Bronchiolitis guidelines

Up to 48% of infants admitted to Australian hospitals with bronchiolitis receive treatment that has no evidence of benefit. Bronchiolitis remains the most common reason infants are admitted to hospitals in Australia and New Zealand, yet our practice in treating these patients remains variable.  The PREDICT network has conducted a systematic review to produce Australia’s first bronchiolitis guideline based on a robust systematic review. These guidelines broadly agree with the American Academy of Pediatrics and NICE guidelines.

O’Brien S, Wilson S, Gill FJ, Cotterell E, Borland ML, Oakley E, Dalziel SR, Paediatric Research in Emergency Departments International Collaborative (PREDICT) network, Australasia. The management of children with bronchiolitis in the Australasian hospital setting: development of a clinical practice guideline. J Paediatric Child Health, 2018. doi:10.1111/jpc.14104

Based on their robust evidence review, the authors have produced 22 recommendations. Let’s examine their key recommendations.

What investigations should we do?

• Routine blood and urine testing is not recommended.
• Viral swabs are not recommended (although the authors mention that further study needs to be done to determine the benefit of cohorting in wards, i.e. when all babies with the same virus are put in the same bay together to avoid spread).
• The authors note that in infants under two months old with bronchiolitis, there is an increased risk of a concurrent UTI.

Therefore, in babies under two months old with pyrexia, likely bronchiolitis but some clinical uncertainty – send urine for MC&S.

 

 

What treatments are effective?

• Salbutamol – there is no benefit in using salbutamol in infants with bronchiolitis (and some evidence of adverse effects)
• Nebulised adrenaline – no benefit
• Nebulised hypertonic saline – there is weak evidence of a reduction in length of stay of 0.45 days. However, when two studies were removed, both used a different discharge criteria than most hospitals, there was no benefit. This is not recommended routinely, although the authors suggest it should be used only as part of an RCT.
• Glucocorticoids – no benefit
• Antibiotics – not recommended

The risk of a secondary bacterial infection is very low, and there is potential harm from giving antibiotics

• Oxygen – no evidence of benefit in infants with no hypoxia, and low-level evidence that maintaining the sats over 91% with oxygen actually prolongs the length of stay. There are no reports of long-term adverse neurodevelopmental outcomes in infants with bronchiolitis. However, there is also no data on the safety of targeting sats <92%

Commence oxygen therapy to maintain sats over 91%

• Sats monitoring – moderate evidence suggests that continuous sats monitoring increases the length of stay in stable infants.
• High flow – there is low to very low level evidence of benefit with high flow.
• Chest physiotherapy – not recommended
• Saline drops – routine saline drops are not recommended, but a trial with feeds may help
• Feeds – both NG and IV are acceptable routes for hydration.

 

This is the first robust Australasian acute paediatric guideline on bronchiolitis. It provides clear guidance for the management of patients with bronchiolitis seen in Australasian EDs and general paediatric wards and is in line with US and UK recommendations. Our current practice often deviates from this evidence-based practice, and hopefully, these guidelines will start the shift towards unifying evidence-based practice in managing infants with bronchiolitis.

 

 

References

American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics 2006; 118: 1774–93.

Ricci V, Delgado Nunes V, Murphy MS, Cunningham S; on behalf of the Guideline Development Group and Technical Team. Bronchiolitis in children: Summary of NICE guidance. BMJ 2015; 350: h2305.