ABSTRACT
Introduction
Lung ultrasound (LUS) has emerged as a reliable, noninvasive tool for bedside assessment of acute bronchiolitis (AB) in infants. Its role in guiding therapeutic decisions is increasingly recognized.
Aims
This study aimed to determine the predictive value of LUS in identifying infants with AB at risk of HFNC therapy failure.
Materials and Methods
This prospective, single‐center study was conducted in the pediatric department of Fattouma Bourguiba Hospital in Monastir from January 2022 to March 2024. Infants under 12 months hospitalized with moderate to severe AB and requiring HFNC therapy were enrolled. LUS was performed within 3–6 h of HFNC initiation and repeated 24 h later. Clinical and laboratory data, including the Wang score and LUS findings, were analyzed to predict HFNC failure.
Results
Among 124 enrolled infants, 98 (79%) responded successfully to HFNC therapy, while 26 (21%) failed. Baseline characteristics, including age, weight, and clinical symptomes, were comparable between groups, except for a higher Wang score in the failure group (p = 0.008). LUS scores were significantly higher in the failure group on both day 1 and day 2 (p < 0.001), with a more pronounced score progression (p < 0.001). ROC analysis identified a LUS score > 7 on day 1 and > 9 on day 2 as predictive thresholds for HFNC failure. Multivariate analysis confirmed the day 2 LUS score as an independent predictor of HFNC failure (p = 0.022).
Conclusion
LUS is a valuable prognostic tool in infants with AB undergoing HFNC therapy. Incorporating LUS into routine clinical assessments may help predict therapy failure early, allowing timely escalation of care.
Keywords: bronchiolitis, failure factors, high flow nasal cannula, infants, lung‐ultrasound, prognosis
1. Introduction
Acute bronchiolitis (AB) is the most prevalent respiratory infection and a leading cause of hospitalization in infants under 12 months [1]. The diagnosis of AB is primarily clinical, marked by symptoms such as coughing, wheezing, and, in severe cases, respiratory failure. The cornerstone of treatment of AB is supportive care, with respiratory support varying from oxygen therapy to invasive ventilation [2].
High Flow Nasal Cannula (HFNC), delivering high‐flow, heated, and humidified oxygen through a nasal cannula, has reduced intubation rates and alleviated respiratory distress in hospitalized infants with AB. This represents a significant advancement in medical care, offering a cost‐effective and better‐tolerated alternative to other ventilation modalities [2, 3, 4, 5]. However, HFNC is not universally effective for all infants with bronchiolitis, the availability of a noninvasive tool that can predict the clinical course in infants with AB would significantly improve the patient management. Lung ultrasound (LUS) has recently gained recognition as a valuable imaging tool in pediatric care for diagnosing various lung conditions. LUS is a safe, noninvasive, and non‐irradiating technique that provides real‐time imaging at the patient's bedside, it has largely replaced chest X‐ray in the evaluation of pulmonary conditions in pediatrics [6]. Recently, LUS has been employed to assess the severity of various lung pathologies and to predict the need for escalated care in these children [7].
Our study aimed to evaluate the effectiveness of LUS in predicting the risk of HFNC failure in infants with AB.
2. Patients and Methods
2.1. Study Population and Settings
This is a prospective observational and analytical study conducted from January 2022 to March 2024 at the Pediatric Department of a University Hospital in Monastir, Tunisia. The study aimed to evaluate the predictive value of lung ultrasound (LUS) in identifying high‐flow nasal cannula (HFNC) therapy failure in infants under 12 months of age, who were admitted with moderate to severe acute bronchiolitis and required HFNC therapy. To prevent overfitting, the criteria for excluding patients were based on established literature [8]. Children were non‐included if they had immunosuppression, complex heart diseases, pneumonia, neuromuscular diseases, cystic fibrosis, bronchopulmonary dysplasia, a history of inhaling foreign objects, infant asthma, unstable critical conditions requiring immediate life‐saving interventions, or if parental consent was not obtained. Additionally, patients who could not undergo LUS due to time constraints were not included in the study.
We also excluded BA patients who had received HFNC following mechanical ventilation or another form of noninvasive ventilation as a weaning modality. After parental consent, all participants underwent a clinical assessment, with the severity of bronchiolitis evaluated using the Wang score [9]. Blood gas analysis and chest X‐rays were performed for all included patients, and a septic workup was conducted when a superimposed infection was suspected.
