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\begin{document}

\title{Agreements and controversies of national Guidelines for bronchiolitis:
results from an Italian Survey among paediatricians.}



\author[1]{Sara Manti}%
\author[2]{Amelia Licari}%
\author[2]{Ilaria Brambilla}%
\author[3]{Carlo Caffarelli}%
\author[4]{Mauro Calvani}%
\author[5]{Fabio Cardinale}%
\author[6]{Giorgio Ciprandi}%
\author[7]{Claudio Cravidi}%
\author[8]{Marzia Duse}%
\author[9]{Alberto Martelli}%
\author[10]{Domenico Minasi}%
\author[11]{Michele Miraglia del Giudice}%
\author[12]{Giovan Battista Pajno}%
\author[13]{Maria Angela Tosca}%
\author[14]{Elena Chiappini}%
\author[15]{Gian Luigi Marseglia}%
\affil[1]{University of Catania}%
\affil[2]{Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia}%
\affil[3]{Università di Parma}%
\affil[4]{Ospedale S. Camillo-Forlanini}%
\affil[5]{University of Bari}%
\affil[6]{Casa di Cura Villa Montallegro}%
\affil[7]{ATS Pavia}%
\affil[8]{Policlinico Umberto I, Università Sapienza di Roma}%
\affil[9]{Azienda Ospedaliera G. Salvini, Ospedali di Garbagnate Milanese e Bollate}%
\affil[10]{Grande Ospedale Metropolitano}%
\affil[11]{1Department of Woman, Child and of General and Specialized Surgery. University of Campania "Luigi Vanvitelli" }%
\affil[12]{Universita degli Studi di Messina}%
\affil[13]{Istituto Giannina Gaslini}%
\affil[14]{University of Florence}%
\affil[15]{Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Italy}%


\vspace{-1em}



  
  \date{May 04, 2024}


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\selectlanguage{english}
\begin{abstract}
Introduction. Significant variations in the management of bronchiolitis
are often recorded, and, in parallel, to recommend a univocal clinical
approach it is not easy and is still questioned. This study is aimed to
evaluate the diagnostic and therapeutic management of bronchiolitis in
children adopted by Italian paediatricians following the national
guidelines. Material and methods. A survey study was designed and
carried out by sending an email an open-ended questionnaire developed by
an expert panel of the Scientific Board of the Italian Society of
Pediatric Allergology and Immunology (SIAIP). Questions were designed
according to the national inter-society consensus document on treatment
and prevention of bronchiolitis in newborns and infants. Results.
Overall, 234 paediatricians were taking part in the study. When
diagnosing bronchiolitis, only 44.01\% (103/234) of participants were
correctly following the national guidelines. All participants (100\%)
would perform laboratory tests and/or radiological exams. 44.01\%
administered oxygen (O2) when O2 saturation was major than 92\%. About
the therapeutic regimen, marked discrepancies between national
guidelines and recorded answers were reported. Indications for hospital
admission and discharge criteria were in line with the national
guidelines. Conclusions. There is a significant practise variation in
the management of acute bronchiolitis among Italians physicians. Some
wrong attitudes need to be further discouraged, such use of diagnostic
procedures and therapeutic approaches. Further research is urgently
required to define the best management of patients with bronchiolitis as
well as implement strategies to standardize care and improve the quality
of care.%
\end{abstract}%



\sloppy


\textbf{1. Introduction}

Bronchiolitis is the leading cause of hospital admission for respiratory
disease among infants younger than one-year-old. Clinically, children
with bronchiolitis may present with a wide range of clinical symptoms,
from mild to incipient respiratory failure\textsuperscript{1}. Diagnosis
of bronchiolitis is based on clinical history and a careful physical
examination. However, clinical signs, such as rhinorrhea, cough,
dyspnea, polypnea, apnea, crackles, wheezing, and feeding difficulties,
are not specific and they significantly overlap with symptoms and signs
of other diseases\textsuperscript{2}. Bronchodilators, corticosteroid,
antiviral therapy and methods of oxygen delivery have been suggested as
pharmacological interventions in treating acute bronchiolitis; however,
the evidence base for their benefit is poor\textsuperscript{3,4}.
Accordingly, a previous systematic review demonstrated heterogeneous
behaviours regarding the adopted diagnostic and therapeutic approaches
adopted among several European countries, based on the panel's
expertise\textsuperscript{5}. Moreover, several aspects are still under
debate, including the choice of the best diagnostic and therapeutic
management as well as the caregivers' adherence to validated protocols.
Therefore, significant variations in the therapeutic management of
bronchiolitis between clinicians and hospitals are often recorded, and,
in parallel, to recommend a univocal clinical approach, it is difficult
and is still questioned\textsuperscript{3-5}.

