For Bronchiolitis, Less is More

 

By Shabnam Jain sjain@emory.edu

By Shabnam Jain
sjain@emory.edu

 

Bronchiolitis is a self-limited, viral lower respiratory tract infection that affects infants and young children.  It is the most common cause of hospital admission in infants in the US. In 2014, the American Academy of Pediatrics published a clinical practice guideline (CPG) entitled The Diagnosis, Management, and Prevention of Bronchiolitis.(1)   The CPG excludes infants under 1 month of age, those with hemodynamically significant cardiac disease, significant pulmonary disease, or major chronic conditions. Based on this CPG, in 2015 the AAP Section on Emergency Medicine developed a clinical algorithm for bronchiolitis in the ED setting, addressing some newer therapies that can be considered in severe or undifferentiated presentations. (2) It also offers criteria for which patients can be discharged from the ED and may be helpful for primary care providers in making decisions on whom to refer to the ED. Children’s Healthcare of Atlanta has its own guidelines as well. (3)  These resources may be useful for the generally healthy infant with bronchiolitis with the following recommendations applicable to pediatric outpatient practice:

 

  1. Diagnosis and severity assessment is made on the basis of history and physical exam and assessment of risk factors. Routine chest X-rays and RSV testing are not recommended. 
  2. Management: Albuterol may improve respiratory score (subjective), but has no effect on clinical course, disease resolution, admission, or length of stay.  It does however, increase adverse effects (tremors, tachycardia) which outweighs any small potential benefits. Albuterol is not recommended for routine use in bronchiolitis.  Furthermore, there is no benefit from routine use of epinephrine in inpatients or outpatient settings. Epinephrine may be used as a rescue agent in severe disease.  Finally, steroids have no role in the management of bronchiolitis.
  3. Oxygen and Pulse oximetry: There is poor correlation between respiratory distress and oxygen sats.  Transient hypoxemia is common in bronchiolitis; pulse oximetry has been associated with perceived need for admission and is a primary determinant of inpatient LOS. Providers may choose not to give O2 if sats >90%  and may choose not to use continuous pulse oximetry
  4. Antibiotics are not indicated unless there is a concomitant bacterial infection.

 

Patients who meet the following are generally considered appropriate for discharge home:

  • Room air sats consistently ≥ 90% while awake or >88% while asleep
  • Able to handle secretions or need bulb suctioning only
  • Adequate activity & hydration
  • Parents able to follow-up with PCP within 48 hours or access emergency care if needed

 

For the previously healthy, mild to moderate bronchiolitis patient, the current strategy is: Don’t just do something, stand there!

 

  1. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014;134(5):e1474–e1502 – October 01, 2015.    http://pediatrics.aappublications.org/content/134/5/e1474
  2. Jain S, Stack A, Baskin M, et al. Clinical Algorithm for Bronchiolitis in the Emergency Department Setting    http://www2.aap.org/sections/pem/PDF/AAPSOEMCOQTBronchiolitisGuideline.pdf
  3. Children’s Healthcare of Atlanta (Clinical Excellence page). https://md.choa.org/clinical-excellence/clinical-practice-guidelines/bronchiolitis
Advertisements

Bronchiolitis Update 2015

By Maggie Kilgore and Javier Tejedor-Sojo

Margaret.Killgore@choa.org

javier.tejedor-sojo@choa.org

jtspicmkpic

As we move into bronchiolitis season, we wanted to remind you all of the new recommendations for inpatient and outpatient bronchiolitis treatment published by the AAP in 2014. These new recommendations were incorporated into Children’s Healthcare of Atlanta’s updated guidelines in the fall of 2014. Bronchiolitis is one of the top three admission diagnoses at Children’s. The 2014 Children’s guideline fosters patient-centered, value-based outcomes, more closely supports evidence-based therapies and interventions, and recommends that care providers deliver a consistent message to families.

Some of the key elements of the 2014 AAP guideline are that:

  • Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination. Chest X-Rays or laboratory studies should not be obtained routinely
  • Clinicians should not routinely administer albuterol or epinephrine to patients with a diagnosis of bronchiolitis
  • Clinicians should not administer antibacterial medications to infants and children with a diagnosis of bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one
  • In infants with bronchiolitis, clinicians may choose not to administer supplemental oxygen if the O2 saturation exceeds 90%

It can be difficult to explain to families that the best treatment for their child is supportive care. The evidence and the new recommendations support that supportive care is what patients benefit from the most. In regards to albuterol, current recommendations discouraging its use in bronchiolitis are derived from the 2010 Cochrane review which included 10 inpatient and 10 outpatient trials. There was no statistical difference in the rate of hospitalization, length of hospitalization, oximetry nor time to resolution of illness at home between albuterol and placebo treated children. Some brief improvement in clinical respiratory scores was noted among outpatient and hospitalized patients but the standard mean difference was very small and no impact on clinical care would be expected.

There may be a sub-group of children with an underlying predisposition to asthma who may exhibit a response to albuterol. These children are generally older (>12 months) and have either a previous history of wheezing or atopy or a strong family history of asthma in first degree relatives. In the bronchiolitis guideline, these children may receive a single trial of albuterol without other concurrent interventions to determine whether they exhibit a positive clinical response to it. If they indeed have a positive documented response to albuterol these children would be managed under the ED/Inpatient asthma pathway.

Families should be educated that bronchiolitis is a disease that may last for two to three weeks. Many parents present for care because they are concerned their child is not feeding as usual. During the acute illness it is common and expected that children will feed less than their baseline. We need to help parents understand that if their child can sustain their basic fluid needs (even if they take sometimes half of what they typically drink), they are not likely to get dehydrated. Patients who maintain saturations >90% on room air, are able to handle secretions, and can maintain acceptable hydration and activity can generally be treated at home with supportive therapy.

On October 1, 2014 Children’s implemented the guidelines in the ED, Urgent Care, and Inpatient Settings. During the Sept 2014—April 2015 season, we decreased albuterol usage in 1-12 month olds with bronchiolitis from 45% to 25% in the ED and from 40% to 11% for patients who were admitted. We were able to achieve these results without negatively impacting our length of stay or 7 day readmission rate. Reducing the use of therapies that have not demonstrated benefit to our patients and helping them return home sooner if medically stable, is an example of delivering value to them and their families.

If there are any questions about the guideline, feel free to contact :

Dr Shabnam Jain sjain@emory.edu

Dr Tejedor-Sojo  javier.tejedor-sojo@choa.org

Please see the link below to the clinical guideline page on the physician portal for access to our guidelines, link to the AAP 2014 recommendations, and see Children’s full evidence summary that is posted on the physician portal:

https://md.choa.org/clinical-excellence/clinical-practice-guidelines/bronchiolitis