Bronchiolitis Clinical Practice Guideline

7/30/2019 Bronchiolitis Clinical Practice Guideline

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Clinical Practice Guideline

Viral Bronchiolitis

OUTLINE

I. Intention/Purpose StatementII. Clinical Inpatient Protocol (CLIP)III. Patient Information SheetIV. Introduction

A. EpidemiologyB. PathogenesisC. Outcomes

V. DiagnosisA. Diagnostic CriteriaB. Viral TestingC. Chest Radiography

D. Complete Blood CountsE. Assessment for Risk of

Severity/ComplicationsVI. Management

A. Hospitalization CriteriaB. Prevention of Nosocomial

TransmissionC. Supportive CareD. Supplemental OxygenE. Inhaled Beta-AgonistsF. Inhaled Epinephrine

G. CorticosteroidsH. AntibioticsI. RibavirinJ. Inhaled Hypertonic Saline

VII. ComplicationsA. Predictors of Disease

Severity at PresentationB. Need for Ventilatory SupportC. Concurrent Bacterial

PneumoniaD. Hyponatremia

E. Other ExtrapulmonaryComplicationsVIII. Discharge CriteriaIX. Discharge Anticipatory Guidance.X. References

I. INTENTION/PURPOSE STATEMENT

UNC Pediatric InpatientClinicalPractice Guidelines (CPGs) areevidence-based decision-making toolsdesigned to optimize the inpatientmanagement of common pediatricillnesses. In addition to guidingclinicians in the delivery of high qualitymedical care tailored to the individualpatients needs, these guidelines willimprove resource utilization, patientsafety, clinical efficiency, and patient

throughput. These recommendations arenot intended to replace clinical judgmentand may not universally apply to allpatients. These guidelines are consistentwith the American Academy ofPediatrics 2006 guidelines on thediagnosis and management ofbronchiolitis. General recommendationsare italicized.


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no

no

yes

Admit to general

pediatrics

no

yes

Patient diagnosed with bronchiolitis

no

yes

Implement preventive measures to decrease nosocomial transmission

Provide supportive care and monitoring

Titrate supplemental oxygen to maintain SpO2 consistently 90%

See Bronchodilator Trial In

yes

Aggressively wean oxygen to maintain

SpO2 between 90-94% (weaning per RT)

Discontinue continuous pulse oximetry when

patient clinically improving

no

yes

Bulb suction nose/mouth, reposition airway, re-position pulse

oximetry probe

Consider Bronchodilator Trial*, particularly if history of

wheezing or + FHx allergic disease

Individualized

therapy

Discharge when crite

Consider CXR; re-ev

Discharge when criteria met

Patient at risk for severe disease or needing ICU level care?

SpO2 consistently < 90% on room air?

SpO2 consistently < 90% on room air? +/- Unable to

maintain oral hydration? +/- RR> 70 bpm? +/- Severely

increased WOB? +/- Significant caregiver anxiety?

Bronchodilator trial desired

or positive trial in ED?

Patient improving as anticipated?

* 5

II. CLINICAL INPATIENT PROTOCOL (CLIP): BRONCHIOLITISAdapted from American Academy of Pediatrics, Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and Management of Bronchiolitis. Pediatrics.2006; 118(4):1774-93.


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Table 1. Respiratory Distress Assessment Instrument89

III. PATIENT INFORMATION SHEET: Viral Bronchiolitis*

What is bronchiolitis?

Bronchiolitis is a lower lung infection caused by a virus, most commonlyRSV (Respiratory Syncytial Virus). It occurs only in children less than 2years old.

The symptoms of bronchiolitis include:

Wheezing (making a high-pitched whistling sound when breathing out)

Taking more than 40 breaths per minute

Using extra muscles to breathe (working harder to breathe than normal) Coughing

Fever

Runny nose and "cold" symptoms before the breathing problems started

Your child's healthcare provider will make the diagnosis based on your child'ssymptoms and physical examination. Special testing and x-rays are not necessary.

