RESUMEN
OBJECTIVES: To identify the epidemiologic predictors and stratify the risk of critical care unit (CCU) admission or death in bronchiolitis following emergency department discharge. This information has not yet been explored. STUDY DESIGN: A population-based cohort study using Ontario-wide demographic and healthcare databases linked at the individual level. We assessed all infants with bronchiolitis discharged home from all emergency departments in Ontario, Canada, 2003-2014. Targeted information included plausible demographic and clinical predictors of CCU admission/death within 14 days of emergency department discharge. Using multivariable logistic regression analyses, we identified independent predictors of this outcome and stratified the outcome risk by the type of multivariable predictor. RESULTS: Of 34 270 study infants, 102 (0.3%) were admitted to CCU or died after discharge. Predictors of CCU admission/death were: comorbidities (OR 5.33; 95% CI 2.82-10.10), younger age [months] (OR 1.47; 95%CI 1.33-1.61), low income (OR 1.53; 95% CI 1.01-2.34), younger gestational age [weeks] (OR 1.14; 95%CI 1.06-1.22), and emergent presentation (Canadian Triage and Acuity Scale 2) at the index visit (OR 1.55, 95% CI 1.03-2.33). The absolute event risk of CCU admission/death in infants with versus without comorbidities were 1.5% versus 0.26%, respectively (P < .001). The odds of these outcomes in infants with comorbidities plus ≥2 other predictors were 25 times higher than in infants without predictors (OR 25.1, 95% CI 11.4-55.3). CONCLUSIONS: Infants with comorbidities plus other predictors discharged from the emergency department with bronchiolitis are at considerable risk of subsequent CCU admission and death. These risk factors should augment current clinical and social considerations determining patient disposition.
Asunto(s)
Bronquiolitis/mortalidad , Bronquiolitis/terapia , Cuidados Críticos/estadística & datos numéricos , Servicio de Urgencia en Hospital , Utilización de Instalaciones y Servicios/estadística & datos numéricos , Alta del Paciente , Femenino , Humanos , Lactante , Recién Nacido , Modelos Logísticos , Masculino , Ontario/epidemiología , Factores de RiesgoRESUMEN
Bronchiolitis is a prevalent disease in children under two years of age, which carries significant morbidity and mortality. However, there is controversy regarding the optimal therapeutic management. Leukotriene inhibitors have been proposed as an alternative, although its efficacy is not clear yet. Searching in Epistemonikos database, which is maintained by screening multiple databases, we identified two systematic reviews comprising six trials addressing the question of this article. We extracted data, combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded leukotriene inhibitors might not decrease mortality levels on bronchiolitis patients and it is not clear whether they decrease length of hospital stay. They might reduce recurrent wheezing, but the certainty of the evidence is low, and they increase adverse effects.
Asunto(s)
Bronquiolitis/tratamiento farmacológico , Hospitalización/estadística & datos numéricos , Antagonistas de Leucotrieno/uso terapéutico , Bronquiolitis/mortalidad , Bronquiolitis/fisiopatología , Humanos , Lactante , Tiempo de Internación , Antagonistas de Leucotrieno/efectos adversosRESUMEN
BACKGROUND: The clinical and physiologic features of respiratory bronchiolitis (RB)-interstitial lung disease (ILD) have been previously described; however, the natural history and outcome have not been systematically evaluated. The majority of published reports consider RB-ILD to be a nonprogressive ILD that clinically improves with smoking cessation and antiinflammatory treatment. In this study, we sought to determine the outcome of RB-ILD patients with and without smoking cessation and with and without corticosteroid therapy. METHODS: Thirty-two RB-ILD cases confirmed by surgical lung biopsy were identified from a prospectively enrolled cohort of subjects with ILD. Initial and follow-up data on symptoms, physiology, treatment, and outcome were collected and analyzed. RESULTS: Kaplan-Meier analysis revealed that at least 75% of RB-ILD patients survived > 7 years after diagnosis. Clinical improvement occurred in only 28% of cases, and physiologic improvement occurred in 10.5% of cases. One patient died of progressive ILD, and two patients died of non-small cell lung cancer. While physiologic improvement was limited to those who had ceased smoking, corticosteroids and/or other immunosuppressive therapy had little effect on symptoms or physiology. CONCLUSIONS: This study shows that prolonged survival is common in RB-ILD. However, symptomatic and physiologic improvement occurs in only a minority of patients, and neither smoking cessation nor immunosuppressive therapy is regularly associated with clinically significant benefit.
