Clinical Study Of NCPAP As Priority Strategy In Bronchiolitis

Purpose:To investigate the clinical value of nasal continuous positive airway pressure(nCPAP) as priority strategy in treatment of bronchitis, understanding the influence of nCPAP treatment on oxygenation and ventilation function in bronchiolitis, understanding the effect of nCPAP priority strategy trachea intubation rate and time in bronchiolitis in PICU.Method:This study was made up of two parts. The first part was retrospective analysis. Inclusive criteria:cases were in line with the diagnosis standard of bronchiolitis, ages ranging from 1 to 6 months, wheezing occurred for the first time and has one of the following conditions:(1) obvious wheezing, severe respiratory distress (rest R>60 beats/min, three depression sign); (2) increased oxygen demand: cases who need to be transferred to PICU in pediatric ward because they need inhalation oxygen with facemask, while oxygen inhalation is given through nasal catheter SaO2 is less than 92%, or cases who directly admitted to the PICU need inhalation oxygen with facemask to maintain oxygen saturation,while oxygen inhalation is given through nasal catheter SaO2 is less than 92%; (3) PaCO2>50mmHg.Exclusive criteria:(1) congenital heart disease; (2) neuromuscular diseases; (3) chronic bronchopulmonary dysplasia; (4) immunodeficiency disease; (5) frequent apnea; (6) high fever, body temperature≥39℃; (7) critically ill infants need instantly tracheal intubation with diseases such as hypopnea, weak spontaneous breathing, systemic failure, severe shock, central respiratory failure, severe acidosis(PH<7.0); (8) cases not covered in the exclusion criteria, but not implemented nCPAP priority strategy; (9) Cases admitted less than 24 hours or nCPAP treatment less than 24 hours.nCPAP priority strategy:Among children with bronchiolitis admitted to PICU in our hospital who conforms to the standard of research standards, all treat with nCPAP in the first time, and the respiratory, blood oxygen saturation, blood gas analysis and general condition were observed closely in a short time. According to the effect of treatment determines whether or not to proceed with nCPAP.Evaluation criteria of curative effect:After nCPAP treatment, if the patients’ condition improved, such as dyspnea, oxygen saturation and blood gas analysis improved significantly. Cases who need not endotracheal intubation mechanical ventilation is defined as effective nCPAP treatment; if the disease continues to deteriorate after nCPAP treatment, such as worsened dyspnea or cyanosis, frequent respiratory pause, hypopnea, irregular respiratory rhythm, SaO2 is less than 90% while FiO2 is less than 0.6, PaO2<50mmHg; PaCO2 is increased significantly in the short term. Cases who need endotracheal intubation mechanical ventilation is defined as nCPAP treatment invalid.Retrospective analysis was made on cases which met the study criteria and treated with nCPAP as priority strategy in our hospital from August 2012 to December 2014. According to the admission and discharge registration of PICU, medical records data and rescue registration in our PICU, the cases who were in line with the research conditions were screened out.In the second part, on the basis of retrospective study, a prospective randomized controlled study is conducted. Infants which are diagnosed with bronchiolitis and treated are chosen as the research objects in PICU of our hospital from January 2015 to January 2016. The cases inclusion criteria are line with the diagnosis standard, ages ranging from 1 to 6 months, wheezing for the first time and has one of the following conditions:(1) respiratory distress score:Wang’s scoring system (Wang’clinical score system, CSS), cases with CSS score≥5 points. (2) increased oxygen demand: cases who need to be transferred to PICU in pediatric ward because they need inhalation oxygen with facemask, while oxygen inhalation is given through nasal catheter SaO2 is less than 92%, or cases who directly admitted to the PICU need inhalation oxygen with facemask to maintain oxygen saturation,while oxygen inhalation is given through nasal catheter SaO2 is less than 92%; (3) PaCO2>50mmHg.Exclusive criteria:(1) congenital heart disease; (2) neuromuscular diseases; (3) chronic bronchopulmonary dysplasia; (4) immunodeficiency disease; (5) frequent apnea; (6) high fever, body temperature≥39℃; (7) critically ill infants who need instantly tracheal intubation such as hypopnea, weak spontaneous breathing, body exhaustion, severe shock, central respiratory failure, severe acidosis (PH<7.0); (8) the family refuse to use nCPAP.For patients who died, or failed to complete the test, the withdrawal reasons will be recorded. For patients whose operation does not conform to the specification and may affect the outcome of the treatment, or treated with nCPAP less than 24 hours, they also will be eliminated.nCPAP priority strategy:In priority group, among infants with bronchiolitis admitted to PICU in our hospital who conforms to the standard of research standards, all treat with nCPAP in the first time, and in a short time observe the respiratory, blood oxygen saturation, blood gas analysis and general condition. According to the effect of treatment determines whether or not to proceed with nCPAP. If tracheal