Bronchiolitis guidelines: Diagnosis, management, and prevention
Bronchiolitis, an acute inflammatory injury of the bronchioles, is the most common cause of lower respiratory tract infection in children aged younger than 12 months.
Bronchiolitis, an acute inflammatory injury of the bronchioles, is the most common cause of lower respiratory tract infection in children aged younger than 12 months. It usually affects children aged younger than 2 years and peaks in infants aged between 3 and 6 months.1 A number of viral pathogens can cause bronchiolitis, with respiratory syncytial virus (RSV) being the most common in children aged younger than 2 years and the most common virus found in children hospitalized for bronchiolitis.
Over the years, the rate of hospitalizations for children with bronchiolitis has increased and is the most common reason for hospitalization among infants aged 12 months and younger.2 Despite this, controversy still exists over the best way to treat these children.
To help provide guidance to pediatricians and other healthcare providers who care for children with bronchiolitis, the American Academy of Pediatrics (AAP) updated its 2006 clinical practice guidelines on the diagnosis and management of bronchiolitis based on new evidence that has emerged since that time.3
The updated 2014 clinical practice guidelines, targeted at the diagnosis, management, and prevention of bronchiolitis in children aged from 1 month through 23 months, provide stronger recommendations against unnecessary testing and use of bronchodilators, and recommend select use of prophylaxis palivizumab.2 Overall, the guidelines emphasize supportive care that includes hydration and oxygen as the main approach to treatment.4
This article highlights key recommendations made in the new guidelines to facilitate an easy approach for pediatricians and other healthcare providers when meeting with an infant with suspected bronchiolitis.
A word on guidelines
As with all guidelines, these are meant as a guide and not the final word on diagnosing and treating bronchiolitis. In an interview on the rationale behind the new guidelines, lead author Shawn L. Ralston, MD, visiting associate professor and instructor of pediatrics at the Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, emphasized that the guideline are intended to address typical cases of bronchiolitis and are not meant to advise healthcare providers on how to care for every individual patient.5
What the guidelines do is to provide healthcare providers with the most recent data from the best evidence available on recommended approaches to diagnosing, treating, and preventing bronchiolitis in infants and children.
As is true of all evidence-based guidelines, recommendations reflect the quality of the available evidence and the balancing of the benefit and harm anticipated when the recommendation is followed.2 Recommendations are therefore graded based on the quality of the evidence and whether a benefit or harm predominates or is balanced. Recommendations are given a rating of “strong,” “moderate,” and “weak” based on the AAP grading system.6 The definition and clinical implication of each rated recommendation are provided in Tables 1, 2, and 3.2
Updated 2014 guidelines: Key recommendations
As stated earlier, the 2014 guidelines are targeted at the diagnosis, management, and prevention of bronchiolitis in children aged from 1 month through 23 months. The guidelines do not apply to children with a number of comorbidities, which are listed in Table 4.2
Changes from the 2006 guidelines include the following:
· Testing for specific viruses including RSV is generally unnecessary.
· Routine radiographic or laboratory studies are not needed for diagnosis.
· History and physical examination should be the basis for assessing and diagnosing bronchiolitis.
· A trial dose of a bronchodilator (ie, albuterol or salbutamol) is no longer recommended.
· Use of prophylaxis palivizumab is limited to select patients.
Diagnosis: Key recommendations
Table 1 highlights the key recommendations for the diagnosis of bronchiolitis. Emphasis is placed on diagnosis based on history and physical examination.2 New from the 2006 guidelines is the recommendation against testing for RSV or other viruses, or the use of imaging and laboratory tests.
According to Ralston, conflicting evidence on what predicts disease severity did not permit the guidelines to offer a specific set of risk factors to determine disease severity, but she said that the main skill in weathering bronchiolitis is the ability to cough. Therefore, she said that more potentially severe disease is often found (but not always) in younger patients; those born prematurely; and those with other complicating illnesses that in particular impair their ability to cough (ie, neuromuscular disorders).5 In addition, she emphasized that a truly effective therapy is lacking to treat bronchiolitis and therefore knowing disease severity in most children with bronchiolitis, other than those who need intensive therapy, does not affect treatment.
