Bronchiolitis: Applying Evidence-Based Guidelines to Clinical Care

Denise M. Goodman, MD

By mid-winter through early spring, pediatricians once again will treat thousands of babies with bronchiolitis. This seasonal viral infection of the lower respiratory tract affects nearly all children by the age of 2, but it is most severe in infants 1 to 3 months old. Many therapies for bronchiolitis have shown limited benefit in clinical trials, but many physicians continue to use potentially unproductive treatments. In order to provide the most safe and effective evidence-based care, a multidisciplinary team at Children’s Memorial developed “best practices” guidelines for bronchiolitis management, as part of the hospital’s ongoing best practices program.

The Children’s Memorial inpatient guidelines for bronchiolitis management are listed in Table 1. Most of these recommendations apply to outpatient care as well. In fact, the majority of studies we examined referred to uncomplicated cases, such as those seen by community-based physicians. Also, awareness of these guidelines can help referring physicians when talking to families about what to expect if their child is admitted to Children’s Memorial for bronchiolitis treatment. Although bronchiolitis is predominantly an outpatient disease, with less than 3% of cases requiring hospitalization, Children’s Memorial annually sees on the average about 300 children with this diagnosis.

Bronchiolitis best practices team:
Community-based physicians add clinical expertise

Highest quality patient care is the ultimate goal of the Children’s Memorial best practices program. Through consistent evidence-based plans of care we aim to engender family confidence, shorten hospital stays, and reduce costs by eliminating unnecessary procedures.

Community-based physicians were invaluable members of the bronchiolitis best practices team, working with the hospital physicians from medical management, critical care, emergency medicine, infectious diseases, pulmonary medicine, and general academic pediatrics, as well as with nurses, respiratory therapists, pharmacists, and the hospital’s quality management, case management and patient placement administrators. Since pediatricians in the community see most of the bronchiolitis patients, we wanted to incorporate their experience as we critically evaluated clinical trials and expert reviews. The resulting practice guidelines merge clinical expertise with the most advanced scientific knowledge.

Balancing clinical judgment and recommended practice

The self-limiting nature of typical bronchiolitis calls for supportive care, with adequate oxygenation and hydration as the primary treatment goals. According to the literature, infants with bronchiolitis are little helped by routine chest radiographs and routine treatments with bronchodilators, antibiotics, antihistamines, oral decongestants, nasal vasoconstrictors, theophylline and steroids.

The clinical scenario, of course, is not always so clear. This is why the definition of intended population for bronchiolitis guidelines is critical. We aim to exclude asthma cases, which are commonly confused with bronchiolitis. At times, this misdiagnosis is impossible to avoid, which might contribute to the widespread use of bronchodilators to treat bronchiolitis, despite limited efficacy documented by clinical trials.

Differentiation from asthma becomes very important in efforts to offer appropriate therapy. Bronchiolitis is caused by airway edema due to viral infection, as opposed to the bronchospasm in asthma that is induced by allergic inflammation. Clinically, during the child’s first wheezing episode, these conditions are hard to separate. However, asthma can be distinguished from bronchiolitis by recurrent episodes of wheezing, as well as absence of viral prodrome and family history.

Another possible explanation for persistent use of bronchodilators is the long-recognized connection between acute bronchiolitis and incidence of asthma development. However, we still are not certain whether bronchiolitis actually triggers an immune response that later becomes asthma, or if the viral infection simply reveals a predisposition for asthma in the affected children.

Table 1
Children’s Memorial Hospital Best Practice: Bronchiolitis Clinical Inpatient Guideline Highlights
Note: These guidelines do not reflect all relevant medical considerations and are not intended to replace clinical judgment.

Population Intended

Includes: Bronchiolitis patients with typical clinical course, ages 1 year or less, admitted for the first time
Excludes: Infants with history of bronchopulmonary dysplasia, immunodeficiencies, cystic fybrosis; infants requiring ventilated care or if admitted to intensive or intermediary care

Radiological Studies

Chest radiographs not recommended and may be obtained only as needed for specific patients

Feeding Protocol

Regular diet using formula, breast milk and age appropriate solids recommended
Clear liquids not recommended
Consider discontinuing feedings if any of the following not relieved by suctioning:
- Persistent respiratory rate >80/min
- Persistent vomiting
- Oxygen saturation <90% despite supplemental oxygen therapy during feeding
- Marked increase in work of breathing with poor coordination of suckling, swallowing and breathing

Fluids and Electrolytes

Routine placement of saline or heparin “locked” IV catheters not recommended
Consider intravenous fluids if patient is clinically dehydrated or not taking a minimum of 80 cc/kg/day

Oxygen Therapy and Pulse Oximetry Monitoring

Supplemental oxygen and continuous pulse oximetry not recommended for children in room air who have oxygen saturation values >93%, except if age <3 months, former prematurity, or other complicating comorbidities
Pulse oximetry recommended if patient requires supplemental oxygen, but not after supplemental oxygen is discontinued
Reduce supplemental oxygen if child is quiet and has saturations >93%
Oxygen therapy not recommended for transient decreases in saturation values <93% unless associated with clinical symptoms (e.g., respiratory distress)

