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
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