We adhered to international ethical standards regarding patient confidentiality and data protection throughout the study. Ethical approval was obtained from the ethics committee at the Faculty of Medicine in Monastir (reference number: IORG 0009738 N° 162 OMB 0990‐0279).
2.2. High Flow Nasal Cannula Therapy
Two available HFNC devices were used during the study: the Optiflow Airvo 2 (Fisher and Paykel Healthcare, Auckland, New Zealand) and the BMC H‐80 (BMC, Beijing, China). Optiflow Junior nasal cannulas (Fisher and Paykel Healthcare, Auckland, New Zealand) and the BMC nasal cannula (BMC Medical Co. Ltd.) were selected and adapted for each patient based on age, weight, and the required flow rate, ensuring that the cannula tip diameter was less than half the diameter of the nostril. A mixed flow of humidified and heated air and oxygen was delivered through the circuit, with a safety margin of 2 L/kg/min. The FiO2 was adjusted to maintain a pulse oxygen saturation (SpO2) between 94% and 97%, and the temperature of the delivered gas was set to 37°C.
The initiation of HFNC was at the discretion of the attending physician, guided by general local guidelines. These guidelines included criteria such as a Wang score of ≥ 5, SpO2 < 94% on nasal cannula (2–3 L/min), and the presence of respiratory acidosis on blood gas analysis.
Once the patient's respiratory symptoms improved, the HFNC flow rate was gradually reduced until discontinuation, along with a stepwise decrease in FiO2, ensuring SpO2 remained between 94% and 97%.
2.3. Study Group
Patients were categorized into two groups based on their response to HFNC therapy: the HFNC success group and the HFNC failure group. The success of HFNC therapy was defined as the successful weaning from HFNC to a simple nasal cannula or to room air for more than 24 h. We defined HFNC failure as the need for therapeutic escalation to noninvasive ventilation (NIV) or invasive mechanical ventilation (IMV).
The decision to escalate respiratory support was determined by the attending physician, guided by general local guidelines. These guidelines are based on a comprehensive evaluation of clinical, radiological, and biochemical data, including: Persistence or worsening of increased respiratory efforts, FiO2 requirement above 60% for more than 2 h to maintain SpO2 ≥ 94%, the persistence or worsening of respiratory acidosis on blood gas analysis and occurrence of ventilatory complications such as pneumothorax or significant atelectasis.
2.4. Lung Ultrasound
An ultrasound machine (Samsung) equipped with a 10 MHz linear probe, standard abdominal preset, mechanical index lower than 0.7, intermediate gain to obtain a pleural line defined but not too saturated, unique focus on the pleural line and depth 3–5 cm was used. LUS was standardized in terms of both examination methods and timing. The acquisitions were achieved by three pediatricians having more than 1 year of experience in pediatric LUS. The first LUS was carried out within 3–6 h of HFNC initiation. The second ultrasound was performed 24 h after the first LUS. Six pulmonary fields were explored in each ultrasound [10]: Each hemithorax was divided into two sections: one anterior area delimited by parasternal and anterior axillary lines and one lateral area between the anterior and posterior axillary lines. The anterior section was further divided into an antero‐superior and an antero‐inferior section by drawing a virtual horizontal line through the mammillary line. These three areas of the chest wall were examined using both longitudinal and transverse sections.
The ultrasound score of each patient was obtained from the sum of the individual scores of each involved area, considering the worst finding of each area. Each lung area was assigned a score ranging from 0 to 3 points, resulting in a total score ranging from 0 to 18. The LUS scoring system was structured as follows: a score of 0 indicated an A‐pattern (characterized by the presence of only A‐lines); a score of 1 represented a B‐pattern (defined by the presence of ≥ 3 well‐spaced B‐lines); a score of 2 denoted a severe B‐pattern (marked by crowded and coalescent B‐lines with or without consolidations confined to the subpleural space); and a score of 3 signified extensive consolidations [11].
2.5. Statistical Analysis
Statistical analysis was performed using the SPSS software (IBM Statistical Package for the Social Science Statistics, version 25.0).
