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Variability of intensive care management for children with bronchiolitis
Heather C Pierce1, Jonathan M Mansbach2, Erin S Fisher3
1Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, California; hpierce@rchsd.org.
Insights
Treatment for pediatric bronchiolitis requiring intensive care varies significantly between hospitals, even when patient severity is similar. This variability impacts the use of continuous positive airway pressure (CPAP), intubation, and high-flow nasal cannula (HFNC).
Area of Science:
- Pediatric critical care medicine
- Respiratory infections
- Health services research
Background:
- Bronchiolitis is a common cause of pediatric hospitalization requiring intensive care.
- Current management strategies for severe bronchiolitis show considerable variation.
- Understanding this variability is crucial for standardizing care and improving outcomes.
Purpose of the Study:
- To quantify the extent of variability in the testing and treatment of children with bronchiolitis admitted to intensive care units (ICUs).
- To investigate whether patient characteristics explain the observed differences in care.
- To highlight the need for evidence-based guidelines in pediatric intensive care for bronchiolitis.
Main Methods:
- Prospective, multicenter observational study involving 16 academic children's hospitals in the U.S.
- Included 342 children under 2 years old hospitalized with bronchiolitis requiring ICU admission and/or continuous positive airway pressure (CPAP) within 24 hours.
- Collected clinical data and nasopharyngeal aspirates; analyzed respiratory distress severity scores and intraclass correlation coefficients for treatment variations.
Main Results:
- Significant institutional variability was observed in the use of continuous positive airway pressure (CPAP) (median 15%, range 3%-100%), intubation (median 26%, range 0%-100%), and high-flow nasal cannula (HFNC) (median 24%, range 0%-94%).
- Intraclass correlation coefficients indicated substantial variability: 21% for CPAP/intubation and 44.7% for HFNC, after adjusting for patient demographics and illness severity.
- Variability in testing and treatment was not explained by differences in patient characteristics or severity of illness across the participating sites.
Conclusions:
- Substantial institutional variability exists in the intensive care management of pediatric bronchiolitis, affecting the utilization of key respiratory support modalities.
- Observed treatment differences are not attributable to variations in patient populations or illness severity between institutions.
- Further research is essential to establish best practices for intensive care interventions in bronchiolitis to reduce unwarranted clinical practice variation.
Objective:
To determine the extent of variability in testing and treatment of children with bronchiolitis requiring intensive care.
Methods:
This prospective, multicenter observational study included 16 academic children's hospitals across the United States during the 2007 to 2010 fall and winter seasons. The study included children<2 years old hospitalized with bronchiolitis who required admission to the ICU and/or continuous positive airway pressure (CPAP) within 24 hours of admission. Among the 2207 enrolled patients with bronchiolitis, 342 children met inclusion criteria. Clinical data and nasopharyngeal aspirates were collected.
Results:
Respiratory distress severity scores and intraclass correlation coefficients were calculated. The study patients' median age was 2.6 months, and 59% were male. Across the 16 sites, the median respiratory distress severity score was 5.1 (interquartile range: 4.5-5.4; P<.001). The median value of the percentages for all sites using CPAP was 15% (range: 3%-100%), intubation was 26% (range: 0%-100%), and high-flow nasal cannula (HFNC) was 24% (range: 0%-94%). Adjusting for site-specific random effects (as well as children's demographic characteristics and severity of bronchiolitis), the intraclass correlation coefficient for CPAP and/or intubation was 21% (95% confidence interval: 8-44); for HFNC, it was 44.7% (95% confidence interval: 24-67).
Conclusions:
In this multicenter study of children requiring intensive care for bronchiolitis, we identified substantial institutional variability in testing and treatment, including use of CPAP, intubation, and HFNC. These differences were not explained by between-site differences in patient characteristics, including severity of illness. Further research is needed to identify best practices for intensive care interventions for this major cause of pediatric hospitalization.
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