Medications

Routine use of bronchodilators not recommended^{1-5,9,16,17,18}
Albuterol: May try test dose in selected patients
Racemic Epinephrine: May try test dose in selected patients^6,8
MDI and nebulizations equally effective
Syrup not recommended^2,3
Antibiotics recommended only when high likelihood of bacterial disease^10-12
Antihistamines, oral decongestants and nasal vasoconstrictors not recommended for routine therapy
Theophylline not recommended for routine therapy
Steroids not recommended for routine use^7,13-15
Consider use when:
- Previous medical history/comorbidity
- Nebulizations worked but clinical condition has deteriorated
- Recurrent episodes of wheezing
- No improvement in clinical condition

Respiratory Care Therapies

Normal saline nose drops may be used prior to bulb suctioning
Chest physiotherapy should be used when there is subsegmental atelectasis
Cool mist therapy not recommended
Supervised cough and deep suctioning not recommended
Aerosol therapy with saline not recommended^1,2,4

Cardiorespiratory Monitoring

Monitoring is indicated when:
- Infants <3 months
- History of apnea or experiencing apnea
- History of prematurity, bronchopulmonary dysplasia, any underlying heart or lung disease
- Increasing respiratory distress

Isolation Guidelines

RSV bronchiolitis patient requires single room without negative air pressure
Apply Special Respiratory Infection Control Measures
Cohort patients known to be infected with the same organism
solate neonate with fever based on clinical symptoms and suspected source

Given these gray areas, a trial dose of inhaled bronchodilator may be justified in selected patients. Repeated doses are not indicated, however, unless the medication has been clearly helpful when the child is re-examined after the trial dose. Corticosteroids also are used frequently, although gains are uncertain. The bronchiolitis team agreed that the risks and side effects outweigh the theoretical benefits, and so did not recommend routine use of steroids for infants with bronchiolitis. The situations in which steroid use may be appropriate are listed in Table 1.

Naturally, clinical judgment is paramount and the best practice guidelines are not a substitute. The bronchiolitis recommendations are intended to support evidence-based practice, and thereby reduce indiscriminate use of therapies when efficacy is questionable.

The Children’s Memorial best practices program currently encompasses a wide range of clinical areas. In addition to bronchiolitis, these include: neonatology, asthma, pediatric critical care, ventriculo-peritoneal shunt malfunction, liver transplantation, allogeneic and autologous stem cell transplantation, cardiovascular surgery, typical and ruptured appendicitis, pyloric stenosis, diabetic ketoacidosis, cystic fibrosis, spinal fusion surgery, epilepsy, tethered cord, orthopaedic tumors, and tonsillectomy and adenoidectomy.

PRIMARY REFERENCES

Include evidence from randomized controlled trials, prospective trials, retrospective analyses and meta-analyses

1. Chowdhury D, et al. The role of bronchodilators in the management of bronchiolitis: a clinical trial. Annals of Tropical Paediatrics 1995;15:77-84.

2. Gadomski AM, et al. Efficacy of albuterol in the management of bronchiolitis. Pediatrics 1994;93:907-912.

3. Gadomski AM, et al. Oral versus nebulized albuterol in the management of bronchiolitis in Egypt. J Pediatr 1994;124:131-138.

4. Ho L, et al. Effect of salbutamol on oxygen saturation in bronchiolitis. Arch Dis Childhood 1991;66:1061-1064.

5. Klassen TP, et al. Randomized trial of salbutamol in acute bronchiolitis. J Pediatr 1991;118:807-811.

6. Menon K, et al. A randomized trial comparing the efficacy of epinephrine with salbutamol in the treatment of acute bronchiolitis. J Pediatr 1995;126:1004-1007.

7. Roosevelt G, et al. Dexamethasone in bronchiolitis: a randomised controlled trial. Lancet 1996;348:292-295.

8. Sanchez I, et al. Effect of racemic epinephrine and salbutamol on clinical score and pulmonary mechanics in infants with bronchiolitis. J Pediatr 1993;122:145-151.

9. Wang EEL, et al. Bronchodilators for treatment of mild bronchiolitis: a factorial randomised trial. Arch Dis Childhood 1992;67:289-293.

10. Friis B, et al. Antibiotic treatment of pneumonia and bronchiolitis: a prospective randomised study. Arch Dis Childhood 1984;59:1038-1045.

11. Kuppermann N, et al. Risks for bacteremia and urinary tract infections in young febrile children with bronchiolitis. Arch Pediatr Adolesc Med 1997;151:1207-1214.

12. Liebelt EL, et al. Diagnostic testing for serious bacterial infections in infants aged 90 days or younger with bronchiolitis. Arch Pediatr Adolesc Med 1999;153:525-530.

13. Klassen TP, et al. Dexamethasone in salbutamol-treated inpatients with acute bronchiolitis: a randomized controlled trial. J Pediatr 1997;130:191-196.

14. Garrison MM, et al. Systemic corticosteroids in infant bronchiolitis: a meta-analysis. Pediatrics 2000 (April);105:e44.

15. Bulow SM, et al. Prednisolone treatment of respiratory syncytial virus infection: a randomized controlled trial of 147 infants. Pediatrics 1999 (December);104:e77.

16. Dobson JV, et al. The use of albuterol in hospitalized infants with bronchiolitis. Pediatrics 1998 (March);101:361-368.

17. Kellner JD, et al. Efficacy of bronchodilator therapy in bronchiolitis: a meta-analysis. Arch Pediatr Adolesc Med 1996;150:1166-1172.

18. Klassen TP. Determining the benefit of bronchodilators in bronchiolitis: when is there enough benefit to warrant adoption into clinical practice? Arch Pediatr Adolesc Med 1996;150:1120-1121.

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