The sample size for this study was initially calculated using the predictive equation described by Whitley and Ball [12]. The proportion of HFNC failure was estimated to be 35% based on a previous study conducted at the Pediatrics Department of Fattouma Bourguiba University Hospital in Monastir [13]. To achieve a 95% confidence level with a margin of error of 8.5%, the following formula was applied: N = (Zα/22 × p × (1−p)) × D/E2, where “N” was the number of needed participants, “Z α/2” was the two‐tailed normal deviate for type 1 error (Z α/2 = 1.96 for 95% level of significance), “P” was the prevalence identified from a previous study (35%), “D” was the design (D = 1 for simple random sampling), and “E” was the precision (8.5%). This calculation yielded a required sample size of 120 patients. To account for a potential attrition rate of 3%, the final sample size was adjusted to 124 patients.
The study presents quantitative data as mean and standard deviation or median and interquartile range, and qualitative data as counts and percentages, as appropriate. Univariate analysis was used to compare the HFNC success group to the HFNC failure group. For qualitative variables, the Chi‐square test or Fisher's exact test was performed. For quantitative variables, the paired t‐test was used. The discriminatory ability of the predictive value for HFNC failure was evaluated by calculating the area under the receiver operating characteristic (ROC) curve for the Wang score and the LUS on day 1 and day 2. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the LUS score were then calculated. Multivariate analysis was carried out to determine if the LUS score is an independent risk factor of HFNC failure in AB patients. For all tests, p < 0.05 was considered significant.
3. Results
3.1. Patients Characteristics
In this study, 124 consecutive AB infants requiring HFNC support were included, the mean age of the study population was 82.89 days ± 61.11, and the mean weight was 5546.89 ± 1476.27 grams. The mean duration of HFNC was 65.61 ± 63.89 h. The HFNC success group comprised 98 (79%) infants, the HFNC failure group consisted of 26 patients (20.9%) (Figure 1). Persistent increased respiratory effort was the most common reason for respiratory support escalation (73%), followed by worsening hypercapnia (11.5%) and desaturation (7.6%). One patient (3.8%) required mechanical ventilation due to pneumothorax. One patient in the failure group died, due to refractory septic shock with multiorgan failure.
Figure 1.
Patients flow chart.
There were no significant statistical differences in demographic characteristics, clinical, or paraclinical parameters between the groups, except for the following: ‐ the Wang score, which was higher in the failure group compared to the success group (7 ± 1 vs. 6 ± 1, respectively; p = 0.008) (Table 1). The area under the curve (AUC) for the Wang score, was 0.658 (95% CI 0.542–0.774). The minimal cut‐off value was 7, with a specificity of 68.4% and a sensitivity of 55.8%. The FiO2 was adjusted to achieve a target SpO2 ≥ 94% and ≤ 97%. The mean initial FiO2 was 0.32 ± 9 in the success group and 0.29 ± 6 in the failure group, (p = 0.018). The duration of HFNC therapy was statistically longer in the success group, with a mean of 77 ± 66 h, compared to the failure group, which had a mean of 22 ± 25 h, p = 0.039. The white blood cell count was higher in the success group compared to the failure group (13172 ± 5869, vs. 10296 ± 5368, respectively, p = 0.031).
Table 1.
Patients characteristics.
| Variable | Total (n = 124) | Success group (n = 98) | Failure group (n = 26) | p value |
|---|---|---|---|---|
| Median age (Median) (IQR) | 65 (38–114) | 70 (38.0–121) | 60 (40–107.5) | 0.375 |
