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J Pediatr Intensive Care 2024; 13(01): 007-017
DOI: 10.1055/s-0041-1735873
Original Article

Association of Fluid Overload with Escalation of Respiratory Support and Endotracheal Intubation in Acute Bronchiolitis Patients

Orkun Baloglu 
1   Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
,
Lauren K. Flagg
1   Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
,
Ahmad Suleiman
1   Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
,
Vedant Gupta
1   Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
,
Jamie A. Fast
1   Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
,
Lu Wang
2   Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United States
,
Sarah Worley
2   Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United States
,
Hemant S. Agarwal
1   Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
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Abstract

Fluid overload has been associated with increased oxygen requirement, prolonged duration of mechanical ventilation, and longer length of hospital stay in children hospitalized with pulmonary diseases. Critically ill infants with bronchiolitis admitted to the pediatric intensive care unit (PICU) also tend to develop fluid overload and there is limited information of its role on noninvasive respiratory support. Thus, our primary objective was to study the association of fluid overload in patients with bronchiolitis admitted to the PICU with respiratory support escalation (RSE) and need for endotracheal intubation (ETI). Infants ≤24 months of age with bronchiolitis and admitted to the PICU between 9/2009 and 6/2015 were retrospectively studied. Demographic variables, clinical characteristics including type of respiratory support and need for ETI were evaluated. Fluid overload as assessed by net fluid intake and output (net fluid balance), cumulative fluid balance (CFB) (mL/kg), and percentage fluid overload (FO%), was compared between patients requiring and not requiring RSE and among patients requiring ETI and not requiring ETI at 0 (PICU admission), 12, 24, 36, 48, 72, 96, and 120 hours. One-hundred sixty four of 283 patients with bronchiolitis admitted to the PICU qualified for our study. Thirty-four of 164 (21%) patients required escalation of respiratory support within 5 days of PICU admission and of these 34 patients, 11 patients required ETI. Univariate analysis by Kruskal-Wallis test of fluid overload as assessed by net fluid balance, CFB, and FO% between 34 patients requiring and 130 patients not requiring RSE and among 11 patients requiring ETI and 153 patients not requiring ETI, at 0, 12, 24, 36, 48, 72, 96 and 120 hours did not reveal any significant difference (p >0.05) at any time interval. Multivariable logistic regression analysis revealed higher PRISM score (odds ratio [OR]: 4.95, 95% confidence interval [95% CI]: 1.79–13.66; p = 0.002), longer hours on high flow nasal cannula (OR: 4.86, 95% CI: 1.68–14.03; p = 0.003) and longer hours on noninvasive ventilation (OR: 11.16, 95% CI: 3.36–36.98; p < 0.001) were associated with RSE. Fluid overload as assessed by net fluid balance, CFB, and FO% was not associated with RSE or need for ETI in critically ill bronchiolitis patients admitted to the PICU. Further prospective studies involving larger number of patients with bronchiolitis are needed to corroborate our findings.

Keywords

bronchiolitis - fluid overload - endotracheal intubation - respiratory support - pediatric intensive care unit