Asunto(s)
Bronquiolitis/diagnóstico , Enfermedades Pulmonares Intersticiales/diagnóstico , Enfermedades Raras/diagnóstico , Administración por Inhalación , Corticoesteroides/administración & dosificación , Adulto , Anciano , Bronquiolitis/mortalidad , Bronquiolitis/fisiopatología , Bronquiolitis/terapia , Estudios de Cohortes , Terapia Combinada , Progresión de la Enfermedad , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Volumen Espiratorio Forzado/fisiología , Humanos , Inmunosupresores/administración & dosificación , Enfermedades Pulmonares Intersticiales/mortalidad , Enfermedades Pulmonares Intersticiales/fisiopatología , Enfermedades Pulmonares Intersticiales/terapia , Masculino , Persona de Mediana Edad , Oxígeno/sangre , Capacidad de Difusión Pulmonar/efectos de los fármacos , Capacidad de Difusión Pulmonar/fisiología , Intercambio Gaseoso Pulmonar/efectos de los fármacos , Intercambio Gaseoso Pulmonar/fisiología , Enfermedades Raras/mortalidad , Enfermedades Raras/fisiopatología , Enfermedades Raras/terapia , Estudios Retrospectivos , Fumar/efectos adversos , Cese del Hábito de Fumar , Tasa de Supervivencia , Capacidad Vital/efectos de los fármacos , Capacidad Vital/fisiologíaRESUMEN
OBJECTIVE: To evaluate the impact of respiratory syncytial virus (RSV) infections on subsequent health care resource utilization in preterm infants. STUDY DESIGN: Analysis of data from 2415 preterm infants (32 to 35 weeks gestational age [GA]) hospitalized for proven or probable RSV and matched to 20,254 control infants. RESULTS: Mean (SD) age at the index admission was 7.7 (5.5) months; 46% of the infants were male. Mean (SD) subsequent health services, excluding the index event, for the RSV cohort and control infants, respectively, were hospitalization, 2.96 (2.81) versus 1.28 (1.42); special care unit visits, 0.67 (1.70) versus 0.40 (0.33); respiratory therapy visits, 0:31 (0.70) versus 0.13 (0.37); physician consults, 3.61 (4.54) versus 0.89 (1.12); in-hospital procedures, 1.05 (4.02) versus 0.81 (1.51); outpatient visits, 18.4 (10.58) versus 7.54 (4.31); and mean (SD) inpatient days, 14.71 (18.69) versus 5.04 (7.09). All differences were statistically significant (P<.001). Diagnoses for the RSV and control cohorts were respiratory conditions (64% versus 13%), fever (2.7% versus 0.7%), anorexia (2.2% versus 0.6%), lack of normal physiological development (2.8% versus 1.1%; P<.05), overall deaths (8.1% versus 1.6%; P<.001), and sudden death (6.1% versus 0.3%; P<.001). CONCLUSIONS: RSV hospitalization in healthy premature infants is associated with a significant increase in subsequent health care resource utilization and mortality. Results support prophylaxis of premature infants against RSV hospitalization.
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Bronquiolitis/mortalidad , Bronquiolitis/rehabilitación , Enfermedades del Prematuro/rehabilitación , Infecciones por Virus Sincitial Respiratorio/rehabilitación , Bronquiolitis/virología , Canadá/epidemiología , Estudios de Cohortes , Femenino , Edad Gestacional , Hospitalización/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Recien Nacido Prematuro , Enfermedades del Prematuro/virología , Masculino , Infecciones por Virus Sincitial Respiratorio/virología , Tasa de SupervivenciaAsunto(s)
Humanos , Niño , Bronquiolitis/clasificación , Bronquiolitis/complicaciones , Bronquiolitis/diagnóstico , Bronquiolitis/tratamiento farmacológico , Bronquiolitis/epidemiología , Bronquiolitis/etiología , Bronquiolitis/mortalidad , Bronquiolitis/fisiopatología , Bronquiolitis/terapia , Virus Sincitiales Respiratorios/crecimiento & desarrollo , Virus Sincitiales Respiratorios/aislamiento & purificación , Virus Sincitiales Respiratorios/patogenicidad , Virus Sincitiales Respiratorios/fisiologíaRESUMEN
OBJECTIVE: To test the efficacy of a high dose of vitamin A as adjuvant treatment for radiographically confirmed cases of acute lower respiratory tract infection (ALRI). DESIGN: Randomized, double-masked, placebo-controlled clinical trial. SETTING: Two large urban hospitals in Guatemala City. PATIENTS: Sequential sample of 263 children aged 3 to 48 months, identified in the emergency departments and admitted to the hospital. INTERVENTIONS: Vitamin A (100,000 IU for children less than 1 year of age, and 200,000 IU for older children) or placebo in addition to standard treatment for ALRI which included antibiotics, oxygen, bronchodilators, and intravenously administered solutions. MEASUREMENTS AND MAIN RESULTS: The children were assessed every 8 hours. There were neither statistically nor clinically significant differences by treatment group in the rate of normalization in respiratory rate, oxygen saturation, temperature, or clinical score. Duration of hospitalization was not different by treatment group. Adverse outcomes (mechanical ventilation, prolonged hospitalization, readmission or transfer, and death) were equally distributed between the two groups. CONCLUSIONS: Treatment with high doses of vitamin A over and above standard care for infants and children with non-measles-related ALRI is not efficacious for the current episode. Additional trials among populations in which vitamin A deficiency is more prevalent and severe should be considered.