Considering the significant impact of these issues, the Italian Society
of Paediatric Allergy and Immunology (SIAIP) conducted a national survey
in order to evaluate the behaviours of Italian paediatricians in the
diagnostic and therapeutic management of infants and children with acute
bronchiolitis and their adherence to the current national
recommendations\textsuperscript{1} (Table 1), also aiming to improve the
management of bronchiolitis in children and standardize the behaviour of
physicians.

\textbf{2. Materials and methods}

This study is aimed to evaluate the diagnostic and therapeutic
management of bronchiolitis in children adopted by Italian
paediatricians in accordance with the national
guidelines\textsuperscript{1}.

The study was proposed in September 2019 by the Scientific Board of the
Italian Society of Pediatric Allergology and Immunology (SIAIP). A
specific website was prepared for the study.

The Survey was announced and firstly administered to all the
paediatricians attending the ''Opinoni a Confronto'' Annual Meeting,
held in Pavia, Lombardia (Italy) in October 2019. Overall, 100
questionnaires were distributed and full-filled. After that, the study
was carried out by sending by email an open-ended questionnaire.
Participation in the study was voluntary.

\emph{2.1 Structured questionnaire}

The questionnaire included an explanatory cover letter reporting the aim
of the Survey. Experts designed the questions in the field (SM, AL, GLM,
EC).

The structured questionnaire was prepared as a specific form to be
fulfilled online (closed- and open-ended format questions) on the
website. Responses were anonymous, but professional information
(university paediatrician, hospital paediatrician, primary care
paediatrician, or pediatric resident) was requested. The questionnaire
included ten questions in a multiple-choice format. Specifically, the
questionnaire contained questions on diagnostic criteria, diagnostic and
therapeutic management of bronchiolitis in infants and children younger
than 24 months of age. One or more answers for each question were
provided.

The survey was administered in Italian and translated into English for
publication. The English version of the questionnaire is enclosed in
Appendix A.

\emph{2.2 Statistical analysis}

The results were given as absolute numbers and percentages. The
percentages of responses to the questions have been calculated on the
total of the participants. SPSS software package (SPSS 11.5; Chicago,
IL) was used, and p \textless{} 0.05 was considered as statistically
significant.

\textbf{3. Results}

The answers to the survey by the participating Italian paediatricians
are summarized in figure 1 (a, b, c, d, e, f, g, h, i, l).

\emph{3.1 Participants' characteristics}

Overall, 234 paediatricians (27.7\% of physicians registered to the
Congress) returned the questionnaire. The completion rate was 100\%.

The average time taken to answer a question was 5 minutes.

The three Italian macro-regions were represented as follow: North
136/234, Centre 55/234, and South 43/234.

The most of participants in the survey were residents in paediatrics
(39.74\%, 93/234) followed by hospital paediatricians (30.34\%, 71/234),
family paediatricians (18.8\%, 44/234), and university paediatricians
(11.11\%, 26/234).

\emph{3.2 Epidemiological findings}

The mean number of patients reporting physician-diagnosed bronchiolitis
was \textless{}25 (34.18\%, 80/234), 25-50 (32.47\%, 76/234),
\textgreater{}50 (33.33\%, 78/234).

\emph{3.3 Diagnostic criteria}

When diagnosing bronchiolitis, 44.01\% (103/234) of participants
correctly included the presence of all the following criteria: onset
with rhinorrhea and/or upper respiratory tract infections; first episode
of respiratory distress associated with crackles and/or wheezing, use of
accessory muscles or lower chest wall retractions, low O2 saturation
levels, high respiratory rate relative to age, skin colour changes,
nasal flaring, fever; exposure to persons presenting with upper
respiratory tract viral infections; and presentation during the epidemic
season. For 5.5\% (13/234) of participants, diagnostic criteria included
rhinorrhea and/or upper respiratory tract infections. For 33.76\%
(79/234) of participants, diagnostic criteria included the first episode
of respiratory distress associated with crackles and/or wheezing, use of
accessory muscles or lower chest wall retractions, low O2 saturation
levels, high respiratory rate relative to age, skin colour changes,
nasal flaring, fever. For 6\% (14/234) of participants, diagnostic
criteria included exposure to persons presenting with upper respiratory
tract viral infections. For 10.68\% (25/234) of participants, diagnostic
criteria included clinical presentation during the epidemic season.

