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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]?

Clinical Scenario

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.

Search Strategy

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

Search Outcome

5 papers

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Beasley and Jones, 1981	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 2005	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 2008	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 2008	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 2008	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

Comment(s)

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

Editor Comment

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).

References

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2. 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.
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12. 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.
13. 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.
14. 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.
15. Nagakumar P, Doull I. Current therapy for bronchiolitis. Arch Dis Child 2012;97:827–30.
16. Shay DK, Holman RC, Newman RD, et al. Bronchiolitis-associated hospitalizations among US children, 1980–1996. JAMA 1999;282:1440–6.
17. 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.
18. 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
19. 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.
20. Chalom R, Raphaely RC, Costarino AT Jr. Hospital costs of pediatric intensive care. Crit Care Med 1999;27:2079–85.
21. Beasley JM, Jones SME. CPAP in bronchiolitis. BMJ 1981;283:1506–8.
22. 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.
23. 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.
24. 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.
25. 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.
26. McKiernan C, Chua LC, Visintainer PF, et al. High Flow Nasal Cannulae Therapy in Infants with Bronchiolitis. J Pediatr 2010;156:634–8.
27. 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.