Abstract
Background:
Critical bronchiolitis is a common reason for pediatric intensive care unit (PICU) admission, and management varies widely, with limited data from South American PICUs. This study aimed to characterize critical bronchiolitis trajectories in a Brazilian PICU and to measure adherence to a clinical protocol deemphasizing ancillary pharmacologic treatments while using the modified Wood–Downes score (mWDS) to guide respiratory support. It also aimed to assess whether admission mWDS would be associated with the need for subsequent invasive mechanical ventilation.
Methods:
We conducted a retrospective cohort study of infants <24 months admitted with critical bronchiolitis to a Brazilian PICU between March 2021 and April 2023. The protocol was implemented in January 2021 and discouraged the use of inhaled β-agonists, systemic corticosteroids, and inhaled hypertonic saline. It also recommended respiratory support based on the mWDS conventional oxygen for scores ≤3, high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) for scores 4–7, and consideration of mechanical ventilation for scores >7. We assessed patient characteristics, protocol adherence, and predictive value of admission mWDS for intubation.
Results:
Among 299 infants (median age 4.9 mo), 69% had respiratory syncytial virus infection. Maximum respiratory support was conventional oxygen in 61%, HFNC in 22%, NIV in 14%, and mechanical ventilation in 3%. Complete protocol adherence was 43%. Individual component adherence varied: hypertonic saline 100%, corticosteroids 83%, β-agonists 77%, and appropriate respiratory support 54%. Most protocol violations (66%) involved undertreatment with conventional oxygen for mWDS 4–7. The mWDS score at PICU admission was associated with intubation with an area under the curve of 0.77 (95% CI: 0.63–0.91); no subject with mWDS at PICU admission <4 required intubation.
Conclusions:
This Brazilian cohort demonstrated low intubation rates despite suboptimal protocol adherence. The mWDS score at PICU admission showed acceptable discrimination for the need for mechanical ventilation, with scores <4 identifying low-risk patients.
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