\emph{3.4 Approach to the no well-appearing child}

Although neither laboratory tests nor radiological exams are usually
indicated for the routine workup of infants with bronchiolitis {[}1{]},
the proportion of participants who would obtain complete blood count was
43.8\%. 2.37\% would perform blood culture; 85.21\% blood gas analysis,
26.63\% serum electrolytes, 7.69\% glycemia, 46.75\% C-reactive protein
(C-RP), 70.41\% polymerase chain reaction (PCR) on the nasal swab, and
13.61\% chest X-ray.

\emph{3.5 Indications for oxygen administration}

20.08\% (47/234) of participants would administer oxygen
(O\textsubscript{2}), whether O\textsubscript{2} saturation is
persistently lower than 90\% and 35.9\% (84/234) when
O\textsubscript{2}saturation ranges between 90 and 92\%. Conversely, not
following the guideline recommendations {[}1{]}, 15.81\% (37/234) when
O\textsubscript{2} saturation ranges between 92 and 94\%; and 28.2\%
(66/234) when O\textsubscript{2} saturation is persistently lower than
94\%.

\emph{3.6 Administration of medications}

Marked discrepancies between national guidelines {[}1{]} and recorded
answers were reported. The most common treatment administered for
bronchiolitis was high flow oxygen therapy (81.66\%) followed by oxygen
therapy with nasal cannula or face mask (68.05\%), hypertonic solution
(49.70\%), inhaled short-acting beta-agonists (SABA) (39.64\%), inhaled
epinephrine (21.30\%), an inhaled corticosteroid (ICS) (17.16\%),
systemic CS (64.52\%), respiratory physiotherapy (8.88\%), antibiotics
(4.73\%), intravenous SABA (0.59\%). Among paediatricians using systemic
CS, betamethasone was the most common CS administered (64.52\%),
followed by methylprednisone (16.66\%), prednisolone (7.26\%),
beclometasone dipropionate (4.7\%), and dexamethasone (4.7\%). In line
with national guidelines {[}1{]}, only 16.66\% of the participants did
not administer systemic CS.

\emph{3.7 Indications for hospital admission}

The indications for hospital admission included poor feeding or
dehydration (98.82\%), comorbidities (98.22\%), need for supplemental
oxygen therapy (96.45\%), poor social circumstances (82.25\%),
prematurity (82.25\%), presence of apnea (81.66\%), infants less than
three months of age (79.29\%), cyanosis (78.11\%), tachypnea (96.44\%),
fever (\textgreater{}38\selectlanguage{ngerman}°C) (44.97\%), uncertain of diagnosis (29.59\%),
unreliable parents (81.66\%).

\emph{3.8 Discharge criteria}

In line with national guidelines {[}1{]}, the discharge criteria adopted
by interviewed physicians were: improvement in clinical conditions
(47.93\%), adequate oral feeding (92.31\%), improved respiratory effort
(92.90\%), improved O2 saturations
(SaO\textsubscript{2}\textgreater{}97\%) (52.07\%), improved O2
saturations (SaO\textsubscript{2} \textgreater{}94\%) (37.87\%),
improved O2 saturations (SaO\textsubscript{2} \textgreater{}92\%)
(5.33\%), carer ability (78.70\%), adequate social circumstances
(18.34\%), possibility to arrange follow-up (67.46\%).

\textbf{4. Discussion}

Significant variations in the management of bronchiolitis are often
recorded, and, in parallel, to recommend a univocal clinical approach it
is difficult and is still questioned. This study aimed to evaluate the
diagnostic and therapeutic management of bronchiolitis in children
adopted by Italian paediatricians in accordance with the national
guidelines. Our survey showed a significant practice variation in the
management of acute bronchiolitis among Italians physicians.