| Male gender (%) | 69 (55.6%) | 51 (52%) | 18 (69.2%) | 0.117 |
| Previous history of acute bronchiolitis (%) | 13 (10.5%) | 8 (8.2%) | 5 (19.2%) | 0.144 |
| Heart disease (%) | 5 (4%) | 5 (5.1%) | 0 (0%) | 0.583 |
| Full‐term birth (%) | 114 (91.9%) | 89 (90.8%) | 25 (96.2%) | 0.687 |
| Mean birth weight (SD) (grams) | 3301.53 (± 581.92) | 3303.27 (± 554.83) | 3295 (± 686.72) | 0.948 |
| IUGRa (%) | 11 (8.9%) | 5 (5.1%) | 3 (11.5%) | 0.363 |
| Previous History of mechanical ventilation (%) | 7 (5.6%) | 6 (6.1%) | 1 (3.8%) | 0.547 |
| Mean weight (SD) (grams) | 5546.89 (± 1476.27) | 5581.73 (± 1544.19) | 5415.57 (± 1203.29) | 0.612 |
| Weight < 10th percentile (%) | 17 (13.7%) | 14 (14.3%) | 3 (11.5%) | 0.495 |
| Median duration of symptom at admission (IQR) | 2 (2–4) | 2.5 (2–3.2) | 2 (2–5) | 0.346 |
| Mean respiratory rate (SD) (Cpm) | 64 (± 8) | 63 (± 7) | 65 (± 8) | 0.464 |
| Mean heart rate (SD) (Bpm) | 143 (± 19) | 144 (± 19) | 139 (± 17) | 0.210 |
| Mean oxygen saturation (%) (SD) | 91 (± 4) | 91 (± 4) | 92 (± 4) | 0.330 |
| Mean Wang score (SD) | 6 (± 1) | 6 (± 1) | 7 (± 1) | 0.008 |
| Wang score > 7 | 35 (28.2%) | 23 (23.5%) | 12 (46.1%) | 0.022 |
| Mean pH (SD) | 7.43 (± 0.07) | 7.43 (± 0.06) | 7.41 (± 0.06) | 0.120 |
| Mean pCO2 (SD) (mmHg) | 30 (± 7) | 30 (± 7.5) | 37.5 (± 7.5) | 0.06 |
| Mean WBC (SD) (/mm³) | 12500 (± 5860) | 13172 (± 5869) | 10296 (± 5368) | 0.031 |
| Mean hemoglobin (SD) (g/dL) | 10.6 (± 1.5) | 10.5 (± 1.5=) | 11 (± 1.5) | 0.202 |
| Mean CRP (SD) mg/L | 35 (± 52) | 38 (± 57) | 26 (± 36) | 0.349 |
IUGR, intra‐utirine growth retardation.
3.2. Lung Ultrasound
Lung ultrasounds were performed on all patients on both day 1 and day 2 of HFNC treatment. The ultrasound score was significantly higher in the failure group on day 1 (9 ± 2 vs. 6 ± 2, p < 0.001), and on day 2 (10 ± 1 vs. 6 ± 2, p < 0.001). The mean LUS score progression between day 1 and day 2 differed significantly between the success and failure groups. In the success group, the mean LUS score decreased by 0.5 ±, while in the failure group, the mean score increased by 1.5 ± 2 (p = 0.017). The LUS findings are illustrated in Table 2.
Table 2.
Comparison of LUS findings between the success and failure groups.
| Day 1 | Total n = 124 | Success group n = 98 | Failure group n = 26 | p value |
|---|---|---|---|---|
| Mean LUS score on day 1 (SD) | 6 (± 3) | 6 (± 2) | 9 (± 2) | < 0.001 |
| LUS on day 1 > 7 (%) | 57 | 37 | 20 | < 0.001 |
| Day 2 | n = 102 | n = 97 | n = 5 | p value |
|---|---|---|---|---|
| Mean LUS score on day 2 (SD) | 5 (± 3) | 6 (± 2) | 10 (± 1) | < 0.001 |
| LUS on day 2 > 9 (%) | 4% | 1% | 80% | < 0.001 |
|
Mean LUS score progression Day1‐Day2 (SD) |
−1.5 (± 1) | −0.5 (± 1) | +1.5 (± 2) | 0.017 |
We employed ROC curve analysis to identify the optimal ultrasound score threshold for predicting HFNC failure. On the first day, the LUS score achieved an AUC of 0.807, (95% CI 0.713–0.900). The minimal threshold value identified was 7, (OR 6.938; 95% CI 2.679–17.967; p < 0.001), demonstrating a sensitivity of 73% and a specificity of 68.9%, the PPV was 90.2% and the NPV was 42.9%.
On the second day, the LUS score achieved the highest AUC (0.990), (95% CI 0.971–1). The minimal threshold value identified was 9, demonstrating a sensitivity of 90% and a specificity of 96.4% (p < 0.001), the PPV was 99% and the NPV was 80%. (Figure 2).
Figure 2.
ROC curve analysis to determine the performance of the Wang score, LUS on day 1 and on day 2 for predicting HFNC failure.
On multivariate analysis only LUS score on day 2 was an independent factor associated with HFNC therapy failure, (OR 21.339; 95% CI 1.56–291.11; p = 0.022).
