The Science Journal of the American Association for Respiratory Care

2003 OPEN FORUM Abstracts

THE UTILIZATION OF CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) IN THE TREATMENT OF BRONCHIOLITIS PATIENTS.

Kim Bennion BS RRT, Julie Ballard BS RRT and Glenna McKinley BS RRT, Primary Children's Medical Center, Salt Lake City, UT.

 Introduction:
Our hospital has a multi-disciplinary assessment team that specializes in the care of bronchiolitis patients (pts). Eight specially trained respiratory therapists daily assess all bronchiolitics ordered on respiratory interventions. The team employs a bronchiolitis clinical practice guideline (CPG). The CPG includes a symptom-based scoring system called the Bronchiolitis Score (BS). The score is based on respiratory rate, breath sounds and retractions with each of these being scored on 4 levels (0-3). Respiratory distress is defined as: 0-1 normal, 2-3 mild, 4-6 moderate, and 7-9 severe. Improved score is defined as a decrease in the BS by > 1 from pre- to post-intervention. We have reported that about 60% of pts have an improved BS following NPS, and that only about 15-21% of bronchiolitics have an improved score post inhaled albuterol1,2,3. Despite hydration, suction, oxygenation and inhaled medications when deemed effective, which are our mainstays of care, a small percent (<10%) of our bronchiolitis admits develop respiratory distress consistent with impending failure. In the past, we felt that symptom scores improved 4 hours (hr) post CPAP placement, but a database to track this was not available. Previous to the 2002-2003 season (Nov-April), bronchiolitis pts requiring CPAP were admitted to our pediatric intensive care unit (PICU). As PICU beds were unavailable and a record setting volume of pts with increasing severity of illness were being admitted, a need for safe CPAP utilization in the non-PICU setting was identified. A bronchiolitis CPAP CPG was developed in an effort to test the assumption that CPAP is beneficial in decreasing respiratory distress (decreasing BS) and is safe to use in the non-PICU setting. Seeking only to compare uncomplicated bronchiolitis cases, pts with co-morbidities such as congenital heart disease, chronic lung and neuromuscular diseases were excluded.

Methods:
Data were extracted concurrently and retrospectively from our data systems. Inclusion criteria were: (1) primary diagnosis of bronchiolitis, (2) < 24 months of age, (3) CPAP initiated in a non-PICU area, (4) BS > 6 prior to CPAP, and (5) baseline and 4 hour post CPAP scores recorded.

RESULTS:
There were 43 patients who met the initial criteria. Seven pts with co-morbidities were excluded leaving us 36 pts. Twelve pts were further excluded for having no baseline or 4 hour post CPAP score(s), which left us 24 to analyze.  Results of score changes from baseline to 4 hr post CPAP are reported in Table 1. One adverse event was noted, with the pt experiencing a pneumothorax within 8 hrs of CPAP institution.

CONCLUSION:
We conclude that CPAP is of benefit in decreasing respiratory distress in a subset of bronchiolitis pts. Given the low incidence of complications, we feel it can be instituted safely in the non-ICU setting when clear guidelines and education are in place.

 Table 1: BS Scores from Baseline to 4 Hr. Post CPAP Placement 

  4 hr Post CPAP Placement # (%)
Improvement 19(79)
No Change 3 (13)
Worsened 2 (8)
Total 24 (100)


 

 1Respir Care (abstract), Zemlicka-Dunn, 2001;46:1071
 2Respir Care (abstract), McKinley, 2001;46:1071
 3Respir Care (abstract), Bennion, 2001;46:1072

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