Detection of new respiratory viruses in hospitalized infants with bronchiolitis: a three‐year prospective study

Aim: We have designed a study with the objective of describing the clinical impact of other viruses different from the respiratory syncytial virus (RSV) in hospitalized infants with bronchiolitis. Methods: A 3 year prospective study was conducted on infants admitted to the Paediatrics Department of the Severo Ochoa Hospital (Spain). We studied the frequency of 16 respiratory viruses. Clinical characteristics of RSV‐only infections were compared with other single agent viral infections. Results: Positive results were confirmed in 275 (86.5%) of the 318 children studied. A single virus was detected in 196 patients and 79 were dual or multiple viral infections. RSV was detected in 61.3% of total bronchiolitis. Rhinovirus (RV) was 17.4% of the identified virus, followed by human bocavirus (HBoV), adenovirus and metapneumovirus (hMPV). Only RV, HBoV and hMPV were significant as single infections. RSV patients were younger than HBoV (p > 0.0001) and hMPV (p = 0.025). Seasonality was clearly different between them. Children with RSV infection needed treatment in the intensive care unit more frequently than others. Conclusions: In hospitalized infants, RSV was the most frequent agent in bronchiolitis in winter, but other viruses were present in 47% of the patients. RV, HBoV and hMPV had a significant proportion of single infections. Clinical characteristics were similar amongst them, but seasonality was clearly different.     

Glycemic level in mechanically ventilated children with bronchiolitis.

OBJECTIVE: To evaluate in children with bronchiolitis requiring mechanical ventilation the association between blood glucose level and duration of mechanical ventilation and pediatric intensive care unit (PICU) stay. DESIGN: Retrospective cohort study. SETTING: University hospital PICU. PATIENTS: Children admitted to a university hospital PICU over a period of 3 yrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, infection with respiratory syncytial virus, history of prematurity, mechanical ventilator settings, and use of inotrope during illness were noted. In addition, C-reactive protein, alanine transaminase, and glucose levels were recorded. Data from 50 children with median (interquartile range) age of 2.2 (1.3-4.7) months were analyzed. There were 37 boys, 21 children had been premature babies, and 30 children were positive for respiratory syncytial virus. Hyperglycemia at any time was frequent (peak glucose > or =6.1 mmol/L [110 mg/dL] in 98% and >8.3 mmol/L [150 mg/dL] in 72%). Children with sustained hyperglycemia were more likely to be boys with higher alanine transaminase and C-reactive protein, requiring inotrope (p < .05). These children are more likely to have required high-frequency oscillation ventilation, required higher airway pressures, and had longer duration of mechanical ventilation and PICU stay (p < .05). Peak glucose and sustained peak glucose were not independently associated with duration of mechanical ventilation or PICU stay. Multiple regression showed that age, C-reactive protein, the need for inotrope, and respiratory syncytial virus infection were independent factors associated with duration of PICU stay. Glucose level was not a factor. CONCLUSIONS: Our findings show that hyperglycemia is frequent in children with bronchiolitis requiring mechanical ventilation, but we failed to show that this phenomenon was independently associated with prolonged duration of mechanical ventilation or PICU stay. Our observations raise the question whether tight glycemic control should be used in children with bronchiolitis.     

Central apnoeas in infants with bronchiolitis admitted to the paediatric intensive care unit