4. Discussion
Our study offers new insights into the management of moderate to severe AB, suggesting that the LUS score may be a valuable tool in predicting the failure of HFNC therapy. To our knowledge, this is the first prospective study to specifically evaluate the predictive value of LUS in infants with AB receiving HFNC therapy using a standardized LUS protocol. The findings have significant clinical implications for pediatric intensive care, where early recognition of HFNC failure can optimize care strategies.
HFNC has become an increasingly popular treatment modality for managing moderate to severe AB, with several studies suggesting that it can reduce the need for escalated respiratory support, including invasive ventilation [2, 4, 14, 15, 16, 17, 18]. However, HFNC is not universally effective for all infants with bronchiolitis, as our study and others have shown. Early identification of patients at risk for HFNC failure is crucial for optimizing treatment strategies and avoiding delays in necessary interventions.
In 2020, expert consensus underscored the importance of LUS in managing pediatric pneumonia and bronchiolitis [19] and many studies have highlighted the expanding role of LUS in assessing the severity of acute bronchiolitis [8, 20, 21, 22, 23, 24, 25, 26, 27], particularly in guiding therapeutic management decisions. A recent literature review analyzing 108 studies found that the LUS score correlates with the clinical course of bronchiolitis and can predict the need for admission to the pediatric intensive care unit. Studies have suggested that a combined score, integrating both clinical and ultrasound parameters, could be a reliable predictor of the need for respiratory support in patients with AB [10, 20]. The dynamic nature of bronchiolitis, which can worsen rapidly over hours or days, underscores the importance of repeated LUS examinations. Gori et al. [8] highlighted the value of LUS for short‐term monitoring in bronchiolitis patients, showing that ultrasound findings evolve with disease progression. This aligns with our results, where we observed a significant difference in LUS progression between the success and failure groups. The success group demonstrated a decrease in LUS score from day 1 to day 2, while the failure group exhibited an increase in their LUS scores, reflecting worsening lung pathology.
Our study demonstrated that infants with elevated LUS scores on both day 1 and day 2, are at an increased risk of HFNC therapy failure. These findings are consistent with previous studies that have explored the utility of LUS in assessing the severity of various lung conditions in children [8, 10, 20, 21, 22, 23, 28].
The ROC curve analysis showed that the LUS score on day 1 had an AUC of 0.807, with a sensitivity of 73% and specificity of 68.9% at a threshold of 7. This indicates that while LUS on the first day provides a good indication of potential HFNC failure. However, by day 2, the predictive accuracy of the LUS score significantly improved, with an AUC of 0.990 and a specificity of 99% at a threshold score of 9. This high specificity on day 2 suggests that LUS becomes a highly reliable tool for ruling out HFNC failure by this time point, allowing for more accurate identification of patients who are unlikely to need escalated respiratory support.
The Wang score, a commonly used clinical tool for assessing the severity of bronchiolitis, showed limited predictive ability for HFNC failure in our study. The AUC for the Wang score was only 0.658, indicating a lower discriminatory power compared to the LUS score. This finding is consistent with previous research that has questioned the utility of clinical scores alone in predicting respiratory failure [10, 20]. In contrast, the LUS score, particularly on day 2, outperformed the Wang score, suggesting that ultrasound‐based assessments may offer a more objective and reliable approach for predicting HFNC failure.
This result's significance was underscored by the multivariate analysis, which identified a high LUS on day 2 as an independent risk factor for HFNC failure in AB patients. Our findings are consistent with the study by Zheng et al. [7], which demonstrated a strong correlation between elevated LUS scores at admission and after 12 h, and the failure of HFNC treatment in infants with severe pneumonia. Various LUS scores have been utilized in the literature [11, 29], which accounts for the differing cutoff values used to predict patient outcomes. In our study, we opted for the simplest approach to enhance convenience, facilitate ease of use, and minimize discomfort for infants by only assessing the anterior and lateral chest areas. A recent study found that LUS scores in the superior lung areas had higher odds ratios for PICU admission and the need for ventilation than those in the inferior areas [30].
The ability to accurately predict HFNC failure using LUS could help clinicians make more informed decisions about the timing of therapeutic escalation, allowing for a more tailored and individualized approach to respiratory support. For example, patients with high LUS scores on day 1 and a worsening trend by day 2 could be closely monitored and potentially prepared for NIV or IMV, thereby reducing the risk of adverse outcomes associated with delayed escalation. In contrast, patients with stable or improving LUS scores might continue on HFNC.
