title: Variability of intensive care management for children with bronchiolitis.
abstract: OBJECTIVE
  To determine the extent of variability in testing and treatment of children with bronchiolitis requiring intensive care.
  
  
  METHODS
  This prospective, multicenter observational study included 16 academic children's hospitals across the United States during the 2007 to 2010 fall and winter seasons. The study included children<2 years old hospitalized with bronchiolitis who required admission to the ICU and/or continuous positive airway pressure (CPAP) within 24 hours of admission. Among the 2207 enrolled patients with bronchiolitis, 342 children met inclusion criteria. Clinical data and nasopharyngeal aspirates were collected.
  
  
  RESULTS
  Respiratory distress severity scores and intraclass correlation coefficients were calculated. The study patients' median age was 2.6 months, and 59% were male. Across the 16 sites, the median respiratory distress severity score was 5.1 (interquartile range: 4.5-5.4; P<.001). The median value of the percentages for all sites using CPAP was 15% (range: 3%-100%), intubation was 26% (range: 0%-100%), and high-flow nasal cannula (HFNC) was 24% (range: 0%-94%). Adjusting for site-specific random effects (as well as children's demographic characteristics and severity of bronchiolitis), the intraclass correlation coefficient for CPAP and/or intubation was 21% (95% confidence interval: 8-44); for HFNC, it was 44.7% (95% confidence interval: 24-67).
  
  
  CONCLUSIONS
  In this multicenter study of children requiring intensive care for bronchiolitis, we identified substantial institutional variability in testing and treatment, including use of CPAP, intubation, and HFNC. These differences were not explained by between-site differences in patient characteristics, including severity of illness. Further research is needed to identify best practices for intensive care interventions for this major cause of pediatric hospitalization.
authors.affiliation: Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, California; hpierce@rchsd.org.
authors.forename: Heather C
authors.initials: HC
authors.lastname: Pierce
authors.affiliation: Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts;
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Mansbach
authors.affiliation: Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, California;
authors.forename: Erin S
authors.initials: ES
authors.lastname: Fisher
authors.affiliation: Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas;
authors.forename: Charles G
authors.initials: CG
authors.lastname: Macias
authors.affiliation: Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri;
authors.forename: Brian M
authors.initials: BM
authors.lastname: Pate
authors.affiliation: Departments of Molecular Virology and Microbiology, and Pediatrics, Baylor College of Medicine, Houston, Texas; and.
authors.forename: Pedro A
authors.initials: PA
authors.lastname: Piedra
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Ashley F
authors.initials: AF
authors.lastname: Sullivan
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Janice A
authors.initials: JA
authors.lastname: Espinola
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Camargo
mesh_terms: D001988:Bronchiolitis / Q000175:diagnosis / Q000628:therapy*; D045422:Continuous Positive Airway Pressure; D003422:Critical Care; D005260:Female; D006612:High-Frequency Ventilation; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D007440:Intubation; D008297:Male; D011446:Prospective Studies; D012720:Severity of Illness Index; D014481:United States
keywords: continuous positive airway pressure; high-flow nasal cannula; institutional variability; intraclass correlation coefficient; intubation; respiratory distress