intubation indications are present, mechanical ventilation is used for infants immediately.Tracheal intubation indications:Non priority groups:disease continues to severe, while oxygen inhalation is given through facemask, SaO2 or PaO2 can not be maintained(SaO2<90%, PaO2<50mmHg); PaCO2 is raised significantly in a short time; hypopnea; frequent apnea; dyspnea severed obviously. Priority group:When FiO2 is more than 0.6, SaO2 or PaO2 can not be maintained(SaO2<90%, PaO2<50mmHg); PaCO2 is raised significantly in a short time; hypopnea; frequent apnea; worsened dyspnea.Transfer indication from PICU:at the same time, meet the following conditions:(1) while oxygen inhalation is given through nasal catheter, SaO2 is more than 95%;(2) CSS scores are less than 5 points;(3) at least 4 hours or more sputum suction was needed, and the patients had no obvious symptoms of airway obstruction.(4) circulation is stable, no high fever, no apnea.According to whether or not treat with CPAP as priority strategy, infants admitted to our hospital PICU who are in line with the study criteria are numbered in accordance with the order of admission to PICU, cases are divided into non priority group and priority group randomly using random number table by a particular person. In non priority group infants are given atomization (30m10.9% sodium chloride +1mg adrenaline), sputum, nasal catheter or oxygen mask after admission to PICU. While oxygen inhalation is given through nasal catheter SaO2 can not be maintained, infants are given oxygen inhalation through facemask. When endotracheal intubation indications are present, infants are given mechanical ventilation. In priority group infants are given atomization (30ml 0.9% sodium chloride+lmg adrenaline) and sputum suction after admission to PICU, then teated with nCPAP in the first time. The initial oxygen concentration is 50%, PEEP is set to 5cmH2O, and gradually adjust the oxygen concentration, untill the minimum oxygen concentration can maintain oxygen saturation above 95%. When endotracheal intubation indications are present, infants are given mechanical ventilation. Compare the rate of tracheal intubation and the time of PICU in the two groups.Results:1 Retrospective study in the first part showed that:(1) 90 cases of infants met the study criteria, including 52 males and 38 females, mean age is (4.6±1.4) months. Respiratory tract virus was positive in 48 cases (53.3%), among them,39 cases were infected with RSV (43.3%),2 cases were infected with PIV (2.2%),1 case was infected with IFV (1.1%),1 case was infected with AdV (1.1%). There were 13 cases whose putum bacterial culture was positive (14.4%), among them,3 cases were infected with Escherichia coli (3.3%),3 cases were infected with Haemophilus influenzae bacteria (3.3%),1 case was infected with Klebsiella pneumoniae (1.1%),1 case was infected with Enterobacter cloacae (1.1%), 1 case was infected with Bauman Acinetobacter genus (1.1%),2 cases were infected with Staphylococcus epidermidis (2.2%),1 case was infected with Streptococcus pneumoniae (1.1%),1 case was infected with Staphylococcus aureus (1.1%); There was 1 case whose Mycoplasma pneumoniae antibody was positive (1.1%), and 1 case whose Chlamydia pneumoniae antibody was positive (1.1%).(2) Among 90 cases of infants met the study criteria, after nCPAP, a slight nasal mucosa injury occurred in 5 cases, mild abdominal distension occurred in 4 cases, no other complications and death cases occurred.(3) nCPAP treatment was effective in 79 cases, of which 43 cases has hypercarbia before treatment.11 ineffective cases, were treated with tracheal intubation and mechanical ventilation.(4) nCPAP effective in 79 cases, including 45 males and 34 females, average age was (4.60±1.39) months, weight was (6.07±1.27) kg. Before treatment PaO2 was (60.09±7.68) mmHg, PaCO2 was (52.77±11.54) mmH, PaO2/FiO2 was (238.56± 38.19), respiratory rate was (69.0±5.43) times/min, heart rate was (160.73±18.37) beats/min. nCPAP invalid in 11 cases,7 cases were males,4 cases were females, average age was (4.86±0.99) months, body weight was (6.63±0.89) kg, Before treatment PaO2 was (52.45±5.39) mmHg, PaC02was (52.45±11.33) mmHg,PaO2/ FiO2 was (176.45±33.33), respiratory rate was (71.27±7.88) times/min, heart rate was (170.45±17.76) beats/min.There was no statistically significant difference in infants’gender, age, body weight, PaCO2, respiratory rate and heart rate before treatment between nCPAP effective cases and nCPAP invalid cases (p>0.05). But before treatment, in nCPAP ineffective group PaO2 and PaO2/FiO2 lower than which in nCPAP effective group, the difference was statistically significant (p<0.05).(5) In 79 nCPAP effective cases, in the treatment of 12 hour and 24 hour, PaCO2 decreased, compared with that before treatment and in the treatment of 2 hour(p<0.05); PaO2/FiO2 increased, compared with that before treatment and 2 hour 0?<0.05). PaO2 improved in the treatment of 2 hour,12 hour and 24 hour (p<0.05); respiratory frequency and heart rate all improved in the treatment of 2 hour,12 hour and 24 hour(p<0.05).