SESSION TITLE: Pediatric Critical Care
SESSION TYPE: Original Investigation Slide
PRESENTED ON: Wednesday, October 30, 2013 at 07:30 AM - 09:00 AM
PURPOSE: Bronchiolitis is a common respiratory infection in infants that is sometimes treated with albuterol. To determine response to albuterol, providers use subjective clinical assessments that may not be reliable. In intubated infants, assessment of response can be determined using pulmonary mechanics and respiratory system resistance (Rrs). The purpose of this study was to compare providers’ clinical assessment of response to the measurement of response defined by pulmonary mechanics.
METHODS: Before and 20 minutes following albuterol therapy, a nurse (RN), respiratory therapist (RT) and physician (MD) performed simultaneous examinations and assessed response to albuterol in a population of intubated infants with bronchiolitis. Providers were also asked to rate degree of wheezing, aeration and expiratory time using a 5-point Likert scale. Measurements of ventilator-derived pulmonary mechanics were obtained at these same times. Providers were blinded to the pulmonary mechanics and to the other providers’ assessments.
RESULTS: Seventy-five paired pre- and post-albuterol clinical assessments were made by providers in 25 infants (median age 44 days, 25-75% IQR 30-81 days). Using pulmonary mechanics, response to albuterol was defined using two thresholds: improvement in Rrs by >20% from baseline and improvement by >30% from baseline. Using the 20% threshold, 36% of children (9/25) were responders; using the 30% threshold, 12% (3/25) were responders. With either definition, providers made poor clinical determinations of response. With the 20% threshold, the positive predictive values (PPVs) of RNs, RTs and MDs were 38%, 25% and 25% respectively, and the negative predictive values (NPVs) were 67%, 54% and 59%. With the 30% threshold, the PPVs of RNs, RTs and MDs were 6%, 8% and 13% respectively, with NPVs of 78%, 85% and 88%, respectively. When comparing assessments of wheezing, aeration and expiratory time between RNs, RTs and MDs, there was poor agreement between groups of providers in all parameters (kappa<0.6).
CONCLUSIONS: A provider’s clinical assessment is not a reliable method for determining response to albuterol in children with bronchiolitis.
CLINICAL IMPLICATIONS: Without assessment of pulmonary mechanics, caution should be used in classifying children with bronchiolitis as responders to albuterol.
DISCLOSURE: The following authors have nothing to disclose: Christopher Carroll, Kathleen Sala, Craig Schramm
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