1. Journal Club 17/09/13
Rob Morton

2. Heliox Therapy in Bronchiolitis:
Phase III Multicentre double blind RCT
Chowdhury et al. Pediatrics 2013; 131:

4. Bronchiolitis season in Sheffield
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5. Bronchiolitis season in Sheffield
Photos removed for copyright reasons

6. Heliox
Airways in bronchiolitis oedematous and inflamed, lined/blocked with mucus.
Mix of 21% O2 and 79% Helium- Lighter than air or O2.
Promotes laminar rather than turbulent flow in congested airways. Also has a higher CO2/02 binary coefficient, may promote alveolar gas exchange.
Safe, inert
? Cheap- $70 dollars a canister- 3-5 canisters a day
= £219 per day

7. Heliox Cochrane review(2010) Liet et al
Heliox Cochrane review(2010) Liet et al. Heliox inhalation therapy for bronchiolitis in infants. Cochrane Database Syst Rev. 2010(4):DD006915
4 trials including children < 2 years
All on intensive care units
3 studies showed improvements in symptoms scores at 1 hr of age
Concluded insufficient evidence, need for a large RCT

8. BREATHE trial (The Bronchiolitis Randomized Controlled Trial Emergency-Assisted Therapy with Heliox— An Evaluation )
4 centres- UK & Australia
? 3 Bronchiolitis seasons

9. Inclusion Criteria
All infants (<12months) with clinically diagnosed bronchiolitis by a doctor from A&E or wards
O2 sats <93% in air or
“Respiratory distress”
Requiring hospital admission

10. Randomised to 2 groups Intervention
“Heliox” via tight fitting face mask
Nasal cannulae if not tolerated
CPAP if requiring >4L/min O2 flow rate (mask), or >2L/min (NC)
“Controls”
“Airox”- same delivery criteria

12. Outcomes
Primary
“Length of time to alleviate hypoxia and respiratory distress”- time from start of trial gas to clinical stability out of O2 for 1 hour
Secondary
Proportion of each treatment group requiring CPAP
Woods asthma score

13. CASP (Critical Appraisal Skills Programme)
1. Did the trial address a clearly focused issue?
Yes/No.
Does Heliox improve length of treatment in bronchiolitis?
Is that the relevant issue? Length of stay more important.
? Severe/ mild bronchiolitics?

14. 2. Was the assignment of patients to treatments randomised?
?Yes
Randomised but ?? not all accountable
? Not all patients eligible approached for trial?
4 centres, 3 seasons = 30 bronchiolitics per year.
Adelaide has a population of 1.3million, Sheffield 0.5 million!

15. 3. Were all of the patients who entered the trial properly accounted for at the end of the trial?
?Yes

17. But…

18. Is it worth continuing??
………? Yes

19. 4. Were patients, health workers and study personnel “blind” to the treatment?
Yes- Good blinding process. Canisters A & B.
? Any smell to heliox? Presumably not.

20. 5. Were the groups similar at the start of the trial?

21. Were the groups similar?
Admitted from A&E? How are they fed? Bottle/ NG/ IV?
Previous bronchiolitis
Time from start of symptoms? Time since admission?
Co-morbidities?

22. 6. Apart from the experimental intervention, were the groups treated equally?
?- No mention of feeds, other cares. As study well blinded we can presume they were equal across the 2 groups.
How much O2 was required in each group, how severe were the patients? % O2 has an effect on use of Heliox.

23. What are the results?
7. How large was the treatment effect?

24. What are the results?

25. Outcomes
Length of treatment- Decreased in group who tolerated facemask, particularly those who are RSV+ve.
If tolerates facemask, and RSV+ve, LOT 1.46 vs 2.01 days, reduces length of treatment by 0.5 days
? Decreases need for CPAP (not statistically significant and small numbers)
“ Reduced respiratory distress”, significant from 8 hrs.
?? Take their word for it.

26. 8. How precise was the treatment effect?
No Confidence intervals, IQR instead, as using medians.

27. What are the results?

28. 9. Can the results be applied to our local population?
Developed country, same patients and pathology
Standard care does not usually involve facemasks or CPAP on wards.
No comparison to standard care.
? Can be used for bronchiolitics who are RSV +ve, if they can tolerate a face mask. May prevent need for CPAP & HDU admission?

29. 10. Were all the clinically important outcomes considered?
No.
Length of treatment of limited use as no comparison to normal care. Need to know length of stay in hospital (impossible to do in this study as no admission/ discharge times)
Eg., does the intervention/ mask lead to a decrease in feeds and prolong admission?
How much heliox was used?

30. 11. Are the benefits worth the harms and costs?
How much Heliox was actually used?
5 canisters seems a lot per day/ per patient.
= $350 per day/ £223
Best intervention group = £312 (1.4 days)
How much extra cost for the nursing care to fit face mask?
How much cost for the additional HDU beds?

31. So….How should a bronchiolitis trial be done?

32. SABRE: Hypertonic Saline in Acute Bronchiolitis: A Randomised Controlled Trial and Economic Evaluation

33. BREATHE
O2 <93% or resp distress
No time limit to recruit
No time of discharge
No economic evaluation
SABRE
O2 <92% on admission
Strict 90 minute limit to recruit
Criteria for “SABRE” fit for discharge- includes feeds
Full economic evaluation

34. Questions?