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To the Editor: It is worth reflecting on the ef- To the Editor: Franklin et al. reported lower
ficiency of high-flow therapy. On the basis of the rates of escalation of care due to treatment fail-
authors’ primary outcome, efficacy would be a ure in infants with bronchiolitis receiving high-
number needed to treat of 9 patients to prevent flow oxygen than in those receiving standard
Success $HFNC
HFNC
Respiratory Failure
$HFNC
treatment
Success
$LFNC
Success
$LFNC+HFNC
LFNC Failure
Failure
$LFNC+HFNC
Success
$79.10
HFNC 0.880
$79.10
Failure
Respiratory $79.10
treatment 0.120
LFNC: $19.03
Success
$0.84; P=0.770
0.770 Success
$19.03 $79.94; P=0.140
0.610
LFNC Failure
$79.94
0.230 Failure $79.94; P=0.090
0.390
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In response to Meskill and Moore: we agree
that care for the majority of children with bron-
Figure 2. Increase in PICU Admissions in the Netherlands from 2006
through 2016. chiolitis can be managed with standard therapy.
Data were extracted from a national pediatric intensive care unit (PICU) The study was neither powered nor designed to
registry that reported PICU admissions in which a diagnosis of primary determine whether late commencement of high-
or secondary bronchiolitis was reported. flow therapy is inferior to early commencement.
De Benedictis and Cogo question the ICU
admission data in the standard-therapy group.
alarming increase in PICU admissions for viral In this group, all 167 patients with treatment
bronchiolitis.3 A trend that is confirmed by pre- failure who required escalation of therapy were
liminary data from the Netherlands in a 10-year not automatically admitted to the ICU (65 pa-
national PICU registry showed an increase in tients were admitted). In the high-flow group,
admissions (Fig. 2). Ironically, as compared with 87 were admitted to the ICU. Further, in an un-
the standard-therapy group, more children in the blinded study, we cannot exclude the possibility
high-flow oxygen group required PICU admis- of a greater bias to tolerate sicker infants in the
sion (65 vs. 87, P = 0.08) and intubation (4 vs. 8). high-flow group, which would explain the high-
We suggest that trials that evaluate interventions er respiratory rate at the point of escalation.
in viral bronchiolitis use PICU admission and in- Modesto i Alapont et al. are correct that an
vasive mechanical ventilation as distinct primary understanding of the comparative costs will be an
outcomes. important consideration in treatment decisions.
Rosalie S. Linssen, M.D. An analysis of health care–related economics is
Job B. van Woensel, M.D., Ph.D. ongoing.
Academic Medical Center Our study showed that the use of high-flow
Amsterdam, the Netherlands oxygen therapy in infants with bronchiolitis can
r.s.linssen@amc.uva.nl be accomplished in the general ward. The most
Louis Bont, M.D., Ph.D. appropriate timing of its deployment remains to
University Medical Center be clarified.
Utrecht, the Netherlands Linssen et al. comment on the upward trend
No potential conflict of interest relevant to this letter was re- of bronchiolitis-related ICU admissions in the
ported.
Netherlands, which is consistent with previously
1. Nishisaki A, Marwaha N, Kasinathan V, et al. Airway man- published registry data from Australia and New
agement in pediatric patients at referring hospitals compared Zealand.1 In the past, high-flow therapy was
to a receiving tertiary pediatric ICU. Resuscitation 2011;82:386-
90. largely restricted to the ICU. Our large random-
2. Heikkilä P, Forma L, Korppi M. Hospitalisation costs for ized, controlled trial demonstrates excellent safe-
infant bronchiolitis are up to 20 times higher if intensive care is ty when applying high-flow therapy to hypox-
needed. Acta Paediatr 2015;104:269-73.
3. Schlapbach LJ, Straney L, Gelbart B, et al. Burden of disease emic infants with bronchiolitis outside ICUs. In
and change in practice in critically ill infants with bronchiolitis. our study, 308 of 13,454 (2.3%) infants with
Eur Respir J 2017;49(6):1601648. bronchiolitis were admitted to ICUs (156 infants
DOI: 10.1056/NEJMc1805312 before enrollment and 152 after enrollment).
(per yr)
800
possibly because of more frequent use of high-
flow oxygen in general wards. We disagree that 600
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intubation rates that varied by a factor of 6 were
reported in infants with bronchiolitis who were
Figure 3. ICU Admissions for Infants with Bronchiolitis in Australia
admitted to ICUs in Australia and New Zealand.3 and New Zealand between 2010 and 2017.
Donna Franklin, B.N., M.B.A. Data are from the Australian and New Zealand Pediatric Intensive Care
Mater Research Institute, University of Queensland (ANZPIC) Registry.1
Brisbane, QLD, Australia
Franz E. Babl, M.D., M.P.H. 1. Australian and New Zealand Paediatric Intensive Care
Murdoch Children’s Research Institute (ANZPIC) Registry (http://www.anzics.com.au/w ww.anzics.com
Melbourne, VIC, Australia .au/pages/CORE/A NZPICR-registry.html).
2. Hasegawa K, Tsugawa Y, Brown DF, Mansbach JM, Camargo
Andreas Schibler, M.D. CA Jr. Trends in bronchiolitis hospitalizations in the United
Centre for Children’s Health Research States, 2000–2009. Pediatrics 2013;132:28-36.
South Brisbane, QLD, Australia 3. Schlapbach LJ, Straney L, Gelbart B, et al. Burden of disease
a.schibler@uq.edu.au and change in practice in critically ill infants with bronchiolitis.
Eur Respir J 2017;49(6):1601648.
Since publication of their article, the authors report no fur-
ther potential conflict of interest. DOI: 10.1056/NEJMc1805312
technology. Key resources include the Radiation Cullen Case, Jr., M.P.A.
Emergency Medical Management website (www. National Marrow Donor Program
Minneapolis, MN
remm.nlm.gov/), which offers medical care pro- ccase@nmdp.org
viders information on response and prepared- No potential conflict of interest relevant to this letter was re-
ness, just-in-time training, educational materials, ported.