4.1. Limitation
Despite the strengths of our study, several limitations should be acknowledged. First, we used a simplified LUS scoring system to enhance feasibility in a busy clinical setting where only three physicians are trained in LUS, and to minimize patient discomfort associated with prolonged ultrasound assessment. However, this approach may limit the comprehensiveness of lung assessment in infants with acute bronchiolitis, a condition characterized by heterogeneous disease patterns influenced by patient positioning and gravity. The recently updated Joint ESPNIC‐ESICM guidelines recommend a more detailed LUS assessment with five zones per hemithorax, which may offer deeper insights into lung pathology in this patient population. Future studies using this extended scoring system, as described by Loi et al. [29], could provide a more comprehensive evaluation.
Additionally, we used HFNC therapy as the primary support modality. Although HFNC is widely used in clinical practice, evidence suggests it may be less effective than continuous positive airway pressure (CPAP) in bronchiolitis patients, as demonstrated in the TRAMONTANE 1 study [31]. CPAP has been shown to reduce the duration of respiratory support and hospital stay, which can alleviate the public health burden during seasonal bronchiolitis outbreaks. However, logistical and resource limitations at our institution currently restrict the use of CPAP, a factor that may impact the generalizability of our findings. Recent European protocols [32, 33] highlight recommended respiratory support for bronchiolitis patients, and we suggest that future studies examine the comparative effectiveness of HFNC and CPAP in resource‐limited settings. Lastly, the sample size calculation was based on an expected HFNC failure rate of 35%, derived from a previous study conducted in our department. The lower actual failure rate observed in this study may have reduced the statistical power, potentially affecting the strength of the associations identified.
5. Conclusion
This study supports the integration of LUS into the standard of care for infants with moderate to severe AB requiring HFNC therapy. The predictive value of LUS, as demonstrated in this study, holds promise for enhancing patient care by allowing for earlier identification of those at risk for treatment failure and enabling more personalized treatment approaches. Continued research and collaboration are essential to refine LUS protocols and confirm its role in diverse clinical settings.
Author Contributions
Farah Thabet: writing–review and editing, onceptualization, supervision. Seyfeddine Zayani: investigation, conceptualization, project administration. Nawrass Haddad: data curation, writing–original draft, formal analysis. Abir Daya: investigation. Cyrine Ben Nasrallah: methodology, validation. Slaheddine Chouchane: project administration, supervision.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgment
Open Access funding enabled and organized by CNUDST.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Data available on request due to privacy restrictions.
References
- 1. Bel Hadj I., Trabelsi I., Tinsa F., et al., “Acute bronchiolitis management in Tunisia: Impact of the national guidelines,” La Tunisie medicale 99 no. 2 (2021): 238–242. [PMC free article] [PubMed]
- 2. Bressan S., Balzani M., Krauss B., Pettenazzo A., Zanconato S., and Baraldi E., “High‐Flow Nasal Cannula Oxygen for Bronchiolitis in a Pediatric Ward: A Pilot Study,” European Journal of Pediatrics 172, no. 12 (2013): 1649–1656. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Goh C. T., Kirby L. J., Schell D. N., and Egan J. R., “Humidified High‐Flow Nasal Cannula Oxygen in Bronchiolitis Reduces Need for Invasive Ventilation But Not Intensive Care Admission,” Journal of Paediatrics and Child Health 53, no. 9 (2017): 897–902. [DOI] [PubMed] [Google Scholar]