Nationally developed evidence-based guidelines are required to reduce
practice variation, minimize nonevidence-based practices, and promote
cost-effective standardization of care\textsuperscript{6}. Nevertheless,
a significant practice variation persists, and it has been previously
reported that several guideline recommendations have been poorly
incorporated into the real clinical settings after their development and
dissemination\textsuperscript{7,8}. Accordingly, several international
studies have detected considerable variation in the management of acute
bronchiolitis\textsuperscript{9}. A significant practice variation in
the monitoring, treatment, and discharge of the children hospitalized
with bronchiolitis among physicians across Italian paediatric hospitals
has also been founding\textsuperscript{5}. Therefore, given the high
risk of inappropriate and unnecessary medicalization and
hospitalizations of patients with bronchiolitis and, consequently, the
bronchiolitis-related high-financial burden, it is important to examine
the diagnostic and therapeutic interventions administered in infants
presenting with bronchiolitis. In this regard, the SIAIP conducted a
national survey to evaluate the behaviours of Italian paediatricians in
the diagnostic and therapeutic management of infants and children with
acute bronchiolitis and their adherence to the current national
recommendations. To the best of our knowledge, a similar investigation
had not yet been conducted in Italy, making this study essential for
understanding the Italian management of patients suffering from
bronchiolitis. This information would also clarify the use of
evidence-based supportive therapies as compared with those that are not
evidence-based, aiming to improve the management of bronchiolitis in
children and standardize the behaviour of physicians.

The diagnosis of bronchiolitis is based on clinical history and physical
examination\textsuperscript{1}. In accordance to the national
guidelines\textsuperscript{1}, \textless{}50\% participants agreed on
the diagnostic criteria, and the most common criteria for bronchiolitis
diagnosis were onset with rhinorrhea and/or upper respiratory tract
infections; the first episode of respiratory distress associated with:
crackles and/or wheezing, use of accessory muscles or lower chest wall
retractions, low O2 saturation levels, high respiratory rate relative to
age, skin colour changes, nasal flaring, fever; exposure to persons
presenting with upper respiratory tract viral infections; and
presentation during the epidemic season. Marked discrepancies could be
observed between the remaining respondents as well as inappropriateness
in the answer.

National guidelines include as criteria for hospital admission the
following: O2 saturation persistently lower than 90-92\%, the entity of
respiratory distress, presence of apnea, dehydration, and moderate to
severe bronchiolitis\textsuperscript{1}. Other important factors should
be taken into consideration are prematurity (gestational
age\selectlanguage{english} \textless{}\selectlanguage{english} 37 weeks or birth age\selectlanguage{english} \textless{}\selectlanguage{english} 6--12 weeks),
responsivity and alertness, poor hydration and feeding (defined as less
than 50\% of usual fluid intake in preceding 24 h), social and
environmental factors, and presence of pre-existing risk
factors\textsuperscript{1}.

The decision to hospitalize a child affected by bronchiolitis is a
complex process impacted by the course of the illness and other
clinical, socio-cultural and geographic factors as well as by the
possibility to access to the follow-up\textsuperscript{1,10}. Moreover,
the local culture of care can influence the decision-making process,
irrespective of disease severity. Thus, although inpatient observation
is recommended for selected infants affected by bronchiolitis,
physicians are more likely to hospitalize infants with milder
bronchiolitis, taking improper advantage of the use of inpatient
resources. On the other hand, the variability in admission criteria
among guidelines may alter unavoidably the hospitalization criterion. In
this regard, it must be considered that some institutions have protocols
that require the ordering of diagnostic tests (e.g., complete blood
count, chest X-ray) on admission. However, \emph{a priori} reasons to
support this clinical practice are not currently supported by
evidence-based medicine (EBM)\textsuperscript{11}. Moreover, this
practice could lead both to perform costly and unnecessary
testing/procedure cascade as well as inappropriate outpatient/inpatient
antibiotic prescriptions.

The administration of non-recommended interventions in our study
occurred at a moderate-to-high rate, as follows: inhaled epinephrine
(21.30\%), ICS (17.16\%), systemic CS (64.52\%), respiratory
physiotherapy (8.88\%), antibiotics (4.73\%), intravenous SABA (0.59\%).
The current literature does not recommend the diagnostic testing for
children with bronchiolitis, except for conducting epidemiological
studies. Moreover, very few data support the impact of testing on
patient outcomes and quality of care, and they do not provide clear
indications for such testing or the impact of testing on relevant
patient outcomes\textsuperscript{1,5,12}. Moreover, the overuse of
instrumental diagnostic tests does not comply with patient safety and,
also, weighs on the healthcare economy.