How did my child get it?

Viruses that cause bronchiolitis are spread through the air by coughing,sneezing, or direct contact (hand-to-hand, hand-to-eyes/nose/mouth). The

viruses are very contagious during the first few days of illness.

How long will the symptoms last?

The breathing problems usually become worse for 2 to 3 days, and thenbegin to improve. The cough may last as long as 3 weeks.

What medications can be used for it?

Continue albuterol and

consider systemic steroids

RT to continue assigning

RDAI score pre/posttreatment and wean inhaled

medication as appropriate

Bulb suction nasopharynx, re-position airway; allow child to recover to baseline

RDAI score decreased by 3 points?

Assign pre-trial RDAI clinical score

Administer one dose of inhaled albuterol

Assign post-trial RDAI clinical score within 15 minutes after treatment completed

noyes

Discontinue albuterol


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There are no medications that completely clear up the symptoms of bronchiolitis.Antibiotics are usually not required, and are not effective for illnesses caused byviruses. Over-the-counter decongestants and cough suppressants are notrecommended for children less than 2 years old due to safety concerns.

Acetaminophen (Tylenol) can be used for fever, fussiness, or discomfort. Ininfants over six months of age, ibuprofen (Children's Motrin) may be used insteadof acetaminophen. Aspirin should never be used in children due to the high riskof liver and neurologic damage.

If your child's symptoms improve with inhaled albuterol treatments, yourhealthcare provider may prescribe this medication. Your child may be moresusceptible to wheezing with future viral illnesses and/or asthma, which youshould discuss with your child's regular healthcare provider.

How else can I take care of my child?

Hydration: Encourage your child to drink plenty of fluids, preferably breast milk,formula, Pedialyte, or whole milk (if over 12 months of age) in small amountsmore frequently. If your child vomits during a coughing spasm, feed him/heragain.

Feeding: It's okay if your child does not want to eat solid foods for a few days as

long as he/she will drink enough fluids.

Suctioning the nose: Suction alone will not remove dry secretions. Warm tap

water or saline nosedrops are best to help clear the nose if congestion isinterfering with feeding or sleeping. You can make saline nosedrops by adding teaspoon of table salt to 1 cup of water. Place three drops of warm water or salinein each nostril. After one minute, use a soft rubber suction bulb to suck out the

mucus. You can repeat this procedure several times until your child's breathingthrough the nose becomes quiet and easy.

Coughing: Warm liquids help to relax the airway and loosen the mucus. Use a

humidifier in the room where your child sleeps. Avoid steam vapors and over-heated cloths as these can cause burns. Propping the head of the bed up withpillows or a 6 inch block may also help. Tobacco smoke exposure, includingsmoke in the clothing and on the skin of smokers, makes coughing worse andshould be avoided.

Activity: Your child may return to daycare when the fever is gone and he/she is

eating well and feeling better. Encourage frequent naps to help recovery.

Hand washing: Because viruses that cause bronchiolitis are very contagious,

wash your hands for at least 20 seconds with soap and warm water before andafter touching your child or any object that has had contact with your child.Alcohol-based hand sanitizers also effectively kill the viruses.

When should my child be seen again?

_____We have scheduled an appointment for your child with ____________________ on____________________ at __________am / pm.

_____Your child needs to be rechecked in ___ days. Call your child's healthcare


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provider to schedule an appointment._____You may schedule an appointment with your child's healthcare provider as needed.

What symptoms should I be watching for that would require me to call my child's

health care provider or come to the emergency room?

Child is not starting to improve after 24-48 hours Very rapid breathing:

o Birth to 6 weeks oldover 60 breaths per minute

o 6 weeks to 2 years oldover 45 breaths per minute

Fever more than 104 orally or more than 102 for 3 consecutive days.

