Bronchiolitis revamp

This article is from Medscape Emergency Medicine Briefs:

AAP Releases New Guidelines on Management of Bronchiolitis CME/CE

News/CME Author: Laurie Barclay, MD

CME/CE Released: 11/19/2014 ; Valid for credit through 11/19/2015

CLINICAL CONTEXT

On the basis of recent evidence, the American Academy of Pediatrics (AAP) has revised its 2006 clinical practice guideline on diagnosis and management of bronchiolitis in otherwise healthy children 1 to 23 months old. Each practice statement includes the underlying level of evidence, benefit-harm relationship, and level of recommendation.

Bronchiolitis is commonly caused by viral lower respiratory tract infection and is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, resulting in increased mucus production. Typical signs and symptoms initially include rhinitis and cough, sometimes followed by tachypnea, wheezing, rales, use of accessory muscles of respiration, and/or nasal flaring.

STUDY SYNOPSIS AND PERSPECTIVE

Management of bronchiolitis in children 1 to 23 months old no longer requires testing for specific viruses or a trial dose of a bronchodilator, according to new guidelines issued by the AAP and published online October 27 in Pediatrics.

According to a comprehensive evidence review, the new AAP guideline on diagnosing, treating, and preventing bronchiolitis updates the previous recommendations published in 2006. It targets pediatricians, family physicians, emergency medicine specialists, hospitalists, nurse practitioners, and physician assistants who care for children.

Bronchiolitis is the most common cause of hospitalization among infants younger than 1 year. The new guideline emphasizes that only supportive care, including oxygen and hydration, is strongly recommended for young children with bronchiolitis.

"Bronchiolitis is a disorder commonly caused by viral lower respiratory tract infection in infants," write Shawn L. Ralston, MD, FAAP, and colleagues from the AAP. "Bronchiolitis is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, and increased mucus production. Signs and symptoms typically begin with rhinitis and cough, which may progress to tachypnea, wheezing, rales, use of accessory muscles, and/or nasal flaring."

Changes from the 2006 guideline are that testing for specific viruses is no longer needed, because multiple viruses may cause bronchiolitis. Routine radiographic or laboratory studies are also unnecessary, and clinicians should diagnose bronchiolitis and assess its severity on the basis of history and physical examination.

The AAP also no longer recommends a trial dose of a bronchodilator, such as albuterol or salbutamol, because evidence to date shows that bronchodilators are ineffective in changing the course of bronchiolitis (evidence quality: B, strong recommendation). In addition, in accordance with a policy statement published in July by the AAP, the new guideline updates recommendations for use of palivizumab to prevent respiratory syncytial virus (RSV) infections: Otherwise-healthy infants with gestational age of 29 weeks or older should not receive palivizumab, but during the first year of life, infants with hemodynamically significant heart disease or chronic lung disease of prematurity should receive palivizumab (maximum of 5 monthly doses, 15 mg/kg per dose, during the RSV season).

Other recommendations are that when making decisions about the assessment and management of bronchiolitis in children, clinicians should evaluate risk factors for severe disease, such as age younger than 12 weeks, prematurity, underlying cardiopulmonary disease, or immunodeficiency. Finally, clinicians should not give epinephrine to infants and children diagnosed with bronchiolitis, nor should these children receive chest physiotherapy.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online October 27, 2014. Full text

STUDY HIGHLIGHTS

• A new recommendation is that a diagnosis of bronchiolitis no longer requires testing for specific viruses, because multiple viruses may cause bronchiolitis.
• Clinicians should diagnose bronchiolitis and determine its severity on the basis of history and physical examination.
• Routine radiographic or laboratory studies are unnecessary.
• When considering the evaluation and management of bronchiolitis in young children, clinicians should assess risk factors for severe disease, such as age younger than 12 weeks, prematurity, underlying cardiopulmonary disease, or immunodeficiency.
• A new recommendation is that management of bronchiolitis no longer requires a trial dose of a bronchodilator, because available evidence shows that bronchodilators do not change the course of bronchiolitis (evidence quality: B, strong recommendation).
• Only supportive care, including oxygen and hydration, is strongly recommended for young children with bronchiolitis.
• Otherwise-healthy infants with a gestational age of 29 weeks or older should not receive palivizumab to prevent RSV infections.
• However, during the first year of life, infants with hemodynamically significant heart disease or chronic lung disease of prematurity should receive palivizumab (maximum of 5 monthly doses, 15 mg/kg per dose, during the RSV season).
• Infants and children diagnosed with bronchiolitis should not receive epinephrine or chest physiotherapy.
• Infants with a diagnosis of bronchiolitis in the emergency department should not receive nebulized hypertonic saline.
• However, infants and children hospitalized for bronchiolitis may receive nebulized hypertonic saline.
• Clinicians may choose not to use continuous pulse oximetry for infants and children diagnosed with bronchiolitis.
• Infants and children with bronchiolitis should not receive antibiotics unless there is a concomitant bacterial infection, or a strong suspicion of such an infection.
• Infants with a diagnosis of bronchiolitis who cannot maintain oral hydration should receive nasogastric or intravenous fluids.
• All people should use alcohol-based rubs for hand decontamination when caring for children with bronchiolitis, or hand-washing with soap and water when alcohol-based rubs are not available.
• Clinicians should encourage exclusive breastfeeding for at least 6 months to reduce the morbidity of respiratory tract infections.
• When evaluating a child for bronchiolitis, clinicians should counsel caregivers about exposing the infant or child to environmental tobacco smoke and should also provide counseling on smoking cessation.
• Clinicians and nurses should educate personnel and family members on evidence-based diagnosis, treatment, and prevention in bronchiolitis.

CLINICAL IMPLICATIONS

• A new recommendation in the updated AAP guideline for bronchiolitis is that a diagnosis of bronchiolitis no longer requires testing for specific viruses, because multiple viruses may cause bronchiolitis.
• Another new recommendation in the updated AAP guideline is that management of bronchiolitis no longer requires a trial dose of a bronchodilator, because available evidence shows that bronchodilators do not change the course of bronchiolitis.