Elsewhere, the guidelines developed by a panel of experts aim to
minimize overtreatment by recommending against the use of noneffective
interventions\textsuperscript{13-19}. Nevertheless, authors of inpatient
bronchiolitis studies published after the 2006 American Academy
Pediatrics (AAP) bronchiolitis guideline have found disappointingly high
use of the non recommended resources\textsuperscript{20,21}. We found a
surprising number of children were treated with medications. Following
the Italian guidelines\textsuperscript{1}, supplemental oxygen
(O\textsubscript{2}) should be administered if
O\textsubscript{2}saturation levels are persistently below 90--92\% at
ambient air\textsuperscript{1,22}.

A recent trial has suggested that outcomes may not differ significantly
when an O\textsubscript{2}saturation target of \selectlanguage{english}[?]90\% is
used\textsuperscript{23}. Whether an increased respiratory effort is
occurring, high-flow oxygen therapy with humidified and heated oxygen
(high-flow nasal cannula, HFNC) should be considered. However, different
O\textsubscript{2} saturation thresholds are recommended for hospital
management and for starting O\textsubscript{2} therapy. Thus, it is
reasonable to hypothesize that both the difference in the evidence
provided by the literature as well as context-specific factors may be
key reasons for the differences in clinical practice. In children with
bronchiolitis who cannot maintain oral hydration intravenous or
nasogastric fluids may be considered\textsuperscript{1,22}. There is
sparse evidence supporting the routine use of hypertonic solution,
nebulized adrenaline, salbutamol, respiratory physiotherapy, systemic or
inhaled or systemic CS, and antibiotics\textsuperscript{1,22}. However,
authors support the use of hypertonic saline to decrease airway oedema
and improve mucociliary clearance in infants\textsuperscript{1,22}.
Unlikely to other respiratory diseases in which CS show a beneficial
effect, their use does not improve the short- and long-term prognosis in
infants with bronchiolitis\textsuperscript{1,22}.

Similarly, the association of systemic CS with epinephrine or SABA does
not produce a significant benefit\textsuperscript{1,22}. The
administration of bronchodilators in managing bronchiolitis is still
contentious and, although evidence is against their routine use, several
guidelines still recommended a trial of bronchodilators in treating
infants with acute bronchiolitis\textsuperscript{5}. Despite the absence
of evidence suggesting a benefit of the use of antibiotic in acute
bronchiolitis, their prescription in primary care settings is commonly
reported\textsuperscript{1,22}. Evidence supporting the use of nebulized
adrenaline, antivirals, antileukotrienes, and chest physiotherapy
(vibration and percussion techniques) during the acute phase of
bronchiolitis is insufficient\textsuperscript{1}.

Surprisingly, regarding the discharge criteria, the healthcare
professional behaviour was in line with the national
guidelines\textsuperscript{1}. An appropriate discharge requires
evaluation of multiple factors including medical (clinical conditions,
adequate feeding, improved respiratory effort), psychosocial (carer
ability), logistic (possibility to arrange follow-up), and economic
(adequate social circumstances) considerations. Discharge planning must
involve both the health care team and patient/family caregivers to
develop a patient-centred plan ensuring that the patient is safely
discharged home and minimizing the risk of adverse events and/or
unplanned readmissions\textsuperscript{22}.

Except for the data on the discharge criteria, we formulated different
hypotheses to explain the striking differences between the findings of
our study and the guideline-related recommendations of nonintervention.
Acute bronchiolitis significantly causes pressures in health service and
throughout the region. Probably, the parental expectation ``to do
something'' might be in part responsible for these results, also
increasing the local practice differences.\selectlanguage{english} In a previous study, authors
reported that bronchiolitis hospitalization caused significant
emotional, physical and organizational consequences both on parents and
siblings persisting up to 3 months after hospital
discharge\textsuperscript{25}. Moreover, it is possible that primary
care paediatricians, who may have limited experience with managing acute
bronchiolitis in advanced stage of disease, are influenced wrongly by
the medical literature showing benefit of SABA and/or ICS in other
respiratory diseases\textsuperscript{22,26}. Furthermore, there is
evidence that exposure to a few cases of patients with bronchiolitis is
associated with the increased use of investigations and
medications\textsuperscript{27}. Lastly, the difficulty and/or the
impossibility to arrange follow-up care can affect disease management.

