What a difference a year makes. AAP recs for pediatric bronchiolitis grow increasingly complex, and knock most common treatment options off the list.
Your next task: Evaluate a four month old with rhinorrhea and three days’ cough who began breathing rapidly last evening and is not feeling well today, with plenty of wet diapers.
The child was born full term and is up-to-date on immunizations without any medical problems. She is alert with a temperature of 38.3, respiratory rate 66, and 92% oxygen saturation on room air. She appears well hydrated and non-toxic, but has had mild retractions, expiratory wheezing and fine crackles in both lungs.
You’re working with a senior medical student. He has correctly identified that the infant most likely has bronchiolitis. His differential includes reactive airways disease (RAD) and pneumonia. His plan: a trial of albuterol, a chest film and placing the infant on a monitor and some low flow oxygen. The student also wants to send a nasal swab for RSV and to observe how the infant is feeding and then make a disposition. This is what the student did last year with a similar infant during his ED rotation, but how do his current recommendations square with the latest guidelines of the American Academy of Pediatrics ? (See below)
Applying AAP’s New Recommendations
The new AAP Guidelines recommend against the use of albuterol, epinephrine, systemic corticosteroids, chest PT, and antibiotics. They also defer to a clinician’s judgment on whether to administer supplemental oxygen or use continuous pulse oximetry. The only specific recommendation in the guidelines is to provide parenteral fluids to patients who cannot tolerate oral hydration.
So, based on these recommendations, what would you tell your medical student? The trial of albuterol is out. So is the chest xray and swab for RSV. She doesn’t meet the criteria for supplemental oxygen at this time. You may decide to place her on a pulse oximeter. Although she appears hydrated now, if her respiratory rate remains above 60, she will have difficulty feeding and will likely need IV fluids to prevent dehydration. Although she does not have any of the risk factors for a severe course of illness, you are likely to admit her if she maintains her current respiratory rate due to the dehydration risk. But watching only hydration status as a tachypneic child with a marginal oxygen saturation seems counterintuitive. How good is the evidence for the AAP’s recommendations?
The recommendation to base the diagnosis on the history and physical examination is fairly robust (evidence quality: B; recommendation strength: strong recommendation). There is no test that can be relied upon to firm up the diagnosis. While RSV is the most common etiology of bronchiolitis, it is by no means the only virus that causes the same clinical presentation. Other culprits include rhinovirus, metapneumovirus, adenovirus, influenza, coronovirus, and parainfluenza virus. Co-infections can occur as well.
So, in a patient that looks like they have bronchiolitis, a positive RSV may make you feel more confident that your diagnosis is correct, but a negative RSV cannot be used to rule out the disease. However, there still may be some utility in obtaining an RSV swab. We know, for example, that young infants with RSV are unlikely to have bacteremia. A multicenter three-year prospective cross-sectional study of febrile infants < 60 days of age included 22% who were positive for RSV. Their rates of serious bacterial infection were significantly lower than in the RSV negative group, and most of the infections were UTIs .
Another retrospective cohort study of 174 RSV positive infants eight weeks or less presenting with fever to an urban emergency department found that these infants had no bacteremia or meningitis but two had UTIs, whereas amoung the 174 age matched RSV-negative febrile infants in the control group 22 had serious bacterial infections, including 17 UTIs .
Therefore, in a five week-old with fever and URI symptoms even without bronchiolitis, the presence of a positive RSV justifies not obtaining blood or CSF in your work-up (clinical evidence still supports getting urine as a small number of these infants will have concomitant UTI).
The AAP’s recommendation not to obtain a chest x-ray in RSV patients has “B” evidence quality and a “moderate” recommendation strength. If you are sure that the child has bronchiolitis based on a typical history (several days of URI symptoms, then development of increased work of breathing) and exam (increased respiratory rate, retractions, nasal flaring with bilateral crackles and wheezing), you likely don’t need a chest x-ray. Many children with bronchiolitis have abnormal chest xrays and there is a lack of evidence that giving these children antibiotics improves outcomes. The evidence is lacking that chest x-rays predict disease severity in children with bronchiolitis.
According to the AAP Guidelines, chest x-rays in bronchiolitis should be reserved for severe disease requiring intensive care admission or suspicion of some airway complication, such as a pneumothorax. If the history and examination are not typical or do not fit the clinical picture of bronchiolitis then it seems reasonable to get a film to look for other problems, but “routine” chest films for bronchiolitis are not necessary.