Aim: To further characterize apnoea(s) complicating bronchiolitis because of respiratory syncytial virus (RSV), to describe the incidence of this complication and identify possible risk factors for apnoea(s) and its development. Methods: The files of infants admitted to the paediatric intensive care unit (PICU) for RSV bronchiolitis during three bronchiolitis seasons (2004–2007) were reviewed for demographic, clinical and laboratory parameters. Parameters were compared between patients with and without apnoeas. Results: Seventy‐nine patients met the study criteria: 43 were admitted to the PICU for central apnoeas and the remainder for respiratory distress or failure. The percentage of infants admitted for apnoea increased during the study period (28.6 to 77.1%, p = 0.004). The overall prevalence of apnoea in this population was 4.3%. Possible risk factors for apnoea(s) were younger age (1.3 vs. 4.3 months, p = 0.002), lower admission weight (3.3 vs. 5 kg, p < 0.001), lower gestational age (35.8 vs. 37.8 weeks, p = 0.01), admission from the emergency room (50% vs. 9.1%, p < 0.001) and lack of hyperthermia (p < 0.001). Respiratory acidosis was found to be a protective factor on logistic regression analysis. Conclusion: The prevalence of apnoea in infants admitted to the PICU for RSV bronchiolitis in our centre may be increasing. Preterm, younger infants with no fever are at relatively high risk of apnoea at presentation, while older infants with fever are at lower risk.     

Impacto clínico de la implantación de la ventilación por alto flujo de oxígeno en el tratamiento de la bronquiolitis en una planta de hospitalización pediátrica

ObjectiveTo analyse the safety and efficacy of high-flow oxygen therapy for treatment of moderate to severe bronchiolitis in children admitted to the paediatric hospital wards.MethodsA prospective observational study was conducted on children < 18 months of age with bronchiolitis admitted to the paediatric ward of a tertiary-care teaching hospital during the 2011-12 respiratory season. Children were treated with a high-flow ventilation system (Fisher & Paykel). Clinical and cardio-respiratory parameters were evaluated every hour for the duration of therapy.ResultsA total of 25 patients, with a median age of 2 months (range: 0.6-11 months) were included. Respiratory syncytial virus (RSV) was positive in 75% of cases. Indications for high-flow therapy included: progressive respiratory distress (Wood-Downes ≥ 8) (88%), apnoea (8%) and desaturation (4%). Median duration of therapy was 4 days (range: 3-7 days), with a median of 9 days in hospital (range: 8-12 days). High flow therapy was associated with a significant decrease in cardio-respiratory parameters, heart rate, respiratory rate, which resulted in a significant improvement of the Wood-Downes Score (from 10±1.21 to 3±0.77, P=.001). No adverse effects were observed. Five patients (20%) were admitted to the Paediatric Intensive Care Unit (PICU), which represents an 80% reduction of PICU admissions compared with historic data of previous years.ConclusionsHigh-flow ventilation therapy achieved a significant improvement in heart rate, respiratory rate, and scale of severity in patients with bronchiolitis. This novel therapeutic strategy allows safe management of bronchiolitis patients in the regular ward, reducing admissions to the PICU.     

Human metapneumovirus in children with bronchiolitis or pneumonia in New Zealand

OBJECTIVES: To confirm the presence of human metapneumovirus (hMPV) in New Zealand and establish its prevalence in selected paediatric patient groups. METHODS: Nasopharyngeal swabs were collected in two separate paediatric studies enrolling children clinically diagnosed with either bronchiolitis or pneumonia and tested for hMPV by polymerase chain reaction. RESULTS: Nucleic acid detection tests demonstrated 5.3% of paediatric bronchiolitis cases were positive for hMPV RNA and 2.7% of children admitted with pneumonia tested positive for hMPV RNA. CONCLUSIONS: The presence of hMPV in New Zealand has been confirmed in two selected paediatric patient groups, namely children diagnosed with bronchiolitis and pneumonia. These results indicate that hMPV is associated with a minority of cases of bronchiolitis or pneumonia in this patient group.     

Factores pronósticos de evolución complicada en la bronquiolitis que requiere ingreso en cuidados intensivos pediátricos