Earache, stiff neck, headache, repeated vomiting or diarrhea

Worsening or persistent fussiness, drowsiness, confusion

No wet diapers for 8 hours, "sunken" eyes, no tears when crying, dry mouth

*The intended use of the information presented above is for education and is not a replacement for medicaladvice or evaluation by a healthcare professional.


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IV. INTRODUCTION

A. Epidemiology

Bronchiolitis is an acute, potentially life-threatening viral infection of thelower respiratory tract. It is the leading cause of hospitalization of children in theUS81 with yearly hospital charges totaling up to $700 million118. In the past 3

decades, the proportion of infant hospitalizations due to bronchiolitis has morethan tripled. Despite the increase in hospitalization rates, mortality frombronchiolitis has dramatically fallen over the past 3 decades, from 4500 deaths in1985119 to 390 in 199982.

Respiratory syncytial virus (RSV) is responsible for causing nearly 70%of bronchiolitis, with the remainder of cases due to human metapneumovirus(HMPV), influenza, parainfluenza, adenovirus, rhinovirus, and, sporadically,mycoplasma144. Co-infection with more than one of these viruses has beenreported and may be responsible for more severe disease1,116. Bronchiolitis occursin predictable annual intervals worldwide, with an average onset in late Decemberand peak in February in the US.

During the 2006-2007 bronchiolitis season at UNC, 59 patients withbronchiolitis were admitted to the general pediatrics inpatient service. When datafor these patients were examined retrospectively, adherence to the 2006 AAPguidelines for the diagnosis and management of bronchiolitis was generallypoor74. Complete blood counts and chest radiography were obtained for 43% and78%, respectively. Of patients who underwent chest radiography, 55% were RSVpositive and only 3% had documentation of change in management based on x-ray findings. Transitioning from continuous to intermittent pulse-oximetrymonitoring was documented for only 13% of patients. Albuterol was given atleast once to 57% of patients, with 52% of these patients having no history ofwheezing and 80% lacking documentation of response to treatment.

B. Pathogenesis

The viruses that cause bronchiolitis are spread by direct inoculation ofinfected secretions from contaminated fomites and by large particle aerosolsentering through the eyes and nose62. Upon inoculation, RSV replicates in thenasopharynx and presumably spreads along the respiratory epithelium to thelower respiratory tract. Small airways become inflamed and edematous, resultingin destruction and necrosis of ciliated epithelial cells and increased mucusproduction6. Airways become physically obstructed with mucus and cellulardebris.

C. OutcomesTypically, symptoms peak on the third day of illness and resolve by 7-10

days. Most will have normal respiratory parameters 2 weeks after the height of theillness and radiologic abnormalities will clear within 9 days of admission106.

The link between infant bronchiolitis and recurrent wheezing has not beenclearly elucidated. A recent study found no difference in pulmonary functionstudies between 29 full term, age, race and sex matched control infants withoutprior wheezing, asthma or lower respiratory illness when compared to a similar


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group of 29 previously healthy infants admitted with a first episode of acute RSVbronchiolitis39. Infants hospitalized with severe bronchiolitis have been observedto have more respiratory problems as older children,especially recurrentwheezing, when compared with those who did not have severe disease92,114,123.

V. DIAGNOSISA. Diagnostic Criteria

*Recommendation: Bronchiolitis should be diagnosed based on history and

physical examination

Bronchiolitis is a clinical diagnosis which should be based on clinicalhistory and physical exam. The wide range of clinical symptoms and severity canmake diagnosis challenging, but consistent features include:

Preceding upper respiratory symptoms, including rhinorrhea and fever

Signs/symptoms of respiratory distress

o Wheezing

o Retractionso Nasal flaring

o Tachypnea

o Hypoxia/cyanosis

o Crackles

o Cough

Difficulty feeding and/or dehydration secondary to respiratory distress

B. Viral Testing

*Recommendations

1. Rapid viral testing is not routinely recommended.2. Rapid viral testing may be considered in febrile infants < 3 months of

age to limit further laboratory testing and prevent theunnecessary

use of broad-spectrum antibiotics.

