Allergologia et Immunopathologia

Allergologia et Immunopathologia

Volume 46, Issue 1, January–February 2018, Pages 15-23
Allergologia et Immunopathologia

Original Article
A comparison of two clinical scores for bronchiolitis. A multicentre and prospective study conducted in hospitalised infants

https://doi.org/10.1016/j.aller.2017.01.012Get rights and content

Abstract

Background

There are a number of clinical scores for bronchiolitis but none of them are firmly recommended in the guidelines.

Method

We designed a study to compare two scales of bronchiolitis (ESBA and Wood Downes Ferres) and determine which of them better predicts the severity. A multicentre prospective study with patients <12 months with acute bronchiolitis was conducted. Each patient was assessed with the two scales when admission was decided. We created a new variable “severe condition” to determine whether one scale afforded better discrimination of severity. A diagnostic test analysis of sensitivity and specificity was made, with a comparison of the AUC. Based on the optimum cut-off points of the ROC curves for classifying bronchiolitis as severe we calculated new Se, Sp, LR+ and LR− for each scale in our sample.

Results

201 patients were included, 66.7% males and median age 2.3 months (IQR = 1.3–4.4). Thirteen patients suffered bronchiolitis considered to be severe, according to the variable severe condition. ESBA showed a Se = 3.6%, Sp = 98.1%, and WDF showed Se = 46.2% and Sp = 91.5%.

The difference between the two AUC for each scale was 0.02 (95%CI: 0.01–0.15), p = 0.72. With new cut-off points we could increase Se and Sp for ESBA: Se = 84.6%, Sp = 78.7%, and WDF showed Se = 92.3% and Sp = 54.8%; with higher LR.

Conclusions

None of the scales studied was considered optimum for assessing our patients. With new cut-off points, the scales increased the ability to classify severe infants. New validation studies are needed to prove these new cut-off points.

Introduction

Acute bronchiolitis (AB) is the most common lower airway infection in infants, with an annual incidence of 10% in infants under 12 months of age and a hospital admission rate in Spain of between 2 and 5% of all affected patients.1, 2 During the epidemic periods, AB constitutes an important healthcare burden in both the primary care and hospital settings.3 Overall, AB is estimated to be the most frequent cause of admission in infants less than one year of age.4 During the 1980s and 1990s, hospital admissions due to AB increased 2.4-fold in the United States,5 with no evidence of increased mortality. At that time, it was suggested that some of these admissions might be unnecessary and could be attributable to other factors.6 Later, in the period between 2000 and 2009, admissions due to AB in infants under 12 months of age began to decrease slightly, although the hospitalisation costs increased by 34%, at the expense of the more serious cases requiring admission to intensive care and mechanical ventilation.4

Adequate assessment of the clinical condition of a patient with AB is of great importance for the paediatrician, since it constitutes the basis of the decision-making process. Severity scales, applied objectively and with rigour, should prove useful in evaluating the clinical course of the patients and the efficacy of the prescribed treatments. While such scales are routinely used, they are supported by observational studies with limitations; as a result, no concrete scale is recommended in the clinical practice guides.7, 8, 9

One of the most widely-used scales in our setting, the Wood–Downes–Ferrés score (WDF), was designed to assess respiratory failure in patients with severe asthma.10, 11 However, a Spanish group has recently proposed a new scale, known as the Acute Bronchiolitis Severity Scale (Escala de Severidad de la Bronquiolitis Aguda, ESBA), based on different clinical parameters specific of AB and which has been evaluated in infants under one year of age, with good interobserver agreement.12

The main objective of this study is to determine whether the ESBA shows a better correlation to the severity of AB than the WDF. As secondary objectives, an analysis is made of the mean stay due to bronchiolitis, admission to the Intensive Care Unit (ICU), the need for ventilation, and the incidence of respiratory acidosis.

Section snippets

Study design

A prospective observational study was carried out, involving the consecutive inclusion of all patients ≤12 months of age admitted due to acute bronchiolitis (McConnochie criteria modified by age) between October 2014 and April 2015 to five second-level hospitals (according to the classification of the World Health Organisation)13 in La Comunidad Valenciana and Castilla la Mancha, in Spain. All the patients in the paediatric ward were visited on a daily basis, with application of the admission

Results

The study included a total of 201 patients, of whom 134 (66.7%) were males. Eight infants were excluded from the study: one male with Down's syndrome, three patients whose informed consent was not obtained, three premature infants with a gestational age of <35 weeks, and one infant with clinical manifestations consistent with serious systemic bacterial infection.

The epidemiological and clinical characteristics of the study sample are described in Table 1. The median patient age was 2.3 months

Discussion

The WD scale in principle does not seem to be a good tool for the clinical evaluation of AB, since it was designed and published in 1972 for the assessment of respiratory failure in only 18 paediatric patients with asthma crisis.10 Valuable parameters such as respiratory frequency or heart rate stratified according to age, the presence of crackles or oxygen saturation were not contemplated in the mentioned publication. In the present study, the WDF scale yielded a high false negative rate with

Confidentiality of data

The authors declare that they have followed the protocols of their work centre on the publication of patient data and that all the patients included in the study have received sufficient information and have given their informed consent in writing to participate in that study.

Right to privacy and informed consent

The authors have obtained the informed consent of the patients and/or subjects mentioned in the article.

Protection of human subjects and animals in research

Authors declare that the procedures followed were in accordance with the regulations of the responsible Clinical

Conflict of interest

The authors have no conflict of interest to declare.

Acknowledgments

Doctors who collected data in all the participating centres: Alicia Coret Sinisterra, Sergio Martín Zamora, Leonor García Maset, Aleixandre Castelló, Lidia Blasco González, José Haro Chuliá, Manuel Andrés Zamorano, Irene Satorre Viejo, Natividad Pons Fernandez, Ana Moriano Gutiérrez, Gemma Pedrón Marzal, Beatriz Beseler Soto, Julia Morata Alba, Pepe Cambra Sirera, Fernando Calvo Rigual, Begoña Pérez García, Marta San Roman, Maraña A, Torrecilla J, Hernández S, De La Osa A, Espadas D, Guardia L

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