ObjectiveTo analyse the prognostic factors for complications in children with bronchiolitis admitted to a pediatric intensive care unit (PICU).Patients and methodA retrospective study was performed on children with bronchiolitis admitted into a PICU between 2000 and 2006. Univariate and multivariate analysis were performed to study the prognostic factors of complications, mechanical ventilation requirements, mortality and PICU stays of more than 15 days.ResultsA total of 110 patients were studied, of whom 72 (65.5%) had high risk factors: prematurity (39.1%), cardiac disease (38.2%) and bronchopulmonary dysplasia (16.3%). A total of 82.7% of patients had complications; 26% need invasive mechanical ventilation and the mortality was 3.6%, and 16.4% stayed in PICU for more than 15 days. Factors associated with mechanical ventilation were the clinical Wood-Downes score and heart disease. A weight less than 5 kg was associated with complications; heart disease and invasive mechanical ventilation were associated with a longer PICU stay; prematurity and mechanical ventilation were associated with mortality.ConclusionsChildren with bronchiolitis admitted into the PICU had a high frequency of complications, often needed mechanical ventilation and had long stays in the PICU, but the mortality is low. The best prognostic factors on admission into the PICU were the acute respiratory insufficiency score, the presence of heart disease and were premature at birth.     

Risk factors for respiratory syncytial virus associated apnoea

Respiratory syncytial virus (RSV) infections are characterized by upper or lower respiratory tract symptoms including bronchiolitis and pneumonia. Apnoea may be the first sign of disease in children with RSV infection. The aims of this study were the identification of independent risk factors for RSV associated apnoea and the prediction of the risk for mechanical ventilation in children with RSV associated apnoea. Medical records of children younger than 12 months of age admitted with RSV infection between 1992 and 1995 to the Sophia Children's Hospital, were reviewed. Demographic parameters, clinical features and laboratory parameters (SaO₂, pCO₂ and pH) were obtained upon admission and during hospitalization. Children with and without apnoea were compared using univariate and multivariate logistic and linear regression analysis. One hundred and eighty-five patients with RSV infection were admitted of whom 38 (21%) presented with apnoea. Patients with apnoea were significantly younger, had a significantly lower temperature, higher pCO₂ and lower pH and had on chest radiographs also more signs of atelectasis. The number of patients admitted to the ICU because of mechanical ventilation and oxygen administration was significantly higher in children with RSV associated apnoea. Apnoea at admission was a strong predictor for recurrent apnoea. The relative risk for mechanical ventilation increased with the number of episodes of apnoea: 2.4 (95% CI 0.8 – 6.6) in children with one episode of apnoea (at admission) versus 6.5 (95% CI 3.3 – 12.9) in children with recurrent episodes of apnoea. Conclusions Age below 2 months is the strongest independent risk factor for RSV associated apnoea. Apnoea at admission increases the risk for recurrent apnoea. The risk for mechanical ventilation significantly increases in children who suffer from recurrent apnoea. Received: 12 May 1997 / Accepted in revised form: 22 August 1997     

Deprivation,ethnicity and prematurity in infant respiratory failure in PICU in the UK

Aim: To describe the epidemiology of infants admitted to Paediatric Intensive Care (PIC) with acute respiratory failure including bronchiolitis. Methods: Data from all consecutive admissions from 2004 to 2007 in all 29 designated Paediatric Intensive Care Units (PICUs) in England and Wales were collected. Admission rates, risk‐adjusted mortality, length of stay, ventilation status, preterm birth, deprivation and ethnicity were studied. Results: A total of 4641 infants under 1 year of age had an unplanned admission to PIC with acute respiratory failure (ARF), an admission rate of 1.80 per 1000 infants per year. There was a reduced rate of admission with bronchiolitis in South Asian children admitted to PICU, which is not explained by case‐mix. Children born preterm had a higher rate of admission and longer stay, but a similar low mortality. Risk‐adjusted mortality was higher in South Asian infants and the highest in those with ARF (OR 1.76, 95% CI 1.20–2.57) compared with the rest of the PICU population. Conclusion: Acute respiratory failure in infants causes most of the seasonal variation in unplanned admission to intensive care. Socioeconomic deprivation and prematurity are additional risk factors for admission. Fewer South Asian infants are admitted to PICU with a diagnosis of bronchiolitis, but risk‐adjusted mortality is higher in South Asian infants overall.     

Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children

Background: Neuromuscular blocking agents (NMBA) are commonly administered to critically ill children in pediatric intensive care units (PICU) in the USA and Europe. Although NMBA are frequently used in PICU patients, their role in the PICU setting has not yet been clearly defined. The aim of this study was to describe the sustained administration of NMBA and its impact on outcome of PICU patients. Methods: A 3‐year retrospective cohort study was conducted to compare mechanically‐ventilated patients who received NMBA for at least 12 h with patients who did not (control group). Results: A total of 317 consecutive patients were ventilated over 3473 days. Patients were similar in age, weight and severity scores. Thirty‐four children (10.7%) received NMBA. Compared with controls, the neuromuscular blockade (NMB) group had a longer duration of mechanical ventilation (13.7 vs 5.5 days, P= 0.000), longer PICU stay (20 vs 11 days, P= 0.000) and increased occurrence of ventilator‐associated pneumonia (6.6 vs 4.1/1000 ventilator days, P= 0.010). The NMB use was not associated with higher mortality (8.8% vs 17.6%, P= 0.287) or longer hospital stay (30.5 vs 23 days, P= 0.117). Conclusion: Although the use of NMBA was not associated with greater mortality, we found that sustained use of NMBA is associated with prolonged mechanical ventilation, longer PICU stay and higher incidence of ventilator‐associated pneumonia when compared with controls. Larger studies are necessary to confirm these findings.     

Prospective regional study of an epidemic of respiratory syncytial virus (RSV) bronchiolitis]

This prospective study was designed to identify risk factors associated with admission in pediatric intensive care units (PICU) among infants hospitalized for treatment of RSV induced bronchiolitis. This study was population-based and was conducted in Burgundy, a French region with 1,800,000 inhabitants where passive immunoprophylaxis for RSV bronchiolitis was not set up at the time of the study. RESULTS: From December 1st 1999 to April 30th 2000, 484 infants were hospitalized for RSV bronchiolitis in Burgundy: 19.6% were born prematurely (gestational age [GA] below 37 weeks) and at admission, 68.3% had a postnatal age below six months (mean = 5 +/- 5.9 months; median value = 3 months). The duration of hospitalization was 7.3 +/- 12.4 days (median value = 6 days). Among the 484 infants, 31 (6.4%) needed admission in PICU, eight needed mechanical ventilation (1.7%) and one died (0.2%). Univariate analysis identified anamnestic risk factors associated with admission in PICU: prematurity; low birth weight; past history of neonatal respiratory distress syndrome (RDS); mechanical ventilation for RDS treatment; bronchopulmonary dysplasia (BPD) and congenital heart disease. Multivariate analysis identified three independent factors associated with an increased risk for admission in PICU: GA below 32 weeks; RDS and congenital heart disease. CONCLUSION: This study suggests that population at risk for severe RSV bronchiolitis with PICU admission should include all very preterm infants with RDS whatever the outcome of RDS (with or without BPD). These epidemiological data could be helpful to set up indications for passive immunoprophylaxis of RSV induced bronchiolitis.     

Factors affecting survival in children requiring intensive care after hematopoietic stem cell transplantation. A retrospective single‐center study

Allo‐HSCT is associated with life‐threatening complications. Therefore, a considerable number of patients require admission to a PICU. We evaluated the incidence and outcome of PICU admissions after allo‐HSCT in children, along with the potential factors influencing PICU survival. A retrospective chart review of 668 children who underwent first allo‐HSCT in the Department of Pediatric Hematology/Oncology and BMT in Wroc?aw during years 2005‐2017, particularly focusing on patients admitted to the PICU within 1‐year post‐HSCT. Fifty‐eight (8.7%) patients required 64 admissions to the PICU. Twenty‐four (41.5%) were discharged, and 34 (58.6%) patients died. Among the discharged patients, 6‐month survival was 66.7%. Compared with survivors, death cases were more likely to have required MV (31/34; 91.2% vs. 16/24; 66.7% P = .049), received more aggressive cardiac support (17/34; 50% vs. 2/24; 8.3% P = .002), and had a lower ANC on the last day of their PICU stay (P = .004). Five patients were successfully treated with NIV and survived longer than 6 months post‐discharge. The intensity of cardiac support and ANC on the last day of PICU treatment was independent factors influencing PICU survival. Children admitted to the PICU after allo‐HSCT have a high mortality rate. Mainly those who needed a more aggressive approach and had a lower ANC on the last day of treatment had a greater risk of death. While requiring MV is associated with decreased PICU survival, early implementation of NIV might be considered.     