The recommendation not to give albuterol for bronchiolitis has generated some push-back among pediatric emergency physicians. The AAP’s position is that the literature on patients with bronchiolitis has not supported a significant clinical benefit from bronchodilators. However, some ED providers have noted that an undifferentiated wheezing child under 24 months of age may not have bronchiolitis. In the discussion accompanying the guidelines, it is acknowledged that a subset of patients may have reversible bronchospasm but attempts to define this subset or objectively measure their response have been unsuccessful. It is reasonable to conclude that if you are sure that this child has bronchiolitis then albuterol won’t help. If you are not sure, a trial of albuterol may be justified.
Epinephrine, Hypertonic Saline and Steroids
Withholding epinephrine in bronchiolitis has evidence quality: B and is a strong recommendation in the new guidelines. Inhaled epinephrine was shown to give transient improvement in the ED setting but did not reduce the risk of hospitalization overall. And folks were not comfortable discharging patients with inhaled epinephrine to use at home. Similarly, hypertonic saline (evidence quality: B; recommendation strength: weak recommendation) has been found inconsistently to reduce length of stay in hospitalized patients but there is no clear evidence of benefit in the ED setting. Withholding steroids (evidence quality: A; recommendation strength: strong recommendation) should be an easy decision for the Emergency Physician as multiple studies over the years have failed to show any benefit.
Recommendations on use of supplemental oxygen (evidence quality: D; recommendation strength: weak recommendation) and monitoring (evidence quality: C; recommendation strength: weak recommendation) are weak recommendations based on lower quality evidence. The AAP Guidelines argue that oxygen saturation is not a good predictor of respiratory distress but its measurement increases the likelihood of admission. The Guidelines also note that transient hypoxia may not be harmful and that pulse oximetry is prone to error. Your treatment decisions may or may not be swayed by these arguments
Finally, giving parenteral fluids to prevent dehydration in patients with bronchiolitis has an evidence quality of “X” and is a strong recommendation. An evidence quality “X” means that “validating studies cannot be performed and there is a clear preponderance of benefit or harm”. It would be difficult to argue that dehydrated children who cannot tolerate oral fluids would not benefit from parenteral fluids.
So, bottom line, most of what your student proposes is no longer recommended management. Despite wanting to do something, some would argue, there’s not much to be offered except supportive care.
Finally, it is important to note that the guidelines are geared toward physician management and do not cover discharge instructions and that they do not included case scenarios. In regard to bouncebacks to the ED, we do know that patients with bronchiolitis can progress over 48-72 hours after the onset of cough and increased work of breathing. Good discharge instructions should include watching for increased work of breathing, change in alertness or tone, poor feeding, and decreased wet diapers. Babies in the first 24 hours of clinical bronchiolitis are likely to progress and should be seen by their primary physicians in follow-up the day after their ED visit, if possible.
- Clinicians should diagnose bronchiolitis and assess the severity of illness based on the history and physical exam.
- Xrays and laboratory studies should not be obtained routinely.
- Evaluation of disease severity should include risk factors for severe course of illness, including age less than 12 weeks, history of prematurity, underlying cardiopulmonary disease, or history of immunodeficiency.
- Clinicians should not administer albuterol to patients with bronchiolitis.
- Clinicians should not administer epinephrine to patients with bronchiolitis.
- Clinicians should not administer hypertonic saline in the ED, but may administer it to hospitalized patients.
- Clinicians should not administer systemic corticosteroids to patients with bronchiolitis.
- Clinicians may choose not to administer supplemental oxygen to patients with bronchiolitis with oxygen saturations above 90%.
- Clinicians may chose not to use continuous pulse oximetry in patients with bronchiolitis.
- Clinicians should not use chest PT on patients with bronchiolitis.
- Clinicians should not administer antibiotics to patients with bronchiolitis unless there is a bacterial infection or strong suspicion of one.
- Clinicians should administer NG or IV fluids to patients with bronchiolitis who cannot maintain their hydration orally.
1. Pediatrics 2014; 134:5 e1474-e1502.
2. Levine DA, Platt SL, Dayan PS, et al. Pediatrics 2004;113;1728.
3. Titus MO, Wright SW. Pediatrics 2003;112;202.
4. Swingler GH, Hussey GD. Lancet.1998;351(9100):404-408.
5. Schuh s, Lalani A, Allen U, et al. J Pediatr.2007;150(4);429-433