Nasal CPAP in the Pediatric Ward to Reduce PICU Admissions for Severe Bronchiolitis?
Round 1
Reviewer 1 Report
Dear Editor
thanks for give me the opportunity to review this original article aimed to describe a monocentre experience of CPAP use in a general pediatric ward, with the aim to reduce the pressure on the PICU in recent out-breaks of bronchiolitis.
This experience is very interesting and worthy of publication.
However, I feel that authors should stress some issue:
1. Significant variations in the management of bronchiolitis are often recorded, and, in parallel, to recommend a univocal clinical approach is challenging and still questioned. This situation reflects also the significant differences among the healths services. Thus, it is appears how is crucial to implement strategies to standardize care and improve the quality of care. Please, cite : Manti S, et al. Agreements and controversies of national guidelines for bronchiolitis: Results from an Italian survey. Immun Inflamm Dis. 2021 Dec;9(4):1229-1236. doi: 10.1002/iid3.451
2. Please, to be more objective, authors should highlight also the indications, benefits as well as the risks and contraindications related to the use of ventilatory support. Please refer to:
a) Nolasco S, et al. High-Flow Nasal Cannula Oxygen Therapy: Physiological Mechanisms and Clinical Applications in Children. Front Med (Lausanne). 2022 Jun 3;9:920549. doi: 10.3389/fmed.2022.920549. PMID: 35721052; PMCID: PMC9203852.
b)Fainardi V, et al. Update on the Role of High-Flow Nasal Cannula in Infants with Bronchiolitis. Children (Basel). 2021 Jan 20;8(2):66. doi: 10.3390/children8020066.
Author Response
- Significant variations in the management of bronchiolitis are often recorded, and, in parallel, to recommend a univocal clinical approach is challenging and still questioned. This situation reflects also the significant differences among the healths services. Thus, it is appears how is crucial to implement strategies to standardize care and improve the quality of care. Please, cite : Manti S, et al. Agreements and controversies of national guidelines for bronchiolitis: Results from an Italian survey. Immun Inflamm Dis. 2021 Dec;9(4):1229-1236. doi: 10.1002/iid3.451
Re.: This was done, and the paper by Manti et al. is now cited as Ref. 21
- Please, to be more objective, authors should highlight also the indications, benefits as well as the risks and contraindications related to the use of ventilatory support. Please refer to:
a) Nolasco S, et al. High-Flow Nasal Cannula Oxygen Therapy: Physiological Mechanisms and Clinical Applications in Children. Front Med (Lausanne). 2022 Jun 3;9:920549. doi: 10.3389/fmed.2022.920549. PMID: 35721052; PMCID: PMC9203852.
b) Fainardi V, et al. Update on the Role of High-Flow Nasal Cannula in Infants with Bronchiolitis. Children (Basel). 2021 Jan 20;8(2):66. doi: 10.3390/children8020066.
Re.: We thank the reviewer for allowing us to make a more balanced discussion of pros and cons of this approach. The papers by Nolasco et al. and Fainardi et al., have now been introduced and cited as Refs 35 and 36.
Reviewer 2 Report
The topic is up-to-date and proposes a relatively fast solution for a burning problem. I still think it can be applied in only some pediatric wards with better equipment and specially trained staff.
According to the groups studied it seems to me that the nCPAP group consists of patients with worse initial symptoms and vital parameters.
I think that in Table 2 there are some repeated rows - e.g. "To" - Respiratory rate, Heart rate.
I think that the manuscript is important for the pediatric audience and adds useful ideas before the coming autumn peak of bronchiolitis.
Author Response
The topic is up-to-date and proposes a relatively fast solution for a burning problem. I still think it can be applied in only some pediatric wards with better equipment and specially trained staff.
According to the groups studied it seems to me that the nCPAP group consists of patients with worse initial symptoms and vital parameters.
Re.: We agree with the reviewer on this issue. Patients addressed to nCPAP have indeed more adverse features, even with statistical significance, as showed in Table 2. Indeed, this was not a randomized assignment to one or another treatment (in that case the differences would have been cause of inappropriate judgement), but simply reflect the attitude of the physician to assign nCPAP as a more “aggressive” and likely effective therapy for that child. Our aim is to evaluate if this approach, i.e. nCPAP, was indeed effective in sparing at least some of the ICU admissions and the related patient referral to another hospital.
I think that in Table 2 there are some repeated rows - e.g. "To" - Respiratory rate, Heart rate.
Re: We removed the repeated rows.
I think that the manuscript is important for the pediatric audience and adds useful ideas before the coming autumn peak of bronchiolitis.
Re.: We thank the reviewer for his favorable evaluation.