Management: Key recommendations
Table 2 highlights the key recommendations for treatment of bronchiolitis.2 Emphasis is on supportive care including hydration and oxygen. As seen in Table 2, the guidelines recommend the use of nasogastric (NG) or intravenous (IV) fluids for infants with bronchiolitis who cannot maintain hydration orally.
According to Ralston, although 1 randomized clinical trial found both approaches to be equivalent, she said that she personally strongly prefers NG hydration over IV hydration if given a choice.5,7 She emphasized that the gut is functional in bronchiolitis and that some evidence suggests that early nutrition in bronchiolitis may improve the general condition. Further, nutrition in the long run is even more important. She also pointed out that bronchiolitis is a disease with significant risk for iatrogenic hyponatremia, and that a small amount of evidence suggests some risks associated with maintenance IV fluids using a hypotonic solution.5
New from the 2006 guidelines is the stronger recommendation to not use bronchodilators, corticosteroids, and chest physiotherapy, as well as the recommendation against a trial dose of a bronchodilator.2
According to Ralston, this change in recommendation highlights a discrepancy between the available evidence and clinical experience and practice. Although in practice many children with bronchiolitis are treated with albuterol and then observed for their response, as supported by the 2006 guidelines, she emphasized that the evidence does not support this for the vast majority of patients with bronchiolitis and said treating all patients with first-time wheezing would be doing more harm than good.5
The guidelines also discourage the use of continuous pulse oximetry based on the lack of evidence to support its benefit. According to Ralston, epidemiologic data indicate that using this technology across an entire population has resulted in a significant increase in hospitalizations, but the evidence to date has not been sufficient to state this clearly.5 She added, however, that what is known is that continuous pulse oximetry does not predict much in the absence of incorporating clinical findings into the overall assessment of disease severity.
Also new is guidance on the use of a relatively new therapy, nebulized hypertonic saline. Based on the current evidence, the guidelines do not recommend it for short-term use, but evidence suggests it may shorten the length of stay in children hospitalized for longer than 3 days. According to Ralston, the preponderance of the evidence suggests that nebulized hypertonic saline may be useful if administered in a sustained way over a relatively prolonged period of time. She said this is one of the most important recommendations for future research, and that a trial is needed for the use of hypertonic saline in outpatients.5
Prevention: Key recommendations
Table 3 highlights the key recommendations for prevention of bronchiolitis.2 Of particular interest in the new guidelines, which supplement an earlier guideline on palivizumab prophylaxis, is the select use of palivizumab prophylaxis in infants who are most likely to benefit from it.2,8 The new recommendation increases the gestational age for administration of palivizumab and provides more specific criteria on which infants should receive it.
REFERENCES
1. DeNicola LK. Bronchiolitis. Medscape. Available at: http://emedicine.medscape.com/article/961963-overview. Updated November 10, 2014. Accessed December 16, 2014.
2. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502.
3. American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118(4):1774-1793.
4. Lieberthal AS, Ralston SL. New data prompt update to AAP guideline on diagnosis, management of bronchiolitis. AAP News. 2014;35:11. Available at: http://aapnews.aappublications.org/content/35/11/1.1. Published November 1, 2014. Accessed December 16, 2014.
5. Quinonez RA, Ralston SL. Bronchiolitis: the rationale behind the new AAP guideline. Medscape Pediatrics. Available at: http://www.medscape.com/viewarticle/834677. Published November 13, 2014. Accessed December 16, 2014.
6. American Academy of Pediatrics Steering Committee on Quality Improvement and Management. Classifying recommendations for clinical practice guidelines. Pediatrics. 2004;114(3):874-877.
7. Oakley E, Borland M, Neutze J, et al; Paediatric Research in Emergency Departments International Collaborative (PREDICT). Nasogastric hydration versus intravenous hydration for infants with bronchiolitis: a randomised trial. Lancet Respir Med. 2013;1(2):113-120.
8. American Academy of Pediatrics Committee on Infectious Diseases; American Academy of Pediatrics Bronchiolitis Guidelines Committee. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics. 2014;134(2):415-420.
Ms Nierengarten, a medical writer in St. Paul, Minnesota, has over 25 years of medical writing experience, coauthoring articles for Lancet Oncology, Lancet Neurology, Lancet Infectious Diseases, and Medscape. The author has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.
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