A #PedsICU story about bronchiolitis that may be helpful to my adult colleagues who are struggling with who and when to intubate for #COVID19.

A caveat to this. I know that COVID isn’t bronchiolitis, but there are lessons from this story that might be helpful.

Bronchiolitis is ubiquitous in the winter and is one of the most common causes of admission to a #PedsICU. Most infections are minor and just seem like a “cold”, especially in adults, older children, and toddlers.

But in some infants, these infections can be very serious. About 1-2% of children < 1 year old are hospitalized for bronchiolitis. Each year in the state of Connecticut, where there are about 40,000 infants <1 year old, about 500-700 children are admitted to local hospitals.

Most of those admitted to the regular hospital ward need supplemental oxygen via a nasal cannula. They’re hospitalized for a median of 2-3 days and discharged home. But 1 in 7 of these children admitted to the hospital need to go the ICU.

We/I used to intubate a lot of children with bronchioltiis. It was long standing practice to intubate about half of the children in our ICU for impending respiratory failure, concerns about “tiring out” and “struggling to breathe”. https://pubmed.ncbi.nlm.nih.gov/25158108/ 

But then we did a study with some friends at @YalePediatrics examining the regional practice of how we treated bronchiolitis. https://pubmed.ncbi.nlm.nih.gov/27177013/ 

We found that @YalePediatrics was intubating significantly less children with bronchiolitis despite similar population and illness severity. And by intubating less, their lengths of stays and outcomes were better without any readmissions.

There seemed to be two reasons for these differences. First, use of significantly more non-invasive ventilation (HFNC & CPAP). And second, a conscious decision to have an higher threshold for intubation.

So for the next few bronchiolitis seasons we tried to intubate less. It wasn’t easy. We were used to intubating kids breathing 100-120 times a minute so watching them breathe like this for days was challenging for staff and for families.

It took a lot of education and effort (& a huge culture change), but over time we found that our outcomes significantly improved with increased non-invasive ventilation. https://journals.lww.com/ccejournal/Fulltext/2019/08000/Increased_Use_of_Noninvasive_Ventilation.4.aspx

Differentiating that small population of children who need to be intubated from who can be successfully managed with non-invasive remains challenging. And by trialing non-invasive first, the kids who eventually need intubation seem to more sick

But each member of #PedsICU team can tell stories of kids they were sure would need to be intubated & have bad courses “back in the day” who now leave 2-3 days later happy and smiling.