Reviewer 3 Report
The Authors undertook a very important issue of ventilatory support in the era of increasing number of bronchiolitis. They describe their experience with CPAP in infants in general pediatric ward. It is a very interesting study and also very brave initiative of the medical team.
My only suggestion would be to report how many of the treated children had coinfection with RSV and SARS Cov19 and how did this influence their outcome.
Author Response
The Authors undertook a very important issue of ventilatory support in the era of increasing number of bronchiolitis. They describe their experience with CPAP in infants in general pediatric ward. It is a very interesting study and also very brave initiative of the medical team.
My only suggestion would be to report how many of the treated children had coinfection with RSV and SARS Cov19 and how did this influence their outcome.
Re.: We thank the reviewer for his favorable evaluation. Overall, coinfection with RSV and SARS-CoV-2 was observed in 3 patients and SARS-CoV-2 infection in 2 patients. None of them required any type of oxygen or ventilatory support.
This information was introduced in the results section.
Reviewer 4 Report
Clinical data of patients less than 12 months of age, admitted for bronchiolitis were retrospectively collected. Eighty-two infants were admitted for bronchiolitis, 16 (19.5%) of them were treated with nasal CPAP (nCPAP group) and 66 with only LFNC and/or HFNC or without oxygen support (no-nCPAP group). Only 18.7% infants in the nCPAP group were referred to pediatric intensive care unit due to worsening clinical conditions despite nCPAP support. The nCPAP group had a significantly lower mean weight 5,4kg vs the non-CPAP-group 6,6kg. Further, chest X-ray was taken in 56% in the nCPAP group vs 14% in the no-nCPAP-group. This probably means that the no-nCPAP group had a milder disease than the CPAP group. This is an interesting study on nCPAP use to treat bronchiolitis in children. I would like to pay attention into a few comments in below.
Major
- PICU, LFNC and HFNC as abbreviations should be explained when it is first used. They are used in the abstract for the first time.
- ‘After a preliminary experience, during the 2021-2022 RSV outbreak, of nasal CPAP (nCPAP) usage in our pediatric ward, we decided to replicate during the 2022-2023 epidemics, to reduce PICU requirement in an epidemiological situation that predicted an overload of patients for PICUs.’ Please, check the language and consider dividing the sentence into two.
- ‘Clinical data of patients less than 12 months of age, hospitalized for bronchiolitis from 1 October 2021 to 31 March 2023 were collected.’ Were these all the patients hospitalized because of bronchiolitis in this hospital during that time or were some of the patients left out study? If this was only part of the patients, please, explain the inclusion and the exclusion criteria.
- The diagnosis of bronchiolitis was made on a clinical basis. Is there a possibility for bias in here? If there is a possibility for bias, please discuss how it may affect the results.
- Where any of the children started immediately nCPAP or did all the patients receive first LFNC or HFNC? Please, add this information.
- ‘HFNC was the first respiratory support in 44% of children in the nCPAP group and in 23% of those in the no-nCPAP group (p=0.019).’ This is contradictory to the Table 2, where the percentages are 50% and 18%, accordingly. Please, check this and correct.
- Did the infants receive glucocorticoids, other medications (e.g. beta-2-agonists), antimicrobial agents or antiviral therapy? Please, consider adding this information.
- What were the comorbidities of the infants? Please, consider adding this information.
- Were all the LFNC, HFNC and CPAP given before transferring the three patients to the PICU? Should there be information on treatment in the PICU and after PICU? Please, consider this.
- ‘In our experience, the use of nCPAP in pediatric ward allowed us to avoid about 80% of PICU transfers for bronchiolitis.’ Does this mean that without nCPAP in the ward, all the patients in the nCPAP group would have needed PICU? Please, explain the basis for this estimation or calculation.
- ‘It was also envisaged that the nurse-patient ratio, usually 1:6, could be increased to 1:4 according to variable needs of assistance.’ Does this mean that there were first six babies for one nurse and later four babies for one nurse. The meaning of this sentence was not quite clear for me, unfortunately. Please, check this.
Please, take a look at the comments to the Authors.
Author Response
1) PICU, LFNC and HFNC as abbreviations should be explained when it is first used. They are used in the abstract for the first time.
Re: We thank the reviewer for his suggestions: abbreviations have been explained.
2) ‘After a preliminary experience, during the 2021-2022 RSV outbreak, of nasal CPAP (nCPAP) usage in our pediatric ward, we decided to replicate during the 2022-2023 epidemics, to reduce PICU requirement in an epidemiological situation that predicted an overload of patients for PICUs.’ Please, check the language and consider dividing the sentence into two.
Re: We thank the reviewer for his suggestions: this was done.
