Three Part Question
In [an infant less than 2 years old with bronchiolitis] will [early use of CPAP] reduce [the need for intubation and ventilation]?
You are asked to see a 2-month-old boy who has been ill for 3 days. He has respiratory syncytial virus positive bronchiolitis and is needing 1.5 L/min oxygen by low flow. His capillary blood gas has pH 7.26 pCO2 9.9 kPa pO2 4.5 kPa and base excess −5.0. His respiratory rate is 60 and increasing. The family has been told he may need moving to 40 miles to the regional paediatric intensive care unit (PICU). They are worried and angry, not least because his sister is delivering a baby upstairs.
You wonder whether starting continuous positive airway pressure (CPAP) will reduce the need for ventilation and help keep them together.
Medline, CINAHL and EMbase were searched for the term, “Bronchiolitis” “Continuous Positive Airway Pressure” and “CPAP”. The search for, “Bronchiolitis,” was then combined with each of the other three terms. These results were then limited to “Human” and “Below 23 months” or “Infants” “Bronchiolitis” and “CPAP” or “Continuous Positive Airway Pressure”. Twenty-four papers using Medline, four using CINAHL and none using EMBASE were identified.
The four “CPAP” papers identified using CINAHL were duplicates of the four papers identified using Medline. Four of the 24 papers identified using Medline were duplicates. Thirteen of the remaining 20 were excluded on titles or abstracts, two further on full-text review, leaving seven papers to review. Citation searching led to one further study
|Author, date and country
||Study type (level of evidence)
|Beasley and Jones, |
|Case series of 23 patients over 5 years referred to PICU||Retrospective cohort||9/23 were intubated and ventilated||14/23 (60%) did not require ventilation||Supportive evidence but not proof that CPAP prevents the need for ventilation|
|Pirret et al|
|Case series 35 infants less than 12 months old||Case series ||20/35 (57.4%) did not require ventilation||20/35 (57.4%) did not require ventilation||Nasal bubble CPAP may prevent intubation|
|Javouhey et al|
|Outcomes compared to a year of practice using CPAP and non invasive Bi-PAP retrospectively compared to a year when traditional intubation and ventilation was used||Case series with historical controls||NIV reduced intubation rate NIV reduced ventilator dependent pneumonia NIV reduced oxygen dependency Did not increase length of stay||47% intubated in NIV period compared to 89% in traditional ventilation group (p<0.01)||NIV is not exclusively CPAP but this suggests early CPAP may prevent some intubations|
|Thia et al|
|31 children under 1 year of age with bronchiolitis and capillary pCO2 > 6.0 kPa. Comparing nasal CPAP and standard treatment for 12 h||Randomised crossover trial ||CPAP significantly reduced CO2 compared to standard treatment. When CPAP was used first the difference in CO2 was greater compared to using it second||When used first CPAP reduced CO2 by 1.53 kPa compared to standard treatment (p<0.01)||Evidence that especially early CPAP reduces CO2|
|Cambonie et al|
|12 RSV positive infants less than 3 months of age with respiratory distress or raised pCO2 >50 mm Hg on nCPAP||Case series||Modified Woods Clinical Asthma Score (mWCAS) measured after 1 h.. mWCAS reduced with CPAP in 11/12||Only reduction accessory muscle use (1.7 to 0.08 p<0.002) and wheezing (1.3 to 0.3 p=0.002) reached significance||Very weak evidence that nasal CPAP improves respiratory function in bronchiolitis|
Bronchiolitis is the most common cause for lower respiratory tract infection (LRTI) during infancy and accounts for majority of hospital admissions during this period in the UK and the USA.16 ,17
The mainstay of treatment is good supportive care.18 There has been interest in using hypertonic saline. A recent Cochrane Review concluded that infants treated with nebulised 3% saline at least every 8 h had a significantly shorter mean length of hospital stay compared to those treated with nebulised 0.9% saline (mean difference −1.16 days, 95% CI −1.55 to −0.77, p<0.00001).19 The results of a large controlled trial of hypertonic saline underway in the UK (SABRE) are eagerly awaited (http://clinicaltrials.gov/ct2/show/NCT01469845).
When oxygen supplementation is insufficient, infants require mechanical ventilation. In the UK, this requires transporting the child to a PICU where beds cost about £2500 a night (Pitilla L, Retrieval Coordinator, PICU, Great North Children's Hospital, Personal Communciation). In the USA costs are similar.20 There is also the cost of transport, inherent risks of road transport, moving a family away from the support of friends and family and the hidden costs of moving parents and carers away from work. Therefore safe minimally invasive techniques that could be managed in the local hospital with high dependency levels of nursing are attractive. CPAP may offer this.
There are three case series suggesting that CPAP reduces the need for ventilation21 – 23 and one randomised crossover trial showing CPAP improves blood gases, pulse and respiratory rate.24
A well-designed and adequately powered randomised controlled trial of standard therapy versus early CPAP would be helpful. This is complicated by the emergence of humidified high flow nasal oxygen (HHFNO), which has been shown to be as safe and effective as CPAP in neonates.25 It is safe and potentially effective in bronchiolitis.26
CPAP, continuous positive airway pressure; NCAP, nasal continuous positive airway pressure; NIV, noninvasive ventilation; PICU, paediatric intensive care unit; RSV, respiratory syncytial virus.
see http://bestbets.org/bets/bet.php?id=735 for earlier/added information
Clinical Bottom Line
Continuous positive airway pressure (CPAP) improves an infant's physiology in bronchiolitis and may reduce the need for ventilation (Grade C).