Viral culture remains the gold standard for establishing the etiology ofbronchiolitis. Most clinical studies, however, have used rapid RSV antigendetection tests such as direct immunofluoresence (DFA) and enzymeimmunoassay (EIA), which have an overall sensitivity of 80-90%. Viral culture,DFA, and EIA have all been shown to have better sensitivity and accuracy when

performed on nasopharyngeal aspirates rather than nasopharyngeal swabs

7

. AtUNC, EIA is the rapid antigen test performed.Although rapid viral testing is widely available for RSV, no data exists to

suggest that knowing the cause of the disease alters clinical outcomes. However,rapid viral testing in febrile patients < 3 months of age may prevent additionalworkup20,135 and reduce unnecessary treatment with broad-spectrum antibiotics4,24.Testing also allows for cohorting of patients and staff to decrease nosocomialtransmission, although this technique lacks efficacy data.


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C. Chest radiography

*Recommendations1. Chest radiography is not routinely recommended in cases of

uncomplicated bronchiolitis.

2. Chest radiography may be considered if the diagnosis is unclear or ifthe patient is not recovering as anticipated.

Commonly cited reasons for obtaining chest radiography are to rule-outbacterial pneumonia and to assess disease severity. However, insufficientevidence exists to support the ability of chest radiography to distinguish betweenviral and bacterial disease20, particularly since chest x-ray appearance may benormal in patients with clinical signs of pneumonia68. Also, no correlation hasbeen found between clinical respiratory distress scores, as a measure of diseaseseverity, and chest x-ray appearance37.

Chest x-ray findings in bronchiolitis are non-specific and variable, but

may include a normal appearance, patchy atelectasis, peribronchial thickening,perihilar prominence, airspace disease, and/or hyperinflation37,115. Among childrenwith clinical signs and symptoms consistent with mild to moderate bronchiolitis,chest radiography has been found to be consistent with the diagnosis in >99%115,suggesting that chest radiography adds no additional information beyond physicalexamination in cases of clear-cut bronchiolitis. There is also no evidence thatobtaining chest x-rays improves outcome for children with lower respiratory tractdisease126. Therefore, routine chest x-rays are not recommended in uncomplicatedbronchiolitis.

Of note, use of chest radiography has been associated with increased useof antibiotics, but no difference in time to resolution of symptoms was found127.

D. Complete Blood Counts (CBCs)

*Recommendation: CBCs are not routinely recommended.

CBCs have been found to have low specificity and positive predictivevalue in the diagnosis of viral illness. The use of complete blood counts has notbeen shown to be useful in either diagnosing bronchiolitis or guiding itstherapy5,103.

E. Assessment for Risk of Severity/Complications

*Recommendation: Patients should be assessed for factors and/or co-morbidities

which may increase the risk for severe or complicated disease (see Section V.Complications below), including:

Age < 12 weeks

Presence of chronic lung disease

Presence of hemodynamically-significant congenital heart disease

Presence of immunodeficient state

Presence of a genetic defect or chronic disease which could decrease the

patient's ability to compensate for acute illness


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History of prematurity (< 35 weeks gestational age)

Respiratory rate > 70 bpm

The presence of any of the above factors and/or co-morbidities warrantsexclusion from this guideline and management should be tailored to the

individual needs of the patient.

VI. MANAGEMENT

A. Hospitalization Criteria

Inability to maintain consistent oxygen saturations >90% on room air;

and/or

Inability to maintain adequate oral hydration; and/or

Respiratory rate greater than 70 breaths per minute; and/or

Severely increased work of breathing; and/or

Caregiver anxiety requiring more extensive education; and/or

Additional consideration for hospitalization should be given to children atrisk for severe or complicated disease, as listed under Section V.Diagnosis, item E.

