New guidance on diagnosing and managing patients with bronchiolitis calls on clinicians to avoid routinely ordering imaging or lab studies and instead to rely on a patient's history and physical exam to diagnose the disease. The comprehensive guideline, which was developed by the American Academy of Pediatrics, or AAP, with input from the AAFP and other groups, appears in the Dec. 1 issue of Pediatrics.
AAP Issues Guidance on Diagnosing, Managing Bronchiolitis
Clinicians 'Probably Overtreat,' Says AAFP Liaison
By News Staff
According to the article's authors, the guideline is intended "to provide an evidence-based approach to the diagnosis, management and prevention of bronchiolitis in children from 1 month to 2 years of age." Created by a subcommittee of the AAP working with liaisons from the AAFP, American Thoracic Society, American College of Chest Physicians and European Respiratory Society, the guideline includes 20 distinct practice suggestions grouped into 11 recommendations.
In addition to recommending that, in most cases, physicians forgo ordering radiographs and lab studies and instead use historical and physical exam findings to diagnose the illness or assess disease severity, the guideline also recommends against routine use of bronchodilators, corticosteroids and the antiviral ribavirin -- drugs now frequently used to treat the infection.
Other recommendations included in the guideline
In addition to recommending that, in most cases, physicians forgo ordering radiographs and lab studies and instead use historical and physical exam findings to diagnose the illness or assess disease severity, the guideline also recommends against routine use of bronchodilators, corticosteroids and the antiviral ribavirin -- drugs now frequently used to treat the infection.
Other recommendations included in the guideline
- call for clinicians to assess risk factors for severe disease, such as age younger than 12 weeks, a history of prematurity, underlying cardiopulmonary disease or immunodeficiency;
- caution against routine use of chest physiotherapy;
- offer guidance on administration and monitoring of supplemental oxygen to bolster oxyhemoglobin saturation, or SpO2, readings; and
- address prevention of respiratory syncytial virus, or RSV, infection through drug prophylaxis and appropriate hand decontamination.
There's good reason for such a hefty set of recommendations, said family physician Richard Clover, M.D., who served as the AAFP liaison to the AAP subcommittee: "There are such large variations in practice, and we tried to address those variations."
A former chair of the AAFP Commission on Clinical Policies and Research, Clover is dean of the University of Louisville (Ky.) School of Public Health and Information Sciences and associate vice president for health affairs/health informatics for the school.
Overall, he said, the guideline development group's recommendations contained no real surprises. "What was confirmed was that we probably overtreat infants with this disease, when there's little evidence that drug therapy is effective" in most cases, said Clover. What the group saw again and again, he added, "was that there weren't adequate studies to support many of the treatments now used."
"The main therapy is making sure the child is hydrated and maintains a good pO2," said Clover.
The most common lower respiratory infection seen in infants, bronchiolitis is characterized by acute inflammation, edema and cell necrosis within the small airways and results in increased mucus production and bronchospasm. Bronchiolitis is most frequently caused by RSV infection. Of the nearly 90 percent of children infected with RSV by age 2 years, about 40 percent develop lower respiratory infection.
RSV infection leads to more than 90,000 hospitalizations each year. Although RSV-associated mortality continues to decrease -- from 4,500 deaths in 1985 to an estimated 390 deaths in 1999 -- the cost of hospitalization for bronchiolitis in children younger than 1 year is estimated to be more than $700 million per year.
The recommendations in the guideline cannot be applied to all children, say the guideline's developers. For example, they don't pertain to children with immunodeficiencies associated with HIV infection or organ or bone marrow transplants or those with congenital immunodeficiencies. Also, children with underlying respiratory illnesses and those with significant congenital heart disease are excluded from the sections on management unless otherwise noted but are included in the discussion of prevention.
Moreover, further research is needed in several areas, said Clover, such as better determining the efficacy of certain treatment options among particular subsets of patients. "Even though we recommended decreased use of medications overall, there may be specific patients who benefit from use of bronchodilators and corticosteroids," he noted. "People are going to challenge (the guideline's recommendations), and that's fine -- that's how we improve quality of care."
A former chair of the AAFP Commission on Clinical Policies and Research, Clover is dean of the University of Louisville (Ky.) School of Public Health and Information Sciences and associate vice president for health affairs/health informatics for the school.
Overall, he said, the guideline development group's recommendations contained no real surprises. "What was confirmed was that we probably overtreat infants with this disease, when there's little evidence that drug therapy is effective" in most cases, said Clover. What the group saw again and again, he added, "was that there weren't adequate studies to support many of the treatments now used."
"The main therapy is making sure the child is hydrated and maintains a good pO2," said Clover.
The most common lower respiratory infection seen in infants, bronchiolitis is characterized by acute inflammation, edema and cell necrosis within the small airways and results in increased mucus production and bronchospasm. Bronchiolitis is most frequently caused by RSV infection. Of the nearly 90 percent of children infected with RSV by age 2 years, about 40 percent develop lower respiratory infection.
RSV infection leads to more than 90,000 hospitalizations each year. Although RSV-associated mortality continues to decrease -- from 4,500 deaths in 1985 to an estimated 390 deaths in 1999 -- the cost of hospitalization for bronchiolitis in children younger than 1 year is estimated to be more than $700 million per year.
The recommendations in the guideline cannot be applied to all children, say the guideline's developers. For example, they don't pertain to children with immunodeficiencies associated with HIV infection or organ or bone marrow transplants or those with congenital immunodeficiencies. Also, children with underlying respiratory illnesses and those with significant congenital heart disease are excluded from the sections on management unless otherwise noted but are included in the discussion of prevention.
Moreover, further research is needed in several areas, said Clover, such as better determining the efficacy of certain treatment options among particular subsets of patients. "Even though we recommended decreased use of medications overall, there may be specific patients who benefit from use of bronchodilators and corticosteroids," he noted. "People are going to challenge (the guideline's recommendations), and that's fine -- that's how we improve quality of care."
