Comparación de la utilidad de escalas clínicas de gravedad de bronquiolitis en urgencias de pediatría
Several clinical scales have been developed to assess the severity of bronchiolitis as well as the probability of needing inhospital care. A recent systematic review of 32 validated clinical scores for bronchiolitis concluded that 6 of them (Wood-Downes, Respiratory Clinical Score [RCS], Respiratory...
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| Tipo de recurso: | tesis doctoral |
| Estado: | Versión publicada |
| Fecha de publicación: | 2024 |
| País: | España |
| Institución: | Universidad de Valladolid |
| Repositorio: | UVaDOC. Repositorio Documental de la Universidad de Valladolid |
| OAI Identifier: | oai:uvadoc.uva.es:10324/66289 |
| Acceso en línea: | https://doi.org/10.35376/10324/66289 https://uvadoc.uva.es/handle/10324/66289 |
| Access Level: | acceso abierto |
| Palabra clave: | Pediatría Bronchiolitis Bronquioiltis Pediatric emergency medicine Urgencias de pediatría 32 Ciencias Médicas |
| Sumario: | Several clinical scales have been developed to assess the severity of bronchiolitis as well as the probability of needing inhospital care. A recent systematic review of 32 validated clinical scores for bronchiolitis concluded that 6 of them (Wood-Downes, Respiratory Clinical Score [RCS], Respiratory Score [RS], Bronchiolitis risk of admission score [BRAS], Modified Wood’s Clinical Asthma Score [M-WCAS] and Respiratory Severity Score [RSS]) were the best ones regarding reliability, sensitivity, validity, and usability. However, to the best of our knowledge, no study has compared all of them in a clinical scenario. Also, after this review, three more scales were published: BROSJOD, Tal modified, and one score developed by PERN. Our main aim was to compare the ability of different clinical scales for bronchiolitis to predict any relevant outcome. A prospective observational study was conducted that included patients of up to 12 months old attended to, due to bronchiolitis, in the paediatric Emergency Department of a secondary university hospital from October 2019 to January 2022. For each patient, the attending clinician filled in a form with the items of the scales, decomposed, in order to prevent the clinician from knowing the score of each scale. Then, the patient was managed according to the protocol of our Emergency Department. A phone call was made to each patient in order to check whether the patient ended up being admitted in the next 48 h. In the case of those that were impossible to contact by phone, the clinical history was reviewed. For the purpose of the study, any of the following were considered to be a relevant outcome: admission to ward and need for supplementary oxygen, non-invasive ventilation (NIV) or intravenous fluids, and admission to the paediatric intensive care unit (PICU) within the next 48 h or death. For the aim of the study, the area under the curve (AUC) was calculated in each scale. Also, the best cut-off point was estimated according to the Youden index and according to the percentage of patients correctly classified; its sensitivity (Sn) and specificity (Sp) for a relevant outcome were calculated in those points. Additionally, AUC for relevant outcome depending on the experience of the attending physician and depending on evolution time were calculated. We included 265 patients (52.1% male) with a median age of 5.3 months (P25-P75 2.6–7.4). Among them, 46 (17.4%) had some kind of relevant outcome. AUC for prediction of a relevant outcome ranged from 0.705 (Respiratory Score) to 0.786 (BRAS), although no scale performed significantly better than others. RSS was the scale which had a higher global score, considering all analysis made. A score lower or equal to 2 in the PERN scale showed a sensitivity of 91.3% (CI95% 79.7–96.6) for a relevant outcome, with only 4 misdiagnosed patients (only 2 of them needed NIV). RCS was the most specific scale, while BROSJOD and RSS had the better combination of Sn, Sp and positive and negative predictive values. There were no statistically significant differences in the performance of the scales depending on the experience of the attending clinician. Conclusions: There were no differences in the performance of the nine scales to predict relevant outcomes in patients with bronchiolitis. When selecting which scale to use, all factors influencing scales performance should be taken into account, and assessing the presence of “red flags” in the patient’s clinical history and physical examination is likely to be more important that the punctuation on a particular scale. |
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