B. Prevention of Nosocomial Transmission.*Recommendations

1. Use adequate hand sanitation before and after contact with the patient

or inanimate objects in the vicinity of the patient using analcohol-based rub or hand washing with antimicrobial soap.

2. Clinicians should educate personnel and family members on hand

sanitation and other techniques for decreasing viral spread.

3. Implement contact and droplet precautions in addition to standarduniversal precautions.

4. Patients and staff should be cohorted as feasible.

Because frequent hand-washing has been shown to decrease nosocomialviral spread113, hands should be decontaminated before and after contact with thepatient and/or inanimate objects in the vicinity of the patient. All health careproviders and visitors should be educated in preventing patient-to-patient viraltransmission and hand sanitation techniques, including the use of alcohol foamand antimicrobial soap and water21. In addition to implementing universalstandard precautions, contact and droplet precautions should be initiated given the

ability of the causative viral agents to spread via contaminated fomites and largeparticle entry into eyes and nose83,89. Patients and staff should be cohorted, whenfeasible, as this has been shown to decrease nosocomial viral transmission41.

C. Supportive Care and Monitoring

*Recommendations1. Patients should be assessed for the ability to maintain hydration orally.

Oral hydration should be maintained as the patient can tolerate.


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2. If the patient is unable to take sufficient volume to maintain oral

hydration or cannot feed safely, intravenous fluids should be

administered. While receiving IV fluids, the patient should becarefully monitored for the development of hyponatremia.

3. Nasal/oral bulb suctioning should be used to clear secretions prior to

feeding (if necessary), prior to inhaled medication trials, and asneeded for temporary relief of airway obstruction.

4. Chest physiotherapy and deep nasopharyngeal suctioning are not

routinely recommended.5. Infants < 4 weeks of age should be placed on cardiorespiratory

monitors due to the increased risk of apnea.

6. Cardiorespiratory monitoring may be considered for infants between 4

weeks and 12 weeks of age due to the increased risk of apnea.

Infants with respiratory distress and tachypnea have increasedenergy expenditure and insensible fluid losses. Patients may have difficulty

maintaining adequate oral intake given this increased fluid requirement,particularly if respiratory distress interferes with feeding. Also, patients withrespiratory rates greater than 60-70 bpm may be at increased risk of aspiration offeeds75. If the patient is unable to take in sufficient volume to maintain hydrationor cannot feed safely, intravenous fluids should be provided. Given sporadicreports of hyponatremia due to fluid retention, however, serum sodium levelsshould be closely monitored during intravenous fluid administration57,138 (seeSection V, item D below).

In terms of airway clearance, only nasal bulb suctioning and maintenanceof proper airway positioning have been found to be helpful in managingbronchiolitis. Three RCTs have failed to demonstrate any benefit of chestphysiotherapy using vibration and percussion techniques18,96,144. No data existsevaluating the safety and efficacy of routine deep pharyngeal suctioning.

D. Supplemental Oxygen

*Recommendations1. Supplemental oxygen should be administered if the patient is unable to

maintain oxyhemoglobin saturation (Sp02) consistently at or above

90% after nasal and/or oral suctioning, appropriate airway

positioning, and pulse oximetry probe repositioning.2. Oxygen should be titrated primarily by respiratory therapy staff to

maintain Sp02 at or above 90% during both feeding and sleep.

3. Continuous pulse oximetry measurement may be discontinued as thepatient is clinically improving.

Data are lacking to identify specific criteria at which patients withbronchiolitis should be given supplemental oxygen and/or hospitalized. Therelationship between SpO2 and the arterial partial pressure of oxygen (PaO2)suggests that at or above SpO2 of 90%, otherwise healthy children withbronchiolitis are unlikely to receive significant benefit from the application of


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supplemental oxygen. Because transient decreases in SpO2 below 90% occureven in healthy children70, supplemental oxygen should not be initiated untilpersistent decreases in SpO2 below 90% are observed. Patients should beobserved during both sleep and feeding, as these states alter ventilatory effort andmetabolic demand, respectively. Because poor probe positioning and motion

artifact can interfere with the accuracy of pulse oximetry readings, the probeshould be repositioned prior to initiating supplemental oxygen. Finally, thechilds clinical work of breathing should also factor into the decision to startsupplemental oxygen.

