Pierce Heather C, Mansbach Jonathan M, Fisher Erin S, Macias Charles G, Pate Brian M, Piedra Pedro A, Sullivan Ashley F, Espinola Janice A, Camargo Carlos A
Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, California;
Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts;
Hosp Pediatr. 2015 Apr;5(4):175-84. doi: 10.1542/hpeds.2014-0125.
To determine the extent of variability in testing and treatment of children with bronchiolitis requiring intensive care.
This prospective, multicenter observational study included 16 academic children's hospitals across the United States during the 2007 to 2010 fall and winter seasons. The study included children<2 years old hospitalized with bronchiolitis who required admission to the ICU and/or continuous positive airway pressure (CPAP) within 24 hours of admission. Among the 2207 enrolled patients with bronchiolitis, 342 children met inclusion criteria. Clinical data and nasopharyngeal aspirates were collected.
Respiratory distress severity scores and intraclass correlation coefficients were calculated. The study patients' median age was 2.6 months, and 59% were male. Across the 16 sites, the median respiratory distress severity score was 5.1 (interquartile range: 4.5-5.4; P<.001). The median value of the percentages for all sites using CPAP was 15% (range: 3%-100%), intubation was 26% (range: 0%-100%), and high-flow nasal cannula (HFNC) was 24% (range: 0%-94%). Adjusting for site-specific random effects (as well as children's demographic characteristics and severity of bronchiolitis), the intraclass correlation coefficient for CPAP and/or intubation was 21% (95% confidence interval: 8-44); for HFNC, it was 44.7% (95% confidence interval: 24-67).
In this multicenter study of children requiring intensive care for bronchiolitis, we identified substantial institutional variability in testing and treatment, including use of CPAP, intubation, and HFNC. These differences were not explained by between-site differences in patient characteristics, including severity of illness. Further research is needed to identify best practices for intensive care interventions for this major cause of pediatric hospitalization.
确定需要重症监护的毛细支气管炎患儿在检查和治疗方面的变异程度。
这项前瞻性、多中心观察性研究纳入了2007年至2010年秋冬季节美国16家学术性儿童医院。研究对象为2岁以下因毛细支气管炎住院且入院24小时内需入住重症监护病房（ICU）和/或接受持续气道正压通气（CPAP）的患儿。在2207名登记的毛细支气管炎患者中，342名儿童符合纳入标准。收集了临床数据和鼻咽吸出物。
计算了呼吸窘迫严重程度评分和组内相关系数。研究患者的中位年龄为2.6个月，59%为男性。在16个研究地点中，呼吸窘迫严重程度评分的中位数为5.1（四分位间距：4.5 - 5.4；P <.001）。所有地点使用CPAP的百分比中位数为15%（范围：3% - 100%），插管为26%（范围：0% - 100%），高流量鼻导管（HFNC）为24%（范围：0% - 94%）。调整特定地点的随机效应（以及儿童的人口统计学特征和毛细支气管炎的严重程度）后，CPAP和/或插管的组内相关系数为21%（95%置信区间：8 - 44）；HFNC的组内相关系数为44.7%（95%置信区间：24 - 67）。
在这项针对需要重症监护的毛细支气管炎患儿的多中心研究中，我们发现检查和治疗方面存在显著的机构差异，包括CPAP、插管和HFNC的使用。这些差异无法通过患者特征（包括疾病严重程度）在不同地点之间的差异来解释。需要进一步研究以确定针对小儿住院的这一主要原因进行重症监护干预的最佳做法。