Pending multi-centre randomised controlled trials of standard therapy versus early CPAP and/or humidified high flow Nasal oxygen, CPAP is an appropriate treatment (Grade C).
- Oakley E, Babl FE, Acworth J, et al. Paediatric Research in Emergency Departments International Collaborative. A prospective randomised trial comparing nasogastric with intravenous hydration in children with bronchiolitis (protocol): BMC Pediatr 2010;10: 1471–2431
- Prado F, Godoy MA, Godoy M, et al. [Pediatric non-invasive ventilation for acute respiratory failure in an Intermediate Care Unit]. [Spanish] Ventilacion no invasiva como tratamiento de la insuficiencia respiratoria aguda en Pediatria. Rev Med Chil 2005;133:525–33.
- Nunes P, Abadesso C, Almeida E, et al. [Non invasive ventilation in a pediatric intensive care unit]. [Portuguese] Ventilacao nao invasiva numa unidade de cuidados intensivos pediatricos. Acta Med Port 2010;23:399–404.
- Teo WY, Rajadurai VS, Sriram B. Morbidity of parainfluenza 3 outbreak in preterm infants in a neonatal unit. Ann Acad Med Singapore 2010;39:837–6.
- Berner ME, Hanquinet S, Rimensberger PC. High frequency oscillatory ventilation for respiratory failure due to RSV bronchiolitis. Intensive Care Med 2008; 34:1698–702.
- Mayordomo-Colunga J, Medina A, Rey C, et al. Helmet-delivered continuous positive airway pressure with heliox in respiratory syncytial virus bronchiolitis. Acta Paediatr 2010;99:308–11.
- Chowdhury MM, McKenzie SA, Pearson CC, et al. Heliox therapy in bronchiolitis: phase III multicenter double-blind randomized controlled trial. Pediatrics 2013;131:661–9.
- Shah PS, Ohlsson A, Shah JP. Continuous negative extrathoracic pressure or continuous positive airway pressure for acute hypoxemic respiratory failure in children. Cochrane Database Syst Rev 2008;(1) (CD003699): 1361–6137.
- Al-balkhi A, Klonin H, Marinaki K, et al. Review of treatment of bronchiolitis related apnoea in two centres. Arch Dis Child 2005;90:288–91.
- Smedsaas-Lofvenberg A, Nilsson K, Moa G, et al. Nebulization of drugs in a nasal CPAP system. Acta Paediatr 1999;88:89–92.
- Duncan AW, Oh TE, Hillman DR. PEEP and CPAP. Anaesth Intensive Care 1986;14:236–50.
- Mansbach JM, Piedra PA, Stevenson MD, et al. MARC-30 Investigators Prospective multicenter study of children with bronchiolitis requiring mechanical ventilation. Pediatrics 2012;130:e492–500.
- Fleming PF, Richards S, Waterman K, et al Use of continuous positive airway pressure during stabilisation and retrieval of infants with suspected bronchiolitis. J Paediatr Child Health 2012;48:1071–5.
- Kim IK, Phrampus E, Sikes K, et al. Helium-oxygen therapy for infants with bronchiolitis: a randomized controlled trial. Arch Pediatr Adolesc Med 2011;165:1115–22.
- Nagakumar P, Doull I. Current therapy for bronchiolitis. Arch Dis Child 2012;97:827–30.
- Shay DK, Holman RC, Newman RD, et al. Bronchiolitis-associated hospitalizations among US children, 1980–1996. JAMA 1999;282:1440–6.
- Deshpande SA, Northern V. The clinical and health economic burden of respiratory syncytial virus disease among children under 2 years of age in a defined geographical area. Arch Dis Child 2003;88:1065–9.
- Scottish Intercollegiate Guideline Network. 91 Bronchiolitis in Children. SIGN. http://sign.ac.uk/guidelines/fulltext/91/index.html (accessed 28 Sep 2013 June 2012).` http://sign.ac.uk/guidelines/fulltext/91/index.html (accessed 28 Sep 2013
- Zhang L, Mendoza-Sassi RA, Wainwright C, et al. Nebulized hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev 2008;(4):CD006458.
- Chalom R, Raphaely RC, Costarino AT Jr. Hospital costs of pediatric intensive care. Crit Care Med 1999;27:2079–85.
- Beasley JM, Jones SME. CPAP in bronchiolitis. BMJ 1981;283:1506–8.
- Pirret AM, Sherring CL, Tai JA, et al. Local experience with the use of nasal bubble CPAP in infants with bronchiolitis admitted to a combined adult/paediatric intensive care unit. Intensive Crit Care Nurs 2005;21:314–19.
- Javouhey E, Barats A, Richard N, et al. Non-invasive ventilation as primary ventilatory support for infants with severe bronchiolitis. Intensive Care Med 2008;34:1608–14.
- Thia LP, McKenzie SA, Blyth TP, et al. Randomised controlled trial of nasal continuous positive airways pressure (CPAP) in bronchiolitis. Arch Dis Child 2008;93:45–7.
- Yoder BA, Stoddard RA, Li M, et al. Heated, Humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates. Pediatrics 2013;131(5):e1482–90.
- McKiernan C, Chua LC, Visintainer PF, et al. High Flow Nasal Cannulae Therapy in Infants with Bronchiolitis. J Pediatr 2010;156:634–8.
- Cambonie G, Milési C, Jaber S, et al. Nasal continuous positive airway pressure decreases respiratory muscles overload in young infants with severe acute viral bronchiolitis. Intensive Care Med 2008; 34:1865–72.