Bronchiolitis is common in children younger than 24 months. The most common etiology for bronchiolitis is respiratory syncytial virus (RSV) infection. Although bronchiolitis is common, there are wide-ranging practice variations for its diagnosis and management. To address these variations, the American Academy of Pediatrics formed a committee with representatives from the American Academy of Family Physicians, the American Thoracic Society, and the American College of Chest Physicians to develop a clinical practice guideline,1 which is summarized on page 265 of this issue of American Family Physician.2 The guideline focuses on the diagnosis, management, and prevention of bronchiolitis in children one month to two years of age. Each recommendation was given an evidence profile that included statements on aggregate evidence quality, benefits, harms, and a benefits-harms assessment. This editorial highlights some of the key recommendations from the guideline.
The diagnosis of bronchiolitis is clinical and is based on the patient's history and physical examination. Typical symptoms include runny nose, tachypnea, cough, wheezing, crackling, and retractions and nasal flaring with the use of accessory muscles. Laboratory and radiologic testing are not needed to make the diagnosis. Virologic studies for RSV do not affect management decisions in most children with bronchiolitis. However, from an epidemiologic perspective, virologic tests may be helpful for documenting a community's RSV season and for research purposes.
Another major point in the guideline is that the routine use of medications to treat bronchiolitis is not necessary. Although bronchodilators, corticosteroids, and ribavirin (Virazole) are used in practice, there is little evidence to support their use. If a trial of inhaled bronchodilator therapy is initiated, it should be continued only if there is documented improvement in the patient's clinical condition. Furthermore, an antibacterial medication should not be used unless there is specific evidence that a coexisting bacterial infection is present.
The guideline also addresses several nonpharmacologic treatments. Physicians should assess the hydration status of all children with bronchiolitis. If a child is in respiratory distress and adequate oral hydration cannot be achieved, the child should receive intravenous fluids. The use of supplemental oxygen is indicated if functional oxygen saturation persistently falls below 90 percent. The routine use of chest physiotherapy is not indicated.
The guideline recommends adequate handwashing, preferably with an alcohol-based rub, as the most significant approach to preventing the nosocomial spread of RSV. It is important that the medical staff and the patient's family members are educated about adequate hand decontamination.
For bronchiolitis prevention, the guideline focuses on palivizumab (Synagis) for selected children who are premature or who have chronic lung disease of prematurity or congenital heart disease. Prophylactic palivizumab should be given in five monthly doses based on the epidemiology of RSV infection in the community. Although seasonal and regional outbreak variations can occur,3 20 weeks of prophylaxis adequately provides protective serum antibodies in most children for the duration of the RSV season.
editor's note: Dr. Clover served as the AAFP representative on the guideline committee.