Practice Guidelines
AAP Publishes Recommendations for the Diagnosis and Management of Bronchiolitis
Guideline source: American Academy of Pediatrics, American Academy of Family Physicians, Agency for Healthcare Research and Quality, and the RTI International-University of North Carolina Evidence-Based Practice Center
Literature search described? Yes
Evidence rating system used? Yes
Published source: Pediatrics, October 2006
Available at: http://pediatrics.aappublications.org/cgi/content/full/118/4/1774
See related editorial on page 171.
Bronchiolitis usually is caused by a viral lower respiratory tract infection and most commonly causes morbidity and mortality in infants. The condition is characterized by acute inflammation, edema and necrosis of epithelial cells in the small airway, increased mucus production, and bronchospasm. Although mortality from respiratory syncytial virus (RSV; the most common etiology of bronchiolitis) has decreased, the infection leads to more than 90,000 hospitalizations annually, and many patients experience recurrent infection throughout life.
Studies on the diagnosis and management of bronchiolitis have had varying results; therefore, the best clinical practices are unclear. The American Academy of Pediatrics (AAP), with the support of other organizations, convened the Subcommittee on Diagnosis and Management of Bronchiolitis to create a practice guideline for treating patients with the infection. The guideline is based on an evidence report from the American Academy of Family Physicians (AAFP), the Agency for Healthcare Research and Quality, and the RTI International-University of North Carolina Evidence-Based Practice Center. The report, which was created using evidence-based literature, addressed four points: the effectiveness of diagnostic tools, the effectiveness of pharmaceutical therapies, the role of prophylaxis, and the cost-effectiveness of prophylaxis.
The guideline is meant to assist physicians in decision making. It does not apply to children with immunodeficiencies. Children with underlying respiratory illnesses or significant congenital heart disease are excluded from the management recommendations but not from the prevention recommendations.
Evidence levels are given to each recommendation based on the quality of the evidence used: A = well-designed, randomized controlled trials (RCTs) or diagnostic studies on relevant populations; B = RCTs or diagnostic studies with minor limitations or overwhelmingly consistent evidence from observational studies; C = observational studies (case control and cohort design); D = expert opinion, case reports, or reasoning from first principles; and X = exceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit or harm.
Diagnosis
The diagnosis should be based on patient history and physical examination, and the assessment of disease severity should be based on risk factors (B recommendation). Routine laboratory and radiologic diagnostic studies should not be used in the diagnosis (B recommendation).
Goals of the evaluation include differentiating probable bronchiolitis from other disorders in infants presenting with coughing or wheezing, as well as assessing disease severity.
Bronchiolitis presents as a viral upper respiratory prodrome followed by increased respiratory effort and wheezing in children younger than two years. Other signs include rhinorrhea; coughing; wheezing; tachypnea; and grunting, nasal flaring, and intercostal or subcostal retractions from increased respiratory effort. Physical examination findings may include increased respiratory rate, accessory muscle use or retraction, and auscultatory findings (e.g., wheezing, crackles). Radiography may be considered in hospitalized patients who do not improve at a usual rate or if another diagnosis is suspected.
Because the disease course is variable, any history of underlying conditions (e.g., prematurity, cardiac or pulmonary disease, immunodeficiency, prior wheezing) should be identified, and serial observation over time may be needed.
Management
bronchodilators
Routine use of bronchodilators is not recommended; however, bronchodilator therapy may be considered if there is a positive clinical response to an alpha- or beta-adrenergic medication during a carefully managed trial (B recommendation).
The use of bronchodilator therapy is controversial, and RCTs have not shown a consistent benefit from alpha- or beta-adrenergic agents in patients with bronchiolitis. Studies also have not shown that bronchodilators have a long-term impact on the disease course.
Although RCTs do not support the routine use of bronchodilators, the therapy may improve the clinical condition of some infants. Therefore, it may be reasonable to administer a trial of nebulized bronchodilator use in selected infants to evaluate clinical response using an objective measure. Studies suggest that epinephrine may be preferred for inpatients, whereas albuterol (Ventolin) may be preferred for outpatients. If the bronchodilator trial does not lead to documented clinical improvement, the treatment should be discontinued.
corticosteroids
Routine use of corticosteroids is not recommended (B recommendation).