Once oxygen therapy is initiated, flow rates should be titrated primarily byrespiratory therapy staff to maintain SpO2 at or above 90% during both feedingand sleep. As the patients clinical status begins to improve, continuous pulseoximetry should be replaced with intermittent pulse oximetry measurement.

E. Inhaled Beta-Agonists

*Recommendations

1. Inhaled bronchodilators are not routinely recommended.2. A carefully monitored trial of an inhaled bronchodilator is an option.

Nasal suctioning and appropriate airway positioning should be

performed prior to the initiation of the trial. The patient should be

allowed to return to baseline.

The Respiratory Distress Assessment Instrument (RDAI; See CLIP

Table 1) should be used by an MD or respiratory therapist toassign a clinical score immediately before and within 15 minutes

after treatment completion.

Inhaled bronchodilators should be continued only if positive

treatment response has been documented using the RDAI.

Given the significant benefits of inhaled beta-adrenergic agonists in thetreatment of asthma, clinicians have chosen to use these agents in bronchiolitisdespite the paucity of evidence to support the practice. Multiple randomized,controlled trials (RCTs) have been published to date in which the effects ofinhaled albuterol or salbutamol were compared to placebo in children hospitalizedwith acute bronchiolitis26,28,29,40,56,61,69,72,87,90,100,131,137,142. When data were pooled, nosignificant benefit of beta-adrenergic agonist treatment was noted amonginpatients, particularly with respect to shortened symptom duration or length ofstay53. These results are consistent with the underlying pathogenesis ofbronchiolitis being obstruction of small airways with cellular debris and mucus, as

opposed to functional obstruction via bronchospasm. Thus, the routine use ofbeta-adrenergic agonist treatment is not recommended.

Given the possibility of underlying reactive airways disease in childrenpresenting with bronchiolitis, a trial of beta-adrenergic agonist treatment, in whichthe patients response is carefully monitored, is an option8. At UNC, the trialshould be conducted by an MD or a respiratory therapist using inhaled albuterol.Prior to administering the medication, the child's nasal and oral airways should bebulb suctioned and the child should be allowed to recover to baseline after


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suctioning. The Respiratory Distress Assessment Instrument (RDAI), a validatedtool used in many bronchiolitis studies to objectively characterize clinical work ofbreathing88, should be used to assign a clinical score immediately before and againwithin 15 minutes after completion of administration of the medication. The trailis considered positive, meaning the child shows improvement due to the

medication, if the post-treatment RDAI score is 3 or more points lower than thepre-treatment score. Inhaled beta-agonists should only be continued if a positivetrial is documented. The child should subsequently be considered to haveunderlying reactive airways disease and managed accordingly.

F. Inhaled Epinephrine

*Recommendations1. Inhaled epinephrine is not routinely recommended.

2. A carefully monitored trial of inhaled epinephrine is an option.

(See Section VI. Management, Item E, Recommendation 2, above)

Multiple RCTs have been published to date in which the effects of inhaledepinephrine were compared with either an inhaled beta-adrenergic agonist orplacebo in children hospitalized with acute bronchiolitis3,17,77,81,100,104,112,140,143. Short-term improvements in clinical respiratory scores and/or pulse-oximetrymeasurements were observed in four studies77,104,112,143. Length of stay was noteffected in four studies which reported this outcome17,81,100,104. Pooled datademonstrate insufficient evidence to suggest that the routine use of inhaledepinephrine alters the course of illness67.

