Abandon Noninvasive Ventilation in Bronchiolitis? How Unrecognized Bias Can Lead to Problematic Conclusions

Keim, Garrett; Himebauch, Adam S.; Yehya, Nadir; Slovis, Julia; Kilbaugh, Todd J.; Stinson, Hannah; Chiotos, Kathleen; Morgan, Ryan W.

doi:10.1097/ccm.0000000000005531

Cited by 3 publications

(6 citation statements)

References 6 publications

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“…Respectfully, Keim et al (1) have mischaracterized our conclusions; we do not recommend nor believe that clinicians should “abandon noninvasive ventilation in bronchiolitis.” Instead, we conclude that patients with bronchiolitis on noninvasive ventilation should be closely monitored for deteriorating clinical condition. The data highlight potential vulnerabilities for patient safety in the substantial variability that exists for the initiation and monitoring of infants on noninvasive ventilation for bronchiolitis.…”

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confidence: 69%

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Shanahan

Monuteaux

Nagler

et al. 2022

Critical Care Medicine

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confidence: 69%

“…We thank Keim et al (1) for their interest in our recent publication (2) in Critical Care Medicine on noninvasive ventilation and outcomes in bronchiolitis. The authors (1) highlight important caveats in using administrative databases in research, specifically the limited patient-specific data.…”

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confidence: 99%

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Shanahan

Monuteaux

Nagler

et al. 2022

Critical Care Medicine

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“…Regarding diaphragmatic electrophysiology, in 2021 PCCM had a descriptive study of transcutaneous electromyography (23, 24), and in 2023 there was a retrospective report about the range in Edi measurements in the PICU population (25, 26) from the current researchers in Canada (3). Add to all this material the editorial that accompanies the new report (4). It gives a helpful discussion about bringing together bronchiolitis clinical care with diaphragmatic electrophysiology data in a potential protocolized trial (4) (n.b., elsewhere in PCCM we call these pragmatic trials (27, 28)).…”

Section: What Is the Associated Evolution In Respiratory Effort In Pi...mentioning

confidence: 99%

“…Add to all this material the editorial that accompanies the new report (4). It gives a helpful discussion about bringing together bronchiolitis clinical care with diaphragmatic electrophysiology data in a potential protocolized trial (4) (n.b., elsewhere in PCCM we call these pragmatic trials (27, 28)).…”

Section: What Is the Associated Evolution In Respiratory Effort In Pi...mentioning

confidence: 99%

“…First is an article about prognostic modeling in critically ill children in a low- and middle-income (LMIC) PICU in Cambodia (1, 2). The second is a single-center analysis of noninvasive neurally adjusted ventilatory assist (NIV-NAVA) in infants with bronchiolitis (3, 4). The third is a two-center PICU study about a machine learning model designed to improve the conventional clinical criteria to predict need for intubation in the PICU (5, 6).…”

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Editor’s Choice Articles for March

Tasker

2024

Pediatric Critical Care Medicine

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arch 2024 and another month of amazing content in Pediatric Critical Care Medicine (PCCM). Please take the time to read my three Editor's Choice articles, each with editorials. First is an article about prognostic modeling in critically ill children in a low-and middle-income (LMIC) PICU in Cambodia (1, 2). The second is a single-center analysis of noninvasive neurally adjusted ventilatory assist (NIV-NAVA) in infants with bronchiolitis (3, 4). The third is a two-center PICU study about a machine learning model designed to improve the conventional clinical criteria to predict need for intubation in the PICU (5, 6).

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Noninvasive Positive Pressure Ventilation Use and In-Hospital Cardiac Arrest in Bronchiolitis

Shepard,

Mehta,

Graham

et al. 2024

Critical Care Explorations

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IMPORTANCE: A recent study showed an association between high hospital-level noninvasive positive pressure ventilation (NIPPV) use and in-hospital cardiac arrest (IHCA) in children with bronchiolitis. OBJECTIVES: We aimed to determine if patient-level exposure to NIPPV in children with bronchiolitis was associated with IHCA. DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study at a single-center quaternary PICU in North America including children with International Classification of Diseases primary or secondary diagnoses of bronchiolitis in the Virtual Pediatric Systems database. MAIN OUTCOMES AND MEASURES: The primary exposure was NIPPV and the primary outcome was IHCA. MEASUREMENTS AND MAIN RESULTS: Of 4698 eligible ICU admissions with bronchiolitis diagnoses, IHCA occurred in 1.2% (57/4698). At IHCA onset, invasive mechanical ventilation (IMV) was the most frequent level of respiratory support (65%, 37/57), with 12% (7/57) receiving NIPPV. Patients with IHCA had higher Pediatric Risk of Mortality-III scores (3 [0–8] vs. 0 [0–2]; p < 0.001), more frequently had a complex chronic condition (94.7% vs. 46.2%; p < 0.001), and had higher mortality (21.1% vs. 1.0%; p < 0.001) compared with patients without IHCA. Return of spontaneous circulation (ROSC) was achieved in 93% (53/57) of IHCAs; 79% (45/57) survived to hospital discharge. All seven children without chronic medical conditions and with active bronchiolitis symptoms at the time of IHCA achieved ROSC, and 86% (6/7) survived to discharge. In multivariable analysis restricted to patients receiving NIPPV or IMV, NIPPV exposure was associated with lower odds of IHCA (adjusted odds ratio [aOR], 0.07; 95% CI, 0.03–0.18) compared with IMV. In secondary analysis evaluating categorical respiratory support in all patients, compared with IMV, NIPPV was associated with lower odds of IHCA (aOR, 0.35; 95% CI, 0.14–0.87), whereas no difference was found for minimal respiratory support (none/nasal cannula/humidified high-flow nasal cannula [aOR, 0.56; 95% CI, 0.23–1.36]). CONCLUSIONS AND RELEVANCE: Cardiac arrest in children with bronchiolitis is uncommon, occurring in 1.2% of bronchiolitis ICU admissions. NIPPV use in children with bronchiolitis was associated with lower odds of IHCA.

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Abandon Noninvasive Ventilation in Bronchiolitis? How Unrecognized Bias Can Lead to Problematic Conclusions

Cited by 3 publications

References 6 publications

The authors reply

The authors reply

Editor’s Choice Articles for March

Noninvasive Positive Pressure Ventilation Use and In-Hospital Cardiac Arrest in Bronchiolitis

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