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M2E Too!

Bronchiolitis Guidelines a Mismatch with Clinical Practice

Mellick, Larry, MD

doi: 10.1097/01.EEM.0000552803.48810.88
M2E Too!

Dr. Mellick is a professor of emergency medicine, the vice chairman for academic affairs in emergency medicine, the section chief of pediatric emergency medicine, and the assistant residency program director at the University of South Alabama in Mobile. Read his monthly blog at http://bit.ly/EMN-Mellick, and follow him on Twitter @Lmellick.

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The latest American Academy of Pediatrics guidelines for the hospital management of bronchiolitis seem to be causing, unfortunately, confusion for experienced and inexperienced emergency physicians alike.

The guidelines raise unaddressed issues and new questions, and, most importantly, don't tackle important aspects of frontline clinical practice. (Pediatrics 2014;134[5]:e1474; http://bit.ly/2QIGbMX.) These guidelines were developed with the best evidence currently available, and their application mostly causes confusion with our undifferentiated patients. In fact, the guidelines may potentially create unnecessary vulnerabilities in our clinical practice by minimalizing our approach to these wheezing infants. Clinical evaluations, workups, and treatments seem to be discouraged.

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Diagnosis under the Guidelines

  • 1a. Clinicians should diagnose bronchiolitis and assess disease severity based on history and physical examination. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 1b. Clinicians should assess risk factors for severe disease, such as age under 12 weeks, a history of prematurity, underlying cardiopulmonary disease, or immunodeficiency, when making decisions about the evaluation and management of children with bronchiolitis. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)
  • 1c. Radiographic or laboratory studies should not be obtained routinely when clinicians diagnose bronchiolitis based on history and physical examination. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)
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Treatment under the AAP Guidelines

  • 2. Clinicians should not administer albuterol (or salbutamol) to infants and children with a bronchiolitis diagnosis. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 3. Clinicians should not administer epinephrine to infants and children with a bronchiolitis diagnosis. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 4a. Nebulized hypertonic saline should not be administered to infants with a bronchiolitis diagnosis in the emergency department. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)
  • 4b. Clinicians may administer nebulized hypertonic saline to infants and children hospitalized for bronchiolitis. (Evidence Quality: B; Recommendation Strength: Weak Recommendation [based on randomized controlled trials with inconsistent findings].)
  • 5. Clinicians should not administer systemic corticosteroids to infants with a diagnosis of bronchiolitis in any setting. (Evidence Quality: A; Recommendation Strength: Strong Recommendation.)
  • 6a. Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90% in infants and children with a bronchiolitis diagnosis. (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low-level evidence and reasoning from first principles].)
  • 6b. Clinicians may choose not to use continuous pulse oximetry for infants and children with a bronchiolitis diagnosis. (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low-level evidence and reasoning from first principles].)
  • 7. Clinicians should not use chest physiotherapy for infants and children with a bronchiolitis diagnosis. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation.)
  • 8. Clinicians should not administer antibacterial medications to infants and children with a bronchiolitis diagnosis unless there is a concomitant bacterial infection or a strong suspicion of one. (Evidence Quality: B; Recommendation Strength: Strong Recommendation.)
  • 9. Clinicians should administer nasogastric or intravenous fluids for infants with a bronchiolitis diagnosis who cannot maintain hydration orally. (Evidence Quality: X; Recommendation Strength: Strong Recommendation.)
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The Undifferentiated Patient

Wheezing patients presenting to the ED and outpatient clinic will often be undifferentiated patients in contrast to the patients admitted and treated in the hospital. This is where there seems to be a disconnect between the guidelines and the clinical practice of emergency medicine. Unfortunately, the undifferentiated febrile or afebrile patient who presents with varying degrees of respiratory distress may not have bronchiolitis.

Bronchiolitis must be distinguished from a variety of acute and chronic conditions that affect the respiratory tract. The differential to consider includes a number of life-threatening conditions. Whether or not the guidelines acknowledge it, many patients may require further testing and treatment to differentiate better the etiology of the wheezing and adventitial sounds.

Bronchiolitis has some lookalikes, so keep these in mind when diagnosing patients: asthma, recurrent viral-triggered wheezing, pneumonia, chronic pulmonary disease, foreign body aspiration, aspiration pneumonia, congenital heart disease, congestive heart failure, and myocarditis.

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The Differential Diagnosis

Bronchiolitis is at best a syndrome or collection of signs and symptoms. RSV predominates, but multiple other viruses and some atypical bacteria can present with the syndrome. In fact, at least four viruses are commonly associated with wheezing in children: the respiratory syncytial virus, the rhinovirus, the human metapneumovirus, and the influenza viruses.

It helps to know that coinfection with viral and bacterial pathogens such as Haemophilus influenza type b or Streptococcus pneumoniae is uncommon because of the widespread use of conjugate polysaccharide vaccines, Bordetella pertussis, Chlamydia trachomatis, or Mycoplasma pneumoniae must be included in the differential diagnosis of a lower respiratory tract infection in a young child. In fact, one of the videos in my blog shows an infant acutely ill and co-infected with both RSV and pertussis. (http://bit.ly/EMN-Mellick.)

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The Fallacy of ‘Do Less, Not More’

It is possible for seasoned providers in pediatric care to make a bronchiolitis diagnosis without further testing, but it might not be realistic to expect everyone to do the same. And it might be unrealistic to expect learners to be able to confirm the diagnosis without additional steps to differentiate the patient. (Many of my undifferentiated wheezing patients respond to nebulized albuterol and epinephrine.) Furthermore, the overall message of “do less, not more” in the current guidelines may be the predominant message heard by learners or non-pediatricians, inadvertently resulting in sicker patients not being evaluated and treated aggressively when appropriate.

The 2014 AAP guidelines seem to personify therapeutic nihilism, but more optimistic and current evidence should be incorporated into the next revision of these guidelines in 2019. It is not possible to dive deeply into the evidence, but my analysis of the current literature suggests that the following treatment options have now sufficiently matured to allow their routine application in treating bronchiolitis syndrome:

  • Hypertonic saline (3%) nebulization (Cochrane Database Syst Rev 2017;12:CD006458)
  • Nebulized epinephrine (Cochrane Database Syst Rev 2011;[2]:CD006619 and several other studies)
  • High-flow nasal cannula (multiple studies)
  • Heliox therapy (Cochrane Database Syst Rev 2015;[9]:CD006915)

The undifferentiated patient presenting with bronchiolitis syndrome and the health care provider's experience or comfort level pose challenges that are not sufficiently addressed in the guidelines. I am convinced that there is a mismatch between ivory tower recommendations and frontline care. In fact, it is common to hear clinicians sounding like guilty schoolchildren feeling obligated to justify why they are not following these clinical guidelines. Thankfully, there is less to feel guilty about because we now have growing evidence-based treatment options for our bronchiolitis syndrome patients.

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