Given the possibility of underlying reactive airways disease and thedemonstrated short-term benefits, a trial of inhaled epinephrine, in which thepatients response to treatment is carefully observed, is an option8. The RDAIshould be used to assign a clinical score immediately before one dose of inhaledepinephrine and again within 15 minutes after treatment completion. Inhaledepinephrine should be continued only if a positive response is documented usingthe RDAI.

On the general pediatric inpatient service at UNC, inhaled epinephrineshould be given no more than every 2 hours. Patients should be oncardiorespiratory monitors during and at least 3 hours after treatment.

G. Corticosteroids

*Recommendations

1. Corticosteroids, in any form, are not routinely recommended.

2. Corticosteroids may be considered if a positive treatment response toinhaled bronchodilators has been documented, with the

presumption of the existence of underlying reactive airwaysdisease.

Various RCTs have examined the efficacy of various oral, inhaled, andparenteral corticosteroids on symptoms and clinical course of childrenhospitalized with bronchiolitis with mixed results15,16,23,25,27,32-36,38,55,76,79,84,107,111,


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122,131,133,137,139,146,148. Trial design, choice and dosage of drug, and reported outcomevariables are extremely heterogeneous, making comparison between studiesdifficult. Not surprisingly, pooled data do not show a statistically significantdifference in lengths of stay or clinical symptoms99.

Despite the existence of RCTs with sample sizes greater than 100, the

efficacy of corticosteroids remains unclear. Three large RCTs were devoted toexamining oral steroid usage23,33,34. The only study with positive results,specifically shorter length of stay and duration of symptoms in the treatmentgroup, included infants with prior history of wheezing34. Interestingly, twoplacebo-controlled studies with similar designs examined the use of intramusculardexamethasone in infants with bronchiolitis and no history of wheezing: onefound no difference between groups111 and the other found significantly shortersymptom duration and length of stay in the dexamethasone group133. Two largeconflicting RCTs studying inhaled steroids have been conducted: one showing nodifference25 and one showing significantly decreased length of stay and betterclinical respiratory score in the steroid-treated group36. The later study, however,

did not exclude infants with a history of wheezing. These unclear benefits mustbe weighed against the extensive list of potential adverse effects of steroids,including gastrointestinal bleeding11, complicated severe varicella42, cerebral palsyand neurodevelopmental impairment13, adrenal suppression, decreased linearvelocity, and change in bone mineral density73,98. Therefore, insufficient dataexists to support the use of any form of corticosteroid for the treatment ofbronchiolitis.

H. Antibiotics

*Recommendations

1. Antibiotics are not routinely recommended.

2. Antibiotics should be used for specific indications of coexistingbacterial infection, following established guidelines for treatment

in the absence of bronchiolitis.

There have been very few randomized trials examining the efficacy ofantibiotics in bronchiolitis. Two studies found no difference in length of stay orsymptom duration in infants randomized to ampicillin or placebo groups50,52. Amore recent small study with 21 patients found that treatment with clarithromycindecreased length of stay, duration of oxygen requirement, and need for beta(2)-agonist treatment129.

Concern for serious bacterial infection (SBI) in infants with bronchiolitiswho are less than 90 days old has led to the use of broad-spectrum antibiotics. Nostudies examining the incidence of SBI specifically in infants


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In various retrospective and prospective studies, the rate of SBI inhospitalized patients with bronchiolitis was found to be extremely low, withurinary tract infection being the most common. In retrospective studies includingchildren < 36 months, the rate of culture-proven SBI for children hospitalizedwith bronchiolitis was


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airways47,48,108,124. Although the exact mechanism is unknown, it is thought thathypertonic saline facilitates inspissated mucus removal and decreases mucosaledema109,136. In two RCTs evaluating 3% nebulized saline in children hospitalizedwith bronchiolitis, statistically significant improvements in clinical scores andreductions in length of stay were seen80,132.