Although up to 60 percent of infants hospitalized for bronchiolitis receive corticosteroid therapy, studies have not provided sufficient evidence to support the use of steroids for the disease. Inhaled corticosteroids have not been shown to be beneficial, and the safety of high doses in infants is unclear. Until further studies are completed, recommendations cannot be made regarding the use of leukotriene modifiers in the management of bronchiolitis.
antiviral therapy
Routine use of ribavirin (Virazole) is not recommended (B recommendation).
Studies of ribavirin in patients with bronchiolitis have been inconsistent, and other antiviral therapies have been studied. Antiviral therapy for RSV bronchiolitis is controversial because of its marginal benefit, cumbersome delivery, potential risk to caregivers, and high cost. However, ribavirin may be considered in patients with severe RSV bronchiolitis or those at high risk of severe disease.
antibacterial therapy
Antibacterial medications should be used only if the child has specific indications of a coexistent bacterial infection; treatment of the bacterial infection should be the same as that in children without bronchiolitis (B recommendation).
Although many children with bronchiolitis receive antibacterial therapy because of concerns about secondary bacterial infection, RCTs have not shown the therapy to be beneficial in the treatment of bronchiolitis. Furthermore, studies have shown that serious bacterial infection rates in patients with bronchiolitis are low, and if present, urinary tract infections are more common than bacteremia or meningitis.
Bacterial acute otitis media cannot be differentiated from the viral form. Acute otitis media in infants with bronchiolitis should be treated according to AAP/AAFP guidelines.
chest physiotherapy
Hydration and ability to take fluids orally should be assessed (X recommendation); routine chest physiotherapy is not recommended (B recommendation).
An assessment of respiratory distress should guide decisions about respiratory treatments. Infants with mild respiratory distress may only need observation; however, infants whose respiratory distress causes difficulty with feeding should receive intravenous fluids. Fluids should be adjusted if fluid retention occurs.
Airway edema may occur in infants with bronchiolitis. Studies on chest physiotherapy to clear the airway in these patients showed no clinical benefit from vibration and percussion techniques. Suctioning may temporarily relieve symptoms, but no evidence supports routine "deep" suctioning.
oxygen supplementation
Supplemental oxygen should be administered if functional oxygen saturation (SpO2) persistently falls below 90 percent and can be discontinued when an adequate level returns (D recommendation). Routine measurement of SpO2 levels are not recommended (D recommendation), although high-risk infants (i.e., premature infants and those with heart or lung disease) should be monitored closely as they are weaned from the oxygen (B recommendation).
Healthy infants have an oxyhemoglobin saturation above 95 percent when breathing room-temperature air. Bronchiolitis can cause these levels to decrease. Studies support a 90 percent oxyhemoglobin saturation cutoff for initiation of oxygen supplementation in otherwise healthy infants who are feeding well and have minimal respiratory distress. A lower cutoff may be considered in children with risk factors such as fever, acidosis, and some hemoglobinopathies. The patient's respiratory effort also may be considered when determining the need for oxygen supplementation.
High-risk infants who are more likely to develop severe disease have abnormal baseline oxygenation and an inability to cope with the pulmonary inflammation of bronchiolitis. These infants may have more severe and prolonged hypoxia compared with normal infants; therefore, special consideration is needed when using oxygen supplementation in high-risk infants.
complementary and alternative medicine
Physicians should inquire about complementary and alternative therapies (D recommendation).
There are limited data on the effectiveness of complementary and alternative therapies for bronchiolitis; therefore, a recommendation cannot be made. However, an increasing number of patients are using these therapies (e.g., herbal remedies, osteopathic manipulation, applied kinesiology), and more research is underway. Because of the number of patients using these therapies, physicians should be prepared to discuss them.
Prevention
palivizumab prophylaxis
Palivizumab (Synagis) may be considered in select infants and children with chronic lung disease of prematurity, prematurity, or congenital heart disease (A recommendation). If used, palivizumab should be administered intramuscularly in five monthly doses of 15 mg per kg, usually beginning in November or December (C recommendation).
Studies have shown that palivizumab prophylaxis decreased RSV-related hospitalization in infants and children with prematurity, chronic lung disease, or congenital heart disease. RSV outbreaks usually begin in November or December, peak in January or February, and end in March or April; therefore, prophylaxis is most effective if initiated in November.