\emph{4.1 Limits of the study}

The survey design generates findings entirely based on recall over a
previous calendar year. However, given the fact there has been no
national or local implementation of a standardized bronchiolitis
guideline, we can exclude with reasonable certainty that a significant
change in clinical practice has occurred since the time our data were
recorded. Furthermore, what physicians report and what they do in real
clinical practice may often vary. Additionally, data were only collected
from 234 paediatricians, but this denominator can not be definitively
representative of all nation. Moreover, small sample sizes in some sites
have limited our ability to investigate site-to-site variation. On the
other hand, the solid response rate and the broad representation of
sites across the whole country lend weight and credibility to our
results.

\textbf{5.} \textbf{Conclusions}

There is a significant practice variation in the monitoring, treatment,
and discharge of children suffering from acute bronchiolitis among
Italians physicians. Future research is urgently required to define the
best management of patients with bronchiolitis, optimize the use of
therapeutic resources as well as implement strategies to standardize
care and improve the quality of care.

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\end{enumerate}

\textbf{Table}

\textbf{Table 1.} The basic diagnostic and therapeutic management of
bronchiolitis in accordance with the national recommendations {[}1{]}.

\textbf{Appendix}

Appendix A\textbf{.} English version of the questionnaire administered.

\textbf{Figure}

\textbf{Fig. 1 (a, b, c, d, e, f, g, h, i, l).} Answers provided by the
participating Italian pediatricians to the survey. (a, b) Participants'
characteristic (data are expressed in absolute value). (c) Mean number
of patients reporting physician-diagnosed bronchiolitis (data are
expressed in absolute value). d) Diagnostic criteria: A: rhinorrhea
and/or upper respiratory tract infections; B: first episode of
respiratory distress associated with crackles and/or wheezing, use of
accessory muscles or lower chest wall retractions, low O2 saturation
levels, high respiratory rate relative to age, skin colour changes,
nasal flaring, fever; exposure to persons presenting with upper
respiratory tract viral infections; and presentation during the epidemic
season; C: persons presenting with upper respiratory tract viral
infections; D: clinical presentation during the epidemic season; E: all
the previous criteria (data are expressed in percentage). e) Approach to
the no well-appearing child: A: complete blood count, B: blood culture;
C: blood gas analysis; D: serum electrolytes; E: glycemia; F: C-reactive
protein (C-RP); G: polymerase chain reaction (PCR) on the nasal swab; H:
chest X-ray (data are expressed in percentage). f) Indications for
oxygen administration (data are expressed in percentage). g)
Administration of medications: A: high flow oxygen therapy; B: oxygen
therapy with nasal cannula or face mask; C: hypertonic solution; D:
inhaled short-acting beta-agonists; E: inhaled epinephrine; F: inhaled
corticosteroid; G: systemic corticosteroid; H: respiratory
physiotherapy; I: antibiotics; L: intravenous short-acting
beta-agonists; M: antivirals; N: antileukotrienes; O: systemic
epinephrine (data are expressed in percentage). h) The most common
corticosteroids administered: A: betamethasone, B: methylprednisone, C:
prednisolone, D: beclometasone dipropionate, E: dexamethasone; F: none
(data are expressed in percentage). i) Indications for hospital
admission: A: infants less than 3 months of age; B: prematurity; C:
respiratory rate \textgreater{}30 breaths/minute; D: respiratory rate
\textgreater{}50 breaths/minute; E: respiratory rate \textgreater{}60
breaths/minute; F: poor feeding or dehydration; G: cyanosis; H: apnea;
I: comorbidities; L: poor social circumstances; M: uncertain of
diagnosis; N: need for supplemental oxygen therapy; O: fever; P:
unreliable parents (data are expressed in percentage). l) Discharge
criteria: A: SaO2 \textgreater{}97\%, B: SaO2 \textgreater{}94\%; C:
SaO2 \textgreater{}92\%; D: improved respiratory effort; E: adequate
oral feeding; F: adequate social circumstances; G: carer ability; H:
possibility to arrange follow-up; I: improvement in clinical conditions
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