Supplementary Material



Publication History

Received: 06 May 2021

Accepted: 05 August 2021

Article published online:
14 September 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Davis AL, Carcillo JA, Aneja RK. et al. American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal shock. Crit Care Med 2017; 45 (06) 1061-1093
    Google Scholar
  • 2 Alobaidi R, Morgan C, Basu RK. et al. Association between fluid balance and outcomes in critically ill children: a systemic review and meta-analysis. JAMA Pediatr 2018; 172 (03) 257-268
    Google Scholar
  • 3 Kantor DB, Hirshberg EL, McDonald MC. et al. Fluid balance is associated with clinical outcomes and extravascular lung water in children with acute asthma exacerbation. Am J Respir Crit Care Med 2018; 197 (09) 1128-1135
    Google Scholar
  • 4 Valentine SL, Sapru A, Higgerson RA. et al; Pediatric Acute Lung Injury and Sepsis Investigator's (PALISI) Network, Acute Respiratory Distress Syndrome Clinical Research Network (ARDSNet). Fluid balance in critically ill children with acute lung injury. Crit Care Med 2012; 40 (10) 2883-2889
    Google Scholar
  • 5 Flori HR, Church G, Liu KD, Gildengorin G, Matthay MA. Positive fluid balance is associated with higher mortality and prolonged mechanical ventilation in pediatric patients with acute lung injury. Crit Care Res Pract 2011; 2011: 854142
    Google Scholar
  • 6 Arikan AA, Zappitelli M, Goldstein SL, Naipaul A, Jefferson LS, Loftis LL. Fluid overload is associated with impaired oxygenation and morbidity in critically ill children. Pediatr Crit Care Med 2012; 13 (03) 253-258
    Google Scholar
  • 7 Willson DF, Thomas NJ, Tamburro R. et al; Pediatric Acute Lung and Sepsis Investigators Network. The relationship of fluid administration to outcome in the pediatric calfactant in acute respiratory distress syndrome trial. Pediatr Crit Care Med 2013; 14 (07) 666-672
    Google Scholar
  • 8 Flores-González JC, Valladares CM, Yun Castilla C. et al; Bronquiolitis en la Unidad de Cuidados Intensivos Pediátricos (BRUCIP) WorkGroup. Association of fluid overload with clinical outcomes in critically ill children with bronchiolitis. Bronquiolitis en la Unidad de Cuidados Intensivos Pediatricos (BRUCIP) study. Pediatr Crit Care Med 2019; 20 (03) e130-e136
    Google Scholar
  • 9 Ferlini R, Pinheiro FO, Andreolio C, Carvalho PR, Piva JP. Characteristics and progression of children with acute viral bronchiolitis subjected to mechanical ventilation. Rev Bras Ter Intensiva 2016; 28 (01) 55-61
    Google Scholar
  • 10 Mitting RB, Peshimam N, Lillie J. et al. Invasive mechanical ventilation for acute viral bronchiolitis: retrospective multicenter cohort study. Pediatr Crit Care Med 2021; 22 (03) 231-240
    Google Scholar
  • 11 Ingelse SA, Wiegers HM, Calis JC, van Woensel JB, Bem RA. Early fluid overload prolongs mechanical ventilation in children with viral-lower respiratory tract disease. Pediatr Crit Care Med 2017; 18 (03) e106-e111
    Google Scholar
  • 12 Jain S, Williams DJ, Arnold SR. et al; CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med 2015; 372 (09) 835-845
    Google Scholar
  • 13 Ralston SL, Lieberthal AS, Meissner HC. et al; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 2014; 134 (05) e1474-e1502
    Google Scholar
  • 14 Friedman JN, Rieder MJ, Walton JM. Canadian Paediatric Society, Acute Care Committee, Drug Therapy and Hazardous Substances Committee. Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age. Paediatr Child Health 2014; 19 (09) 485-498
    Google Scholar
  • 15 Bronchiolitis in children: diagnosis and management. National Institute for Health and Care Excellence.. NICE guideline; June 01, 2015. Accessed on August 7, 2021 at: https://www.nice.org.uk/Guidance/NG9
    Google Scholar
  • 16 Pelletier JH, Au AK, Fuhrman D, Clark RSB, Horvat C. Trends in bronchiolitis ICU admissions and ventilation practices: 2010–2019. Pediatrics 2021; 147 (06) e202003915