Cost-effectiveness analyses have not shown an overall savings in health care costs with prophylaxis because the cost of treating all high-risk children would be high. Other factors to consider include the cost-effectiveness of prophylaxis in outpatients and whether preventing RSV infection in infancy decreases the risk of wheezing and respiratory problems later in life.
hand decontamination
Hand decontamination is the most important measure in preventing RSV infection; hands should be washed before and after direct contact with a patient, after contact with an inanimate object in the direct vicinity of the patient, and after removing gloves (B recommendation). Alcohol-based rubs are preferred for hand decontamination, although antimicrobial soap is an alternativ (B recommendation). Physicians should educate their staff and the patient's family members about the importance of hand sanitation (C recommendation).
Because RSV and other viruses can be spread easily through hand contact, the Centers for Disease Control and Prevention released an extensive review on hand sanitation. Although the use of masks has not been shown to control the spread of RSV, proper hand decontamination, medical staff and family education, and the use of gloves and gowns are effective. Isolation techniques also are effective but may not be practical in some settings.
smoke exposure
Passive smoke exposure in infants should be avoided (B recommendation).
Studies have shown that parental smoking affects the respiratory health of infants and children. Children whose mothers smoked during and after pregnancy have a significant decrease in pulmonary function compared with children whose mothers did not smoke. Forced expiratory flow and other pulmonary functions also are affected by passive smoke exposure.
breastfeeding
Infants should be breastfed to decrease the risk of lower respiratory tract disease (C recommendation).
Studies have shown that breast milk provides immunity and neutralizing factors against RSV, decreasing hospitalization related to RSV infection and other lower respiratory tract infections.
Future Research
Many common diagnosis and treatment modalities have not been proven effective for bronchiolitis. Future research should be clinically relevant to parents, physicians, and the health care system and include outcomes of hospitalization rates, need for intensive care services, health care costs, and parental satisfaction with treatment. Bronchiolitis is self-limited; therefore, studies should enroll a large number of patients so that meaningful conclusions can be made.
Practice Guideline Briefs
Chronic Kidney Disease Screening Recommended in Patients with CVD
Chronic kidney disease is common in patients with cardiovascular disease (CVD); moreover, it also is a risk factor for developing CVD. Proper management of CVD is much more complex in patients with chronic kidney disease. Therefore, the American Heart Association (AHA) published recommendations for the detection of chronic kidney disease in patients with CVD in the September 5, 2006, issue of Circulation.
The AHA recommends that health care professionals evaluate their patients for chronic kidney disease as part of routine preventive care and treatment. A formal measurement of glomerular filtration rate (GFR) with iothalmate or similar markers and the measurement of cystatin C levels are not consistently accurate. However, several validated estimation equations for GFR use clinical data that are easily obtainable, and these methods allow health care professionals to accurately diagnose chronic kidney disease. A formula developed from the Modification of Diet in Renal Disease study has proved to be the best method for estimating GFR in adults in an office setting.
Calculators to determine the GFR are available online from the National Kidney Foundation (http://www.kidney.org) and the National Kidney Disease Education Program of the National Institutes of Health (http://www.nkdep.nih.gov). However, the formula's accuracy is reduced in patients with normal or only slightly diminished renal function.
The AHA recommends that screening for microalbuminuria, in combination with an estimation of GFR, be performed for all adult patients with CVD, congestive heart failure, or coronary artery disease, as well as patients who have risk factors for CVD such as hypertension or diabetes.
CDC Releases Data on Visual Impairment in Patients with Diabetes
Patients with diabetes are more likely to be visually impaired than those who do not have the disease. However, few studies have examined whether visual impairments in patients with diabetes can be corrected with glasses or contact lenses. To estimate the proportion of patients with diabetes who could benefit from such treatments, the Centers for Disease Control and Prevention (CDC) published data from the National Health and Nutrition Examination Study in the November 3, 2006, issue of Morbidity and Mortality Weekly Report.
Patients with diabetes who had a severe infection in one or both eyes, who were unable to see in either eye, or who were completely blind were excluded from the analysis. Overall, the results suggested that 11 percent of American adults 20 years and older with self-reported diabetes had visual impairments, 65.5 percent of which were correctable. Additionally, 9.7 percent of U.S. adults with diabetes had mild visual impairment, and 1.4 percent of those had a severe visual impairment before correction; after correction, 2.9 percent had mild impairment, and 1 percent of those had severe impairment.
As a result, optimal correction could have restored vision in 73.4 percent of adults with diabetes with mild visual impairments and 9.1 percent of adults with severe impairment. Therefore, health care professionals who care for patients with diabetes should be aware that poor vision often can be corrected, and that doing so can reduce the patient's risk for injury and improve the quality of life.
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