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Archimedes STRUCTURED CLINICAL QUESTION In an infant less than 2 years old with bronchiolitis will early use of CPAP reduce the need for intubation and ventilation?
SEARCH 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 (table 1).
COMMENTARY
QUESTION 2 Will continuous positive airway pressure reduce the need for ventilation in bronchiolitis?
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 6.0 kPa. Comparing nasal CPAP and standard treatment for 12 h
Case series (4)
20/35 (57.4%) did not require ventilation When used first CPAP reduced CO2 by 1.53 kPa compared to standard treatment (p50 mm Hg on nCPAP
Case series (4)
20/35 (57.4%) did not require ventilation CPAP significantly reduced CO2 compared to standard treatment. When CPAP was used first the difference in CO2 was greater compared to using it second Modified Woods Clinical Asthma Score (mWCAS) measured after 1 h.. mWCAS reduced with CPAP in 11/12
Supportive evidence but not proof that CPAP prevents the need for ventilation Nasal bubble CPAP may prevent intubation Evidence that especially early CPAP reduces CO2
Javouhey et al, 200823
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 (4)
Citation
Study group
Randomised crossover trial (2b)
NIV reduced intubation rate NIV reduced ventilator dependent pneumonia NIV reduced oxygen dependency Did not increase length of stay
Only reduction accessory muscle use (1.7 to 0.08 p
Archimedes STRUCTURED CLINICAL QUESTION In an infant less than 2 years old with bronchiolitis will early use of CPAP reduce the need for intubation and ventilation?
SEARCH 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 (table 1).
COMMENTARY
QUESTION 2 Will continuous positive airway pressure reduce the need for ventilation in bronchiolitis?
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 6.0 kPa. Comparing nasal CPAP and standard treatment for 12 h
Case series (4)
20/35 (57.4%) did not require ventilation When used first CPAP reduced CO2 by 1.53 kPa compared to standard treatment (p50 mm Hg on nCPAP
Case series (4)
20/35 (57.4%) did not require ventilation CPAP significantly reduced CO2 compared to standard treatment. When CPAP was used first the difference in CO2 was greater compared to using it second Modified Woods Clinical Asthma Score (mWCAS) measured after 1 h.. mWCAS reduced with CPAP in 11/12
Supportive evidence but not proof that CPAP prevents the need for ventilation Nasal bubble CPAP may prevent intubation Evidence that especially early CPAP reduces CO2
Javouhey et al, 200823
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 (4)
Citation
Study group
Randomised crossover trial (2b)
NIV reduced intubation rate NIV reduced ventilator dependent pneumonia NIV reduced oxygen dependency Did not increase length of stay
Only reduction accessory muscle use (1.7 to 0.08 p