6岁以下儿童急性下呼吸道感染的病毒病原及临床研究

目的　了解北京地区 6岁以下儿童中急性下呼吸道感染 (ALRI)患儿的病毒感染状况 ;探讨人类偏肺病毒 (hMPV)感染在儿童ALRI中的作用及所致支气管肺炎的临床特征。方法　 (1)采集 2 0 0 1年 2月至 2 0 0 3年 3月就诊于首都儿科研究所 4 4 6例年龄 1个月至 5岁的ALRI住院患儿的鼻咽分泌物 ,同时应用间接免疫荧光 (IFA)及病毒分离方法进行人类呼吸道合胞病毒 (hRSV)、流感病毒 (甲、乙型 )、副流感病毒 (Ⅰ、Ⅱ、Ⅲ型 )及腺病毒等 7种常见呼吸道病毒的病原检测。 (2 )采用逆转录聚合酶链反应 (RT PCR)方法对 2 0 0 2年 11月至 2 0 0 3年 3月住我院内科的ALRI患儿中经 7种呼吸道常见病毒病原检测阴性的 2 16份鼻咽洗液 ,进行了hMPV基因检测 ,并分析hMPV感染患儿的临床资料。结果　 (1) 4 4 6例患儿中 7种常见呼吸道病毒总阳性例数为 2 0 9例 (46 86 % ) ,hRSV阳性者最多为 16 3例 (36 5 5 % )。 (2 )在 2 16份上述 7种呼吸道病原检测阴性的标本中 6 9份测到hMPV阳性扩增产物 (31 9% ) ,占同期送检标本的 19 17%。结论　 (1)hRSV是北京地区冬春季节婴幼儿ALRI的主要病原。 (2 )2 0 0 2年 11月至 2 0 0 3年 3月我院ALRI住院患儿中有 19 17%与hMPV感染有关     

Bronchiolitis treated with mechanical ventilation: prognosis factors and outcome in a series of 135 children]

Viral bronchiolitis is usually associated with favorable outcome as regard to mortality. Only few studies reported severe bronchiolitis requiring mechanical ventilation, and respiratory outcome is not well described. METHODS: Therefore, we conducted a retrospective study in a series of 135 children admitted in a single Pediatric Intensive Care Unit (PICU) over a four year period (1994-1998). All of them were admitted for viral bronchiolitis requiring mechanical ventilation. RESULTS: At admission, 83% of them were less than three months old. Prematurity at birth was present in 33,3%. Mortality was observed in four cases (2,9%), all premature babies with mechanical ventilation at birth. Univariate analysis showed as main factors associated to mortality: prematurity (P =0,056) and acute respiratory distress syndrome (P =0,017). Childhood asthma was observed in 40,4% of children without any associated factor wether at birth or in PICU related to such outcome. CONCLUSION: Bronchiolitis associated with mechanical ventilation is particularly observed in very young babies and prematurity is the main factor associated to mortality. Mechanical ventilation seems not to be associated with unfavorable respiratory outcome. Considering physiology and population, non invasive ventilation could be an effective alternative of mechanical ventilation.     

Endotracheal intubation and pediatric status asthmaticus: site of original care affects treatment.