    Google Scholar
  • 17 Schlapbach LJ, Straney L, Gelbart B. et al; Australian & New Zealand Intensive Care Society (ANZICS) Centre for Outcomes & Resource Evaluation (CORE) and the Australian & New Zealand Intensive Care Society (ANZICS) Paediatric Study Group. Burden of disease and change in practice in critically ill infants with bronchiolitis. Eur Respir J 2017; 49 (06) 1601648
    Google Scholar
  • 18 Linssen RS, Bem RA, Kapitein B. et al; PICE Study Group. Burden of respiratory syncytial virus bronchiolitis on the Dutch pediatric intensive care units. Eur J Pediatr 2021; (e-pub ahead of print) DOI: 10.1007/s00431-021-04079-y.
    Google Scholar
  • 19 Ganu SS, Gautam A, Wilkins B, Egan J. Increase in use of non-invasive ventilation for infants with severe bronchiolitis is associated with decline in intubation rates over a decade. Intensive Care Med 2012; 38 (07) 1177-1183
    Google Scholar
  • 20 Fujiogi M, Goto T, Yasunaga H. et al. Trends in bronchiolitis hospitalizations in the United States: 2000–2016. Pediatrics 2019; 144 (06) e20192614
    Google Scholar
  • 21 Clayton JA, McKee B, Slain KN, Rotta AT, Shein SL. Outcomes of children with bronchiolitis treated with high-flow nasal cannula or noninvasive positive pressure ventilation. Pediatr Crit Care Med 2019; 20 (02) 128-135
    Google Scholar
  • 22 Soshnick SH, Carroll CL, Cowl AS. Increased use of noninvasive ventilation associated with decreased use of invasive devices in children with bronchiolitis. Crit Care Explor 2019; 1 (08) e0026
    Google Scholar
  • 23 Fainardi V, Abelli L, Muscarà M, Pisi G, Principi N, Esposito S. Update on the role of high-flow nasal cannula in infants with bronchiolitis. Children (Basel) 2021; 8 (02) 66
    Google Scholar
  • 24 Essouri S, Laurent M, Chevret L. et al. Improved clinical and economic outcomes in severe bronchiolitis with pre-emptive nCPAP ventilatory strategy. Intensive Care Med 2014; 40 (01) 84-91
    Google Scholar
  • 25 Schibler A, Pham TM, Dunster KR. et al. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Med 2011; 37 (05) 847-852
    Google Scholar
  • 26 Franklin D, Babl FE, Schlapbach LJ. et al. A randomized trial of high-flow nasal oxygen therapy in infants with bronchiolitis. N Engl J Med 2018; 378 (12) 1121-1131
    Google Scholar
  • 27 Yurtseven A, Turan C, Erseven E, Saz EU. Comparison of heated humidified high-flow nasal cannula flow rates (1-L·kg·min−1 vs 2-L·kg·min −1 ) in the management of acute bronchiolitis. Pediatr Pulmonol 2019; 54 (06) 894-900
    Google Scholar
  • 28 Johnson DW, Adair C, Brant R, Holmwood J, Mitchell I. Differences in admission rates of children with bronchiolitis by pediatric and general emergency departments. Pediatrics 2002; 110 (04) e49
    Google Scholar
  • 29 Daneshmand KA, Zaritsky AL, Lamb MA. et al. Plasma concentration of N-terminal pro-brain natriuretic peptides and fluid balance in children with bronchiolitis. J Pediatr Intensive Care 2012; 1: 143-151
    Google Scholar
  • 30 Poddar U, Singhi S, Ganguli NK, Sialy R. Water electrolyte homeostasis in acute bronchiolitis. Indian Pediatr 1995; 32 (01) 59-65
    Google Scholar
  • 31 Gozal D, Colin AA, Jaffe M, Hochberg Z. Water, electrolyte, and endocrine homeostasis in infants with bronchiolitis. Pediatr Res 1990; 27 (02) 204-209
    Google Scholar
  • 32 van Steensel-Moll HA, Hazelzet JA, van der Voort E, Neijens HJ, Hackeng WH. Excessive secretion of antidiuretic hormone in infections with respiratory syncytial virus. Arch Dis Child 1990; 65 (11) 1237-1239
    Google Scholar
  • 33 Goldstein SL, Currier H, Graf Cd, Cosio CC, Brewer ED, Sachdeva R. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 2001; 107 (06) 1309-1312
    Google Scholar
  • 34 Pham H, Thompson J, Wurzel D, Duke T. Ten years of severe respiratory syncytial virus infections in a tertiary paediatric intensive care unit. J Paediatr Child Health 2020; 56 (01) 61-67