(6) There were 43 cases accompanied with hypercapnia in 79 nCPAP effective cases before treatment with nCPAP. PaCO2 was (61.30±6.51)mmHg before treatment, PaCO2 was (53.26±8.14)mmHg in the treatment of 2 hour, PaCO2 was (46.74±6.12)mmHg in the treatment of 12 hour, PaCO2 was (45.83±6.89)mmHg in the treatment of 24 hour, differences were statistically significant(F=92.0,p<0.05). PaCO2 decreased in treatment of 2 hour,12 hour and 24 hour (p<0.05).2 Prospective randomized controlled trial in the second part showed that:(1) 88 cases of bronchiolitis meet the inclusion criteria,8 cases are excluded, including 3 cases whose family members refused to nCPAP as priority strategy,2 cases were excluded because they must be given tracheal intubation for frequent apnea or hypopnea in the first time,2 cases were excluded because they are diagnosed as ventricular septal defect (VSD). There are 80 cases met study criteria, and 43 cases in non priority group and 37 cases in priority group. In two groups, each had one case who is removed since the patient’relatives required discharge when treated for less than 24 hours. Finally,78 cases finished the study.(2) There are 19 cases whose respiratory syncytial virus are positive in non priority group, the respiratory syncytial virus infection rate is 45.23%. There are 15 cases whose respiratory syncytial virus are positive in priority group, the respiratory syncytial virus infection rate is 41.67%. In comparison, there is no statistically significant difference in the respiratory syncytial virus infection positive rate between two groups(χ2=0.1, p>0.05).(3) In non priority group, there are 23 males and 19 females, age is (4.69±1.31) months. Before the treatment PaO2 is (60.26±9.29)mmHg, PaCO2 is (53.11±9.64) mmHg, PaO2/FiO2 is (224.81±47.62), respiratory rateis is (70.28±6.41) times/min, heart rate is (16.494±18.88)beats/min, CSS score is (8.59±2.11). In priority group there are 24 males and 12 females, age is (4.43±1.41)months. Before the treatment, PaO2 is (58.92±6.65)mmHg, PaCO2 is (52.72±11.70)mmHg, PaO2/FiO2 is (232.25±37.57) respiratory rate is (68.0±4.96)times/min, heart rate is (159.33±18.54)times/min, CSS score is (8.33±2.39). In comparison, before treatment there is no statistically significant difference in sex ratio, age, PaO2, PaCO2, respiratory rate, heart rate, PaO2/FiO2 and CSS scores in two groups (p>0.05).(4) There are 11 cases given tracheal intubation in non priority group, intubation rate is 26.19%. There are 2 cases given tracheal intubation in priority group, intubation rate is 5.56%(χ2=5.25,p=0.02). However, while 5≤CSS<9, OR is 2.22, 95% confidence interval is 0.18-26.6, there is no significant difference in tracheal intubation rates betweevn non priority group and priority grou(χ2=0.41,p>0.05), and while 9<CSS≤12, OR is 9.69,95% confidence interval is 1.07-97.43, there is statistically significant difference in tracheal intubation rates betweevn non priority group and priority group (χ2=5.30,p<0.05).(5) There are 34 successful cases in priority group and 31 successful cases in non priority group,no death cases occurred in two groups.In the same group, PaCO2 and PaO2/FiO2 in different time showed that in priority group, in the treatment of 2 hour,12 hour and 24 hour PaCO2 is lower than that before treatment (p<0.05); in priority group, in the treatment of 12 hour and 24 hour PaO2/FiO2 is increased comparing with that of before the treatment and 2 hour of treatment (p<0.05); In non priority group, in the treatment of 2 hour and 12 hour, there is no obvious improvement in PaCO2 and PaO2/FiO2 than that before treatment (p>0.05),however, in the treatment of 24 hour, PaCO2 decreased (p<0.05), PaO2/FiO2 increased (p<0.05).Before the treatment there is no statistically significant difference in PaCO2 and FiO2/PaO2 of children between two groups(p>0.05), but in the treatment of 2 hour, 12 hour,24 hour, PaCO2 in the priority group all improved significantly (p<0.05) compared with that of the non priority group. In the treatment of 2 hour, there was no statistically significant difference (p>0.05) in FiO2/PaO2 between priority group and non priority group, but in the treatment of 12 hour and 24 hour, compared with non priority group, the FiO2/PaO2 in the priority group all increased obviously with statistically significant difference (p<0.05).(6) PICU times are (101.07±18.68) hours in non priority group, and PICU times are (98.28±13.74) hours in priority group. PICU times didn’t be extended in priority group, there is no statistically significant difference in two groups (t=0.76, p>0.05).Conclusion:1 Retrospective study suggested that nCPAP can effectively improve the oxygenation and hypercarbia of bronchitis.However, these patients, who suffer from bronchiolitis with minor PaO2 or PaO2/FiO2, may be required mechanical ventilation of endotracheal as soon as possible.2 The results in prospective randomized controlled trial provide further evidence that nCPAP can effectively improve the oxygenation and hypercarbia of bronchitis.3 Prospective randomized controlled trial suggested that nCPAP as priority strategy may reduce the risk of airway intubation in bronchiolitis and does not prolong the time of bronchitis in PICU.4 Especially for infants with severe respiratory distress, nCPAP as priority strategy in treatment of bronchiolitis can significantly reduce the risk of tracheal intubation. Howere,for infants with no severe respiratory distress, those infants may not require nCPAP as priority strategy for respiratory support.