the widespread use of these treatments could be a factor in the shortage of PICU beds, especially during respiratory season, and could be an unnecessary burden on PICU resources.
For their study, the researchers examined 33,816 PICU encounters for children under age 2 with bronchiolitis from 2013 to 2022. They relied on data from 27 PICUs using the Virtual Pediatric Systems (VPS) database.
“When we put our results together on a population level, it really seems like we are using more and more non-invasive therapies, but we are not using them in a way that is keeping the patients off of a breathing tube,” said Dr. Pelletier. “What it seems like we are finding, epidemiologically, is that, instead of taking children who would have gotten breathing tubes and rescuing them with our non-invasive therapies, we are probably taking children who never needed a breathing tube in the first place and we are putting them on a non-invasive therapy and requiring them to go to the ICU.”
This is significant, said Dr. Pelletier, because during the last several bronchiolitis seasons, Akron Children’s and other children’s hospitals have been managing a shortage of critical care beds.
“So what our paper suggests in blunt terms is this could partially be our fault and the greater use of non-invasive therapies like HFNC could be overwhelming our system’s capacity to care for patients,” he said.
Dr. Pelletier stressed that HFNC is a therapy with clinical merit.
“Patients on HFNC look better clinically,” he said. “Their respiratory rates improve. They are breathing slower, more normally. Their work of breathing comes down, meaning there are using the accessory muscles in their neck, rib cage and belly less to breathe. And, in fact, we know from randomized controlled trials of high-flow nasal cannula from the late 2010s that the patients’ clinical exams improved.”
Many children’s hospitals have successfully moved these therapies from the PICU to general patient floors but such a change would require careful planning, taking into consideration how and where patients would be observed, what factors would classify a patient as “low risk” and ensuring proper staffing of respiratory therapists in both the PICU and on the general patient floors.
“Solutions aimed at reducing PICU burden need to consider multiple components in the chain of care,” summarized Dr. Pelletier.
A link to the study is here and the Medpages Today article is here.