    Google Scholar
  • 35 Nishimura M. High-flow nasal cannula oxygen therapy in adults. J Intensive Care 2015; 3 (01) 15
    Google Scholar
  • 36 Sarkar M, Sinha R, Roychowdhoury S. et al. Comparative study between noninvasive continuous positive airway pressure and hot humidified high-flow nasal cannulae as a mode of respiratory support in infants with acute bronchiolitis in pediatric intensive care unit of a tertiary hospital. Indian J Crit Care Med 2018; 22 (02) 85-90
    Google Scholar
  • 37 Kepreotes E, Whitehead B, Attia J. et al. High-flow warm humidified oxygen versus standard low-flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomised controlled trial. Lancet 2017; 389 (10072): 930-939
    Google Scholar
  • 38 Milési C, Essouri S, Pouyau R. et al; Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP). High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: a multicenter randomized controlled trial (TRAMONTANE study). Intensive Care Med 2017; 43 (02) 209-216
    Google Scholar
  • 39 Habra B, Janahi IA, Dauleh H, Chandra P, Veten A. A comparison between high-flow nasal cannula and noninvasive ventilation in the management of infants and young children with acute bronchiolitis in the PICU. Pediatr Pulmonol 2020; 55 (02) 455-461
    Google Scholar
  • 40 Florin TA, Plint AC, Zorc JJ. Viral bronchiolitis. Lancet 2017; 389 (10065): 211-224
    Google Scholar
  • 41 Korppi M. Therapeutic strategies for pediatric bronchiolitis. Expert Rev Respir Med 2019; 13 (01) 95-103
    Google Scholar
  • 42 Stocks J. Effect of nasogastric tubes on nasal resistance during infancy. Arch Dis Child 1980; 55 (01) 17-21
    Google Scholar
  • 43 Khoshoo V, Edell D. Previously healthy infants may have increased risk of aspiration during respiratory syncytial viral bronchiolitis. Pediatrics 1999; 104 (06) 1389-1390
    Google Scholar
  • 44 Oakley E, Borland M, Neutze J. et al; Paediatric Research in Emergency Departments International Collaborative (PREDICT). Nasogastric hydration versus intravenous hydration for infants with bronchiolitis: a randomised trial. Lancet Respir Med 2013; 1 (02) 113-120
    Google Scholar
  • 45 Ingelse SA, Geukers VG, Dijsselhof ME, Lemson J, Bem RA, van Woensel JB. Less is more - a feasibility study of fluid strategy in critically ill children with acute respiratory tract infection. Front Pediatr 2019; 7: 496
    Google Scholar
  • 46 Meissner HC. Viral bronchiolitis in children. N Engl J Med 2016; 374 (01) 62-72
    Google Scholar
  • 47 Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med 2000; 342 (18) 1334-1349
    Google Scholar
  • 48 Ware LB, Matthay MA. Alveolar fluid clearance is impaired in the majority of patients with acute lung injury and the acute respiratory distress syndrome. Am J Respir Crit Care Med 2001; 163 (06) 1376-1383
    Google Scholar
  • 49 Kulkarni M, Slain KN, Rotta AT, Shein SL. The effects of furosemide on oxygenation in mechanically ventilated children with bronchiolitis. J Pediatr Intensive Care 2020; 9 (02) 87-91
    Google Scholar
  • 50 Bontant T, Matrot B, Abdoul H. et al. Assessing fluid balance in critically ill pediatric patients. Eur J Pediatr 2015; 174 (01) 133-137
    Google Scholar
  • 51 Wise LC, Mersch J, Racioppi J, Crosier J, Thompson C. Evaluating the reliability and utility of cumulative intake and output. J Nurs Care Qual 2000; 14 (03) 37-42
    Google Scholar
  • 52 Fu Q, Chen Z, Fan J. et al. Lung ultrasound methods for assessing fluid volume change and monitoring dry weight in pediatric hemodialysis patients. Pediatr Nephrol 2021; 36 (04) 969-976
    Google Scholar
  • 53 Saunders CE. The use of transthoracic electrical bioimpedance in assessing thoracic fluid status in emergency department patients. Am J Emerg Med 1988; 6 (04) 337-340
    Google Scholar