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Practices and Outcomes in a Brazilian Pediatric Intensive Care Unit After Implementation of a Critical Bronchiolitis
Patricia Silva Vasconcellos de Lara1, Andrew G Miller2,3, Leandro Candido de Souza4
1Dr. de Lara is affiliated with Department of Pediatrics, Hospital da Luz, São Paulo, SP, Brazil.
Insights
Critical bronchiolitis management in a Brazilian PICU showed low intubation rates, even with imperfect protocol adherence. The modified Wood-Downes score (mWDS) effectively predicts the need for mechanical ventilation in infants.
Area of Science:
- Pediatrics
- Intensive Care Medicine
- Respiratory Medicine
Background:
- Critical bronchiolitis is a frequent cause for pediatric intensive care unit (PICU) admission.
- Management strategies for critical bronchiolitis vary significantly, with limited data from South American PICUs.
- This study addresses the need for characterizing critical bronchiolitis in a Brazilian PICU context.
Purpose of the Study:
- To characterize critical bronchiolitis trajectories in a Brazilian PICU.
- To assess adherence to a clinical protocol that de-emphasizes ancillary pharmacologic treatments.
- To evaluate the modified Wood-Downes score (mWDS) for guiding respiratory support and predicting mechanical ventilation needs.
Main Methods:
- Retrospective cohort study of infants under 24 months admitted with critical bronchiolitis (March 2021-April 2023).
- Protocol discouraged inhaled beta-agonists, systemic corticosteroids, and inhaled hypertonic saline.
- Respiratory support guided by mWDS: conventional oxygen (≤3), HFNC/NIV (4-7), mechanical ventilation (>7).
Main Results:
- 299 infants studied; 69% had RSV infection.
- Low intubation rate (3%); 61% received conventional oxygen, 22% HFNC, 14% NIV.
- Complete protocol adherence was 43%; mWDS at admission predicted intubation (AUC 0.77), with scores <4 indicating no need for intubation.
Conclusions:
- Brazilian PICU cohort showed low intubation rates for critical bronchiolitis despite suboptimal protocol adherence.
- The mWDS score at PICU admission is a reliable predictor for the need for mechanical ventilation.
- mWDS scores below 4 at admission identify low-risk infants who do not require intubation.
Background:
Critical bronchiolitis is a common reason for pediatric intensive care unit (PICU) admission, and management varies widely, with limited data from South American PICUs. This study aimed to characterize critical bronchiolitis trajectories in a Brazilian PICU and to measure adherence to a clinical protocol deemphasizing ancillary pharmacologic treatments while using the modified Wood-Downes score (mWDS) to guide respiratory support. It also aimed to assess whether admission mWDS would be associated with the need for subsequent invasive mechanical ventilation.
Methods:
We conducted a retrospective cohort study of infants <24 months admitted with critical bronchiolitis to a Brazilian PICU between March 2021 and April 2023. The protocol was implemented in January 2021 and discouraged the use of inhaled β-agonists, systemic corticosteroids, and inhaled hypertonic saline. It also recommended respiratory support based on the mWDS conventional oxygen for scores ≤3, high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) for scores 4-7, and consideration of mechanical ventilation for scores >7. We assessed patient characteristics, protocol adherence, and predictive value of admission mWDS for intubation.
Results:
Among 299 infants (median age 4.9 mo), 69% had respiratory syncytial virus infection. Maximum respiratory support was conventional oxygen in 61%, HFNC in 22%, NIV in 14%, and mechanical ventilation in 3%. Complete protocol adherence was 43%. Individual component adherence varied: hypertonic saline 100%, corticosteroids 83%, β-agonists 77%, and appropriate respiratory support 54%. Most protocol violations (66%) involved undertreatment with conventional oxygen for mWDS 4-7. The mWDS score at PICU admission was associated with intubation with an area under the curve of 0.77 (95% CI: 0.63-0.91); no subject with mWDS at PICU admission <4 required intubation.
Conclusions:
This Brazilian cohort demonstrated low intubation rates despite suboptimal protocol adherence. The mWDS score at PICU admission showed acceptable discrimination for the need for mechanical ventilation, with scores <4 identifying low-risk patients.
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