by Ruggiero Corcella
Experts in France and Italy have created a guide to deal with epidemic waves like the one that just ended. The results in Lancet EClinical Medicine
In recent years, seasonal epidemics of respiratory syncytial virus (RSV), the main cause of bronchiolitis, have been particularly serious and have put a strain on healthcare systems in several European countries, in the United States but also in China where pediatric hospitals they were stormed with images and videos that went around the world. In Europe and North America, neonatal and pediatric intensive care beds proved insufficient and newborns had to be transferred hundreds of kilometers from home to receive adequate care.
The Neonatal and Pediatric Intensive Care Unit of Paris Saclay University, directed by Professor Daniele De Luca, professor of Neonatology, has long been involved in the epidemic front in France and has developed a complex protocol for the care of these children in order to have the most possible number of beds and resources available, with maximum safety and effectiveness. This is news just published in Lancet-EClinicalMedicine.
What is viral bronchiolitis
Viral bronchiolitis is an extremely contagious disease (with an Rt index of approximately 7, that is, each child can infect 7 others). It is usually a seasonal disease with annual or biennial epidemics from October to April in the northern hemisphere, and this seasonality is linked to indoor crowding and the opening of nurseries, although less evident in tropical areas.
The main risk factors
Environmental factors, such as pollution, parental smoking and the impairment of ciliary function and innate immune defenses due to low temperatures, can also influence the severity of the disease. Finally, I note that younger age, male sex, prematurity, exclusive use of artificial breastfeeding, failure to thrive, low socioeconomic status, major comorbidities and immunodeficiencies constitute risk factors for more serious diseases.
Who strikes
Bronchiolitis mainly affects infants and young children under two years of age, with a peak between two and six months. Neonates and infants often end up requiring hospitalization and approximately 5% of them in intensive care for monitoring and respiratory support. A significant percentage (≈10%) of patients in intensive care develop distress syndrome acute respiratory disease (ARDS) and survivors experience adverse outcomes such as long ICU stay, invasive respiratory support, need for oxygen assistance, and high associated costs.
Objectives: safety and efficacy
The protocol developed by Professor De Luca’s team based on respiratory pathophysiology and available evidence to take care of these patients with two objectives: safety, avoiding any nosocomial contamination and, effectiveness, avoiding intubation and other important complications. It involves, in fact, a team effort, the use of dedicated environments and filters as well as advanced non-invasive respiratory assistance techniques, including the so-called neural ventilation (NAVA).
The work – says De Luca, who is also the past-president of Espnic (European Society for Pediatric and Neonatal Intensive Care) – develops the physiopathological background, the technical and medical interventions necessary to best activate during epidemics and to act in so that intensive care is optimized with a rapid turn-over of young patients, in the hope that prophylaxis against bronchiolitis will be increasingly extensive and that the resources at our disposal will increase.
The results: no epidemic in the hospital
It is not just a Parisian recipe since the authors examined the protocol through a cost-effectiveness analysis carried out by public health specialists led by Professor Walter Ricciardi, full professor at the Catholic University. This protocol, adds De Luca, has allowed us to avoid nosocomial epidemics during the last three seasons of bronchiolitis in our intensive care unit, while the clinical results have always been optimal. This is particularly important given the high fragility of the others admitted to the neonatal intensive care unit. The results start from the observation of the unbalanced relationship between the need and availability of intensive places in Europe and were shared in the Espnic network and with important European colleagues, including the Italians Giorgio Conti, Eugenio Baraldi and Maria Rosaria Gualano, professors at the University respectively Cattolica, the University of Padua and UniCamillus.
Waiting for immunization
Since last year there has been the possibility of carrying out a universal, safe (passive) immunization of all newborns and infants with an effective monoclonal antibody with a single administration for the entire winter season. The antibody has been approved by the FDA (Food and Drug Administration) and EMA (European Medicines Agency), and is being administered universally in North America. Available in Europe, but in fact used patchy in the EU. France and Spain began universal immunization campaigns in September, but no other European country, including Italy, does so systematically.
We hope in the future to see less and less bronchiolitis thanks to immunization, but in the meantime, we must prepare to manage them in emergency conditions, update our knowledge and skills including the most recent notions of pathophysiology and resuscitation to offer effective and safe intensive care to the majority number of children even using the most modern ventilation techniques. It’s about both clinical and public health excellence, concludes De Luca.
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February 8, 2024 (modified February 8, 2024 | 09:36)
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