PIP: During October 1991 to March 1993, in Guatemala, clinical researchers conducted a randomized, double-blind, placebo-controlled clinical trial of 263 pediatric patients aged 3-48 months at the Hospital Roosevelt and the Guatemalteco Social Security Institute Hospital, both in Guatemala City. They aimed to determine the efficacy of a high dose of vitamin A (100,000 IU for children under 1 year of age and 200,000 IU for older children) as adjuvant treatment for radiographically confirmed cases of non-measles-related acute lower respiratory tract infection (ALRI). All the children received standard treatment for ALRI (antibiotics, oxygen, bronchodilators, and intravenously administered solutions). 132 children also received vitamin A and 131 received a placebo. Clinicians evaluated the childrens' condition every 8 hours. The two groups were essentially the same in duration of hospitalization; the rate of normalization in the respiratory rate, oxygen saturation, temperature, and clinical score; and adverse outcomes (mechanical ventilation, prolonged hospitalization, readmission or transfer, and death). These findings indicate that high doses of vitamin A in addition to standard treatment for non-measles-related ALRI lack efficacy for the current ALRI episode.
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Bronquiolitis/tratamiento farmacológico , Neumonía/tratamiento farmacológico , Vitamina A/uso terapéutico , Enfermedad Aguda , Antibacterianos/uso terapéutico , Bronquiolitis/microbiología , Bronquiolitis/mortalidad , Bronquiolitis/fisiopatología , Broncodilatadores/uso terapéutico , Quimioterapia Adyuvante , Preescolar , Método Doble Ciego , Femenino , Hospitales Urbanos , Humanos , Lactante , Masculino , Consumo de Oxígeno , Neumonía/microbiología , Neumonía/mortalidad , Neumonía/fisiopatología , Respiración , Esteroides/uso terapéutico , Tasa de Supervivencia , Temperatura , Resultado del TratamientoAsunto(s)
Humanos , Niño , Bronquiolitis/clasificación , Bronquiolitis/complicaciones , Bronquiolitis/diagnóstico , Bronquiolitis/tratamiento farmacológico , Bronquiolitis/epidemiología , Bronquiolitis/etiología , Bronquiolitis/mortalidad , Bronquiolitis/fisiopatología , Bronquiolitis/terapia , Virus Sincitial Respiratorio Humano/patogenicidadRESUMEN
During a 3-year survey of 805 children with acute lower respiratory tract infection (ALRI) who were admitted to three hospitals in Buenos Aires, 31 fatal cases were recorded--a fatality rate of 3.8%. Of the 31 children who died, 77% were less than 1 year of age, 48% were boys, 58% were malnourished, 29% had previous respiratory disease, and 22% had previous congenital disease. All children who died had clinical diagnoses of pneumonia (71%) or bronchiolitis (29%). Autopsies were performed in 14 of the cases. Viral etiology was determined by both cell culture and indirect immunofluorescence (IIF) assay of either nasopharyngeal aspirates (NPA) or lung tissue and bacterial etiology was determined by isolation of organisms from blood, lung tissue, and/or pleural fluid. NPA was examined for Bordetella pertussis by IIF. Pathogens were identified in 65% of fatal cases. Seven cases were bacterial; seven cases were viral; and six cases resulted from mixed infections. Lung tissue yielded positive etiologic results in 10 of 13 cases. Histopathologic examination performed on specimens from the 14 autopsied children revealed necrotizing bronchiolitis with intranuclear inclusions (n = 5) and multifocal pneumonia (n = 9).
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Bronquiolitis/mortalidad , Pulmón/patología , Neumonía/mortalidad , Infecciones del Sistema Respiratorio/mortalidad , Enfermedad Aguda , Factores de Edad , Argentina , Infecciones Bacterianas/complicaciones , Infecciones Bacterianas/mortalidad , Infecciones Bacterianas/patología , Bronquiolitis/complicaciones , Bronquiolitis/patología , Preescolar , Femenino , Cardiopatías Congénitas/complicaciones , Humanos , Lactante , Recién Nacido , Recien Nacido Prematuro , Masculino , Trastornos Nutricionales/complicaciones , Neumonía/complicaciones , Neumonía/patología , Infecciones del Sistema Respiratorio/complicaciones , Infecciones del Sistema Respiratorio/patología , Virosis/complicaciones , Virosis/mortalidad , Virosis/patologíaRESUMEN
This paper summarizes the first study on clinical, etiologic, and epidemiologic features of acute lower respiratory tract infection (ALRI) in children in Argentina. A total of 1,003 children less than 5 years of age (805 inpatients and 198 outpatients) presenting with ALRI were studied during a 40-month period. Nasopharyngeal aspirate (NPA), blood, urine, and throat-swab samples were collected when each child was first seen for care. Virologic studies were performed on the NPA by means of indirect immunofluorescence and isolation of virus in cell culture. Bacteriologic studies primarily were done by means of culture of blood or pleural fluid (when available); Bordetella pertussis and Mycoplasma pneumoniae, however, were searched for by the use of immunofluorescence and complement-fixation testing, respectively, in paired sera. Respiratory syncytial virus was the most commonly isolated virus, followed by adenovirus, parainfluenza virus, and influenza virus. Streptococcus pneumoniae was the most frequently isolated bacterium, followed by B. pertussis and Haemophilus influenzae type b. Overall, the patient fatality rate was 3.8% among inpatients with pneumonia or bronchiolitis.