- 4. Guidi C., Ragusa N., Mussinatto I., et al., “Management of Acute Bronchiolitis in Spoke Hospitals in Northern Italy: Analysis and Outcome,” Diseases 12 (2024): 25, 10.3390/diseases12010025. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Borgi A., Louati A., Ghali N., et al., “High Flow Nasal Cannula Therapy Versus Continuous Positive Airway Pressure and Nasal Positive Pressure Ventilation in Infants With Severe Bronchiolitis: A Randomized Controlled Trial,” The Pan African Medical Journal 40, no. 40 (2021): 133, 10.11604/pamj.2021.40.133.30350. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Thabet F., Zayani S., Daya A., Ben Nasrallah C., Chouchane C., and Chouchane S., “Impact of Routine Bedside Lung Ultrasound Implementation on Chest X‐Ray Requests for Mechanically Ventilated Children: A Before‐After Uncontrolled Quality Improvement Project,” European Journal of Pediatrics 183, no. 10 (2024): 4379–4384. [DOI] [PubMed] [Google Scholar]
- 7. Zheng L. L., Chen R., Zheng C. H., Dai X. J., Zheng W. D., and Zhang J. X., “The Correlation Between Lung Ultrasound Scores and Outcomes of High‐Flow Nasal Cannula Therapy in Infants With Severe Pneumonia,” BMC Pediatrics 24, no. 1 (2024): 51. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Gori L., Amendolea A., Buonsenso D., et al., “Prognostic Role of Lung Ultrasound in Children With Bronchiolitis: Multicentric Prospective Study,” Journal of Clinical Medicine 11, no. 14 (2022): 4233. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Wang E. E. L., Milner R. A., Navas L., and Maj H., “Observer Agreement for Respiratory Signs and Oximetry in Infants Hospitalized With Lower Respiratory Infections,” American Review of Respiratory Disease 145, no. 1 (1992): 106–109. [DOI] [PubMed] [Google Scholar]
- 10. Supino M. C., Buonsenso D., Scateni S., et al., “Point‐of‐Care Lung Ultrasound in Infants With Bronchiolitis in the Pediatric Emergency Department: A Prospective Study,” European Journal of Pediatrics 178, no. 5 (2019): 623–632. [DOI] [PubMed] [Google Scholar]
- 11. Giorno E. P. C., Foronda F. K., De Paulis M., et al., “Point‐of‐Care Lung Ultrasound Score for Predicting Escalated Care in Children With Respiratory Distress,” The American Journal of Emergency Medicine 68 (2023): 112–118. [DOI] [PubMed] [Google Scholar]
- 12. Whitley E. and Ball J., “Statistics Review 4: Sample Size Calculations,” Critical Care 6, no. 4 (2002): 335–341. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Zayani S., Thabet F., Marzouki A., Benfredj M., Chouchane C., and Chouchane S., “Evaluation of Prognostic Factors for High‐Flow Nasal Cannula Therapy Failure in Infants With Bronchiolitis: A Prospective Study,” (2024), https://www.researchsquare.com/article/rs-4714148/v1.
- 14. Weichler K., El Assal O., Forbes M., and Pollauf L., “The Clinical Impact of High Flow Nasal Cannula Utilization in the Emergency Department on the Endotracheal Intubation Rate for Infants and Young Children With Severe Bronchiolitis,” Pediatrics 144, no. 2 (2019): 416. [Google Scholar]
- 15. Alexander E. C., Wadia T. H., and Ramnarayan P., “Effectiveness of High Flow Nasal Cannula (HFNC) Therapy Compared to Standard Oxygen Therapy (SOT) and Continuous Positive Airway Pressure (CPAP) in Bronchiolitis,” Paediatric Respiratory Reviews 11 (2024). Published ahead of print, June 24, 2024, 10.1016/j.prrv.2024.05.004. [DOI] [PubMed] [Google Scholar]
- 16. Franklin D., Babl F. E., Schlapbach L. J., et al., “A Randomized Trial of High‐Flow Oxygen Therapy in Infants With Bronchiolitis,” New England Journal of Medicine 378, no. 12 (2018): 1121–1131. [DOI] [PubMed] [Google Scholar]
- 17. Tinsa F., Bel Hadj I., Khalsi F., et al., “Apport de l'oxygénothérapie avec lunettes nasales à haut débit dans la prise en charge de la bronchiolite sévère,” Perfectionnement en Pédiatrie 2, no. 2 (2019): 183, 10.1016/j.perped.2019.04.014. [DOI] [Google Scholar]