Despite these promising preliminary results, the safety of nebulizedhypertonic saline remains in question due to observed bronchospasm aftertreatment in older patients with cystic fibrosis125. Although no significant adverseeffects were noted in the two studies using inhaled 3% saline the treatment ofbronchiolitis80,132, both studies allowed and/or required the co-administration ofbronchodilators. Therefore, insufficient data exists at this time to recommend theroutine use of hypertonic saline.

VII. COMPLICATIONS

A. Predictors of Disease Severity At Presentation

Ill or toxic appearance117

Oxygen saturation


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patients experienced hyponatremia associated with increased ADH secretion44.The risk of hyponatremia appears to have an even greater correlation with theadministration of hypotonic intravenous fluids66. Thus, patients should bemonitored carefully for hyponatremia while receiving IV fluids and oral hydrationshould be reinitiated as quickly as possible.

E. Other Extrapulmonary Manifestations

During RSV infection, viremia and disseminated infection has beendescribed44. Cardiac complications include arrhythmias, such as atrialand ventricular tachycardia, hypotension with shock97, and myocarditis19,101. Alongwith central apnea, neurologic complications include seizures in up to 1.8% ofinpatients95. Hepatic involvement has also been described, ranging from mildtransaminitis to severe hepatitis with coagulopathy45,46.

VIII. DISCHARGE CRITERIA

Discharge from the hospital is appropriate when the following criteria are met:

Patient is able to maintain consistent oxygen saturation >90% on room air,or the patient is able to maintain consistent oxygen saturation >90% on a

stable and minimal amount of supplemental oxygen

Patient is free of apnea for >24 hours

Patient is able to maintain adequate hydration with oral or enteral tube

feeding

Caregivers have been adequately educated and feel comfortable providing

necessary care for the patient (see Section IX. Discharge Anticipatory

Guidance, below)

More than 3 hours have elapsed since the last inhaled epinephrine treatment

Caregiver has ability to access medical care as needed

Appropriate hospital follow-up and/or home health care, if necessary, has

been arranged, including detailed communication with the primary careprovider about issues requiring follow-up

IX. DISCHARGEANTICIPATORY GUIDANCE

Prior to discharge, caregivers should be educated at an appropriate level ofunderstanding about each of the following:

Airway positioning

Airway clearance techniques, including nasal suction

Maintenance of oral hydration

Temperature control, including appropriate dosages of antipyretics

Use of any prescribed medications

Avoidance of exposure to tobacco smoke or other irritants

Methods to limit transmission (eg, hand washing, avoiding day care while ill)

Criteria for immediate return to a health care provider

Timing of scheduled follow-up with primary healthcare provider


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Compiled Jan 2008 by the University of North Carolina General Pediatric ClinicalPractice Guidelines Development Committee

Authors: Mikelle Key-Solle, MD, General Pediatrics; primary author

Kathy Bradford, MD, General PediatricsJulie Byerley, MD, General PediatricsHarvey Hamrick, MD, General PediatricsCheryl Jackson, MD, Pediatric Emergency MedicineJacob Lohr, MD, General PediatricsKyrie Shomaker, MD, General PediatricsMichael Steiner, MD, General Pediatrics

Consultants: Ki Abel, MD, Pediatric Emergency MedicineKara Bozik, PharmD

Michael Goley, PNPJessica Katz-Nelson, MD, Pediatric Emergency MedicineTiffany Mabe, RRT, Pediatric Respiratory TherapyDan Macklin, Pediatric Emergency Medicine

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5. Agency for Healthcare Research and Quality.Management of Bronchiolitis in Infants and Children.Evidence Report/Technology Assessment No. 69.Rockville, MD: Agency for Healthcare Research andQuality; 2003. AHRQ Publication No. 03-

6. Ahern, W., T. Bird, and S. D. M. Court. 1970. Pathologicchanges in virus infections of the lower respiratory tractin children. J. Clin. Pathol. 23:718.

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Bronchiolitis Clinical Practice Guideline

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Transcript of Bronchiolitis Clinical Practice Guideline