3) ‘Clinical data of patients less than 12 months of age, hospitalized for bronchiolitis from 1 October 2021 to 31 March 2023 were collected.’ Were these all the patients hospitalized because of bronchiolitis in this hospital during that time or were some of the patients left out study? If this was only part of the patients, please, explain the inclusion and the exclusion criteria.
Re: We thank the reviewer for his suggestions: we considered all children hospitalized for bronchiolitis less 12 months old. There were no excluded patients. We added this information.
4) The diagnosis of bronchiolitis was made on a clinical basis. Is there a possibility for bias in here? If there is a possibility for bias, please discuss how it may affect the results.
Re: The diagnosis of bronchiolitis was made on a clinical basis in children admitted to the Emergency Room (ER) with compatible respiratory symptoms: rhinitis, wheezing, respiratory distress, auscultatory findings of crackles and wheezing in multiple lung fields. Thus, no significant bias is expected.
5) Where any of the children started immediately nCPAP or did all the patients receive first LFNC or HFNC? Please, add this information.
Re: We thank the reviewer for his suggestions. We add in Results section this information, previously described only in Table 2.
When admitted, all patients in the nCPAP group received some kind of respiratory support (LFNC, HFNC or nCPAP), while only 27/66 (41%) infants of the no-nCPAP group were supported with LFNC or HFNC. HFNC was the first respiratory support in 8 (50%) of children in the nCPAP group and in 18% of those in the no-nCPAP group (p=0.019). One infant in the nCPAP group received nCPAP as the first respiratory support, 7 (44%) were treated with LFNC as first support and 8 (50%) received first HFNC. As second respiratory support 9 patients received nCPAP and 6 patients received HFNC. nCPAP was the third respiratory support in 6 patients. Total length of support was slightly longer in nCPAP than in no-nCPAP group (p=0.07), while total stay in pediatric ward was significantly longer in nCPAP group (p<0.001). Due to worsening clinical conditions despite support with nCPAP, 3/16 (18.7%) infants were referred to PICU after 1, 2 and 4 days of stay in the pediatric ward respectively.
6) ‘HFNC was the first respiratory support in 44% of children in the nCPAP group and in 23% of those in the no-nCPAP group (p=0.019).’ This is contradictory to the Table 2, where the percentages are 50% and 18%, accordingly. Please, check this and correct.
Re: We thank the reviewer: this was done
7) Did the infants receive glucocorticoids, other medications (e.g. beta-2-agonists), antimicrobial agents or antiviral therapy? Please, consider adding this information.
Re: We thank the reviewer for his suggestion. We added these informations.
Of 82 patients considered, 32 (39%) received glucocorticoids, 48 (58%) received inhaled therapy (salbutamol, adrenalin) and 22 (27%), received at least one dose of antibiotic therapy. No one received antiviral therapy. In nCPAP-group 3 (19%) patients received antibiotic therapy, 4 (25%) received glucocorticoids, 3 (19%) received inhaled therapy.
8) What were the comorbidities of the infants? Please, consider adding this information.
Re: We thank the reviewer: this was done.
In the nCPAP group 2 patients were late preterm and 1 was affected by atrioventricular canal defect in cromosomopathy.
9) Were all the LFNC, HFNC and CPAP given before transferring the three patients to the PICU? Should there be information on treatment in the PICU and after PICU? Please, consider this.
Re: We thank the reviewer.
About three children who required to be referred to PICU, the first patient was a 29 days-old, born late preterm at 36+2; who received first HFNC than nCPAP support, arrived in PICU he continued CPAP support. The second patient was a 20 days-old neonate without risk factor: the patient received first HFNC than nCPAP. When he arrived in PICU, received CPAP support. The third patient was a 7 months-old, with atrioventricular canal defect in cromosomopathy who received fisrt LFNC then nCPAP. After PICU transfer the patient required invasive support and later extra-corporeal membrane oxigenation. First and second patients had been discharged after some days in good clinical conditions, the third patients died two months later.
10) ‘In our experience, the use of nCPAP in pediatric ward allowed us to avoid about 80% of PICU transfers for bronchiolitis.’ Does this mean that without nCPAP in the ward, all the patients in the nCPAP group would have needed PICU? Please, explain the basis for this estimation or calculation.
Re: We thank the reviewer for his suggestions.
Before starting to use nCPAP in the pediatric department, all patients who did not clinically improve with HFNC were transferred to the pediatric intensive care unit. With the start of the use of nCPAP in pediatric ward, only 3/16 (20%) of patients were transferred to Intensive care unit.
11) ‘It was also envisaged that the nurse-patient ratio, usually 1:6, could be increased to 1:4 according to variable needs of assistance.’ Does this mean that there were first six babies for one nurse and later four babies for one nurse. The meaning of this sentence was not quite clear for me, unfortunately. Please, check this.
Re: We thank the reviewer: this was done