- 18. Armarego M., Forde H., Wills K., and Beggs S. A., “High‐Flow Nasal Cannula Therapy for Infants With Bronchiolitis,” The Cochrane Database of Systematic Reviews 3, no. 3 (2024): CD009609. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Jaworska J., Komorowska‐Piotrowska A., Pomiećko A., et al., “Consensus on the Application of Lung Ultrasound in Pneumonia and Bronchiolitis in Children,” Diagnostics 10, no. 11 (2020): 935. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Hernández‐Villarroel A. C., Ruiz‐García A., Manzanaro C., et al., “Lung Ultrasound: A Useful Prognostic Tool in the Management of Bronchiolitis in the Emergency Department,” Journal of Personalized Medicine 13, no. 12 (2023): 1624. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Özkaya A. K., Yilmaz H. L., Kendir Ö. T., Gökay S. S., and Eyüboğlu İ., “Lung Ultrasound Findings and Bronchiolitis Ultrasound Score for Predicting Hospital Admission in Children With Acute Bronchiolitis,” Pediatric Emergency Care 36, no. 3 (2020): e135–e142. [DOI] [PubMed] [Google Scholar]
- 22. Bueno‐Campaña M., Sainz T., Alba M., et al., “Lung Ultrasound for Prediction of Respiratory Support in Infants With Acute Bronchiolitis: A Cohort Study,” Pediatric Pulmonology 54, no. 6 (2019): 873–880. [DOI] [PubMed] [Google Scholar]
- 23. San Sebastian Ruiz N., Rodríguez Albarrán I., Gorostiza I., Galletebeitia Laka I., Delgado Lejonagoitia C., and Samson F., “Point‐Of‐Care Lung Ultrasound in Children With Bronchiolitis in a Pediatric Emergency Department,” Archives de Pédiatrie 28, no. 1 (2021): 64–68. [DOI] [PubMed] [Google Scholar]
- 24. Camporesi A., Morello R., Guzzardella A., et al., “A Combined Rapid Clinical and Lung Ultrasound Score for Predicting Bronchiolitis Severity,” Intensive Care Medicine – Paediatric and Neonatal 1, no. 1 (2023): 14. [Google Scholar]
- 25. Bobillo‐Perez S., Sorribes C., Gebellí P., et al., “Lung Ultrasound to Predict Pediatric Intensive Care Admission in Infants With Bronchiolitis (LUSBRO Study),” European Journal of Pediatrics 180, no. 7 (2021): 2065–2072. [DOI] [PubMed] [Google Scholar]
- 26. Di Mauro A., Ammirabile A., Quercia M., et al., “Acute Bronchiolitis: Is There a Role for Lung Ultrasound?,” Diagnostics 9, no. 4 (2019): 172. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Zoido Garrote E., García Aparicio C., Camila Torrez Villarroel C., Pedro Vega García A., Muñiz Fontán M., and Oulego Erroz I., “Utilidad De La Ecografía Pulmonar Precoz En Bronquiolitis Aguda Leve‐moderada: Estudio Piloto,” Anales de Pediatría 90, no. 1 (2019): 10–18. [DOI] [PubMed] [Google Scholar]
- 28. Basile V., Di Mauro A., Scalini E., et al., “Lung Ultrasound: A Useful Tool in Diagnosis and Management of Bronchiolitis,” BMC Pediatrics 15, no. 1 (2015): 63. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29. Loi B., Vigo G., Baraldi E., et al., “Lung Ultrasound to Monitor Extremely Preterm Infants and Predict Bronchopulmonary Dysplasia. A Multicenter Longitudinal Cohort Study,” American Journal of Respiratory and Critical Care Medicine 203, no. 11 (2021): 1398–1409. [DOI] [PubMed] [Google Scholar]
- 30. Camporesi A., Vetrugno L., Morello R., De Rose C., Ferrario S., and Buonsenso D., “Prognostic Value of the Area of Lung Involved in Severe and Non‐Severe Bronchiolitis: An Observational, Ultrasound‐Based Study,” Journal of Clinical Medicine 13, no. 1 (2024): 84. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Milési C., Essouri S., Pouyau R., et al., “High Flow Nasal Cannula (HFNC) Versus Nasal Continuous Positive Airway Pressure (nCPAP) for the Initial Respiratory Management of Acute Viral Bronchiolitis in Young Infants: A Multicenter Randomized Controlled Trial (Tramontane Study),” Intensive Care Medicine 43 (2017): 209–216. [DOI] [PubMed] [Google Scholar]
- 32. Milési C., Baudin F., Durand P., et al., “Clinical Practice Guidelines: Management of Severe Bronchiolitis in Infants Under 12 Months Old Admitted to a Pediatric Critical Care Unit,” Intensive Care Medicine 49, no. 1 (2023): 5–25. [DOI] [PubMed] [Google Scholar]
- 33. De Luca D., Pezza L., Vivalda L., et al., “Critical Care of Severe Bronchiolitis During Shortage of ICU Resources,” EClinical Medicine 69 (2024): 102450. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Data available on request due to privacy restrictions.