OBJECTIVES: Status asthmaticus is a common cause of admission to a pediatric intensive care unit (PICU). Children unresponsive to medical therapies may require endotracheal intubation; however, this treatment carries significant risk, and thresholds for intubation vary. Our hypothesis was that children who sought care at community hospitals received less aggressive treatment and more frequent intubation than children who sought care at a children's hospital. DESIGN: Retrospective cohort study. SETTING: A university-affiliated children's hospital PICU. PATIENTS: We retrospectively examined data from all children older than 2 yrs admitted to the PICU with status asthmaticus between April 1997 and July 2005. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 251 children admitted to the PICU with status asthmaticus, 130 initially presented to the emergency department of a children's hospital and 116 presented to the emergency department of a community hospital. Despite similar illness severity, children presenting to a community hospital were significantly more likely to be intubated than those presenting to a children's hospital (17% vs. 5%; p = .004). In addition, those children intubated at community hospitals were intubated sooner after presentation (2.4 +/- 5.2 vs. 7.5 +/- 5.8 hrs; p = .009), had shorter durations of intubation (71 +/- 73 vs. 151 +/- 81 hrs; p = .02), and had shorter PICU length of stays (129 +/- 82 vs. 230 +/- 84 hrs; p = .01). CONCLUSIONS: Children with status asthmaticus are more likely to be intubated, and intubated sooner, at a community hospital. The shorter duration of intubation suggests that some children may not have been intubated had they presented to a children's hospital or received more aggressive therapy at their community hospital.     

Contribution of viruses to severe pneumonia in children

ObjectiveCommunity acquired pneumonia (CAP) accounts for more than two million deaths per year in children less than 5 years of age, mostly in developing countries. Viruses causing CAP have been identified in up to 50% of patients in studies using the real-time polymerase chain reaction (PCR). This study aimed at screening of viral etiology among hospitalized children with severe pneumonia.MethodsIn this prospective study conducted at Cairo University Children’s Hospital from 31st March 2010 to 1st April 2011 on 733 children admitted with a clinical and radiological diagnosis of pneumonia, nasopharyngeal or throat swabs were analyzed for common respiratory viruses, including respiratory syncytial virus (RSV), human metapneumovirus (hMPV), influenza B (Flu B), human parainfluenza virus (hPIV), influenza A (H1N1) and adenovirus (ADV) using the real time PCR technique.ResultsOne or more respiratory viruses were detected in 311 patients. RSV was the most commonly detected virus isolated in 197(63.3%) followed by hPIV in 38(12.2%), hMPV in 34(10.9%) and ADV in 26(8.4%) patients. Six cases were positive for H1N1 making the virus the second least common, after Flu B, identified in a single patient in our study. Mixed infection with more than one respiratory virus was detected in 156(45%) cases.ConclusionRSV was the most predominantly isolated virus from all patients in addition to being the most common single virus to cause pneumonia in children with chronic diseases. Although the most commonly isolated virus in our study, RSV came third in causing complications following hPIV & H1N1, but this observation cannot be applied to the community.     

Respiratory syncytial virus infection and recurrent wheeze/asthma in children under five years: an epidemiological survey

AIM: To determine the rates of respiratory syncytial virus (RSV) infection in children under 5 years of age with recurrent wheeze or asthma and compare their clinical presentation, course and outcome with asthmatic children of the same age who did not have RSV. METHODS: Children were recruited prospectively from the emergency department of the Royal Children's Hospital, Melbourne during peak RSV season in 1998. Information was collected regarding past and current asthma presentations, a nasopharyngeal asprirate was taken for viral isolation and all children were reviewed by telephone 1 week following presentation. RESULTS: 73 children were included with a median age of 28 months. RSV was isolated from 33 (45%) of children, one child had adenovirus and in the remainder no virus was isolated. Children less than 12 months were more likely to have RSV (70%). RSV-positive children had a longer duration of illness prior to hospital presentation than RSV-negative children but were not more likely to be admitted or to have a longer duration of ongoing symptoms. CONCLUSION: A high rate of RSV infection was demonstrated in young children with recurrent wheeze or asthma during the RSV season. This information has important implications for the control of nosocomial infection with RSV (i.e. isolation of patients) and in targeting another group to be included for RSV vaccine development.