Pediatric Annals

Special Issue Article 

Less is More: Evidence-Based Management of Bronchiolitis

Elisa Hampton, MD; Erika Abramson, MD, MS

Abstract

Bronchiolitis is a common cause of outpatient visits and hospitalization in children younger than age 2 years. Despite the frequency with which pediatricians manage this diagnosis, there is significant variability in care in both the inpatient and outpatient setting. This may be due in part to changing guidelines set forth by leading pediatric organizations such as the American Academy of Pediatrics, as increasing evidence emerges that traditional therapies are not effective. This article reviews current evidence-based practices for diagnosis and treatment of bronchiolitis, and provides an overview of inpatient management. [Pediatr Ann. 2017;46(7):e252–e256.]

Abstract

Bronchiolitis is a common cause of outpatient visits and hospitalization in children younger than age 2 years. Despite the frequency with which pediatricians manage this diagnosis, there is significant variability in care in both the inpatient and outpatient setting. This may be due in part to changing guidelines set forth by leading pediatric organizations such as the American Academy of Pediatrics, as increasing evidence emerges that traditional therapies are not effective. This article reviews current evidence-based practices for diagnosis and treatment of bronchiolitis, and provides an overview of inpatient management. [Pediatr Ann. 2017;46(7):e252–e256.]

In the winter, pediatricians' offices are often filled with young children with chief complaints of fever, cough, and wheezing. Frequently, this constellation of symptoms is a result of bronchiolitis—a clinical diagnosis made in children younger than age 2 years who present with lower respiratory signs and symptoms (tachypnea, wheezing, increased work of breathing) in the setting of viral infection. The initial presenting symptoms are often rhinorrhea and cough, which later progress to lower respiratory tract illness.1 It will come as no surprise to a general pediatrician that bronchiolitis accounts for more office visits than diaper rash, urinary tract infections, or gastroenteritis, and that bronchiolitis visits make up at least 10% of outpatient pediatric visits and 16% of hospitalizations for children younger than age 2 years.2,3 This article reviews current evidence-based practices for diagnosis and treatment of bronchiolitis, with a focus on inpatient management.

The 2014 American Academy of Pediatrics (AAP) clinical practice guideline on the diagnosis, management, and prevention of bronchiolitis defines bronchiolitis as “a constellation of signs and symptoms occurring in children younger than 2 years including a viral upper respiratory tract prodrome followed by increased respiratory effort and wheezing.”1 A number of viral etiologies have been identified, but the primary cause is respiratory syncytial virus (RSV), which is the causative virus for up to 80% of bronchiolitis in infants.4,5 Bronchiolitis is the most common cause of hospitalization for infants younger than age 12 months,1 and accounts for 18% of all hospitalizations for these children (excluding routine births).2 Hospitalizations for bronchiolitis in the United States result in an estimated $1.73 billion annually in hospital charges.2 Despite the high prevalence of bronchiolitis, mortality rates are low and have been decreasing over time (4 per 10,000 patients in 2011).6 Most deaths from bronchiolitis are in infants younger than age 12 months and in children with complex chronic conditions (most commonly cardiovascular conditions).6

Despite the frequency with which general pediatricians encounter this diagnosis, practice patterns are often highly variable.7 We present a series of important questions that general pediatricians can ask to help them guide their care for pediatric patients presenting with suspected bronchiolitis.

What Laboratory or Imaging Studies Should Be Obtained If Bronchiolitis Is Suspected?

The 2014 AAP clinical practice guideline recommends against routinely obtaining laboratory or radiographic studies for bronchiolitis, as the diagnosis can be made clinically.1 As always, obtaining a careful history is key, and it is important to consider alternative diagnoses such as ingestion of a foreign body. Viral testing is not recommended because there are many viruses that can cause bronchiolitis, but the underlying viral etiology is generally not correlated with specific clinical findings or responsiveness to interventions.5

Therefore, identifying the specific viral etiology is unlikely to add significant information that will change prognosis or management. In addition, polymerase chain reaction testing may uncover prolonged viral shedding from an unrelated prior illness and not be representative of the current etiology for symptoms.1

Routine radiographic imaging is also not recommended due to the high prevalence of abnormalities on chest X-ray in infants with bronchiolitis and the lack of correlation between these abnormalities and clinical outcomes.1 In fact, imaging with chest X-ray is correlated with an increased use of antibiotics.8 Furthermore, reducing the number of chest X-rays has been shown to decrease costs without affecting clinical outcomes.9

What Predisposing Risk Factors Might Lead to a Worse Clinical Course?

Elements of a patient's history that are most relevant for an office visit for bronchiolitis are factors that contribute to an overall risk assessment for the patient. Risk factors for severe disease in bronchiolitis include age younger than 12 weeks and underlying medical conditions such as premature birth, cardiopulmonary disease, and immunodeficiency.1 Children who have had recurrent wheezing or have other chronic pulmonary disease likely represent a distinct population, and the management recommendations reviewed here do not apply to these infants.

In addition to assessing for risk factors for severe disease, another important goal of the initial history and physical examination in the office setting is to assess the patient for severe disease at this moment in time. Of particular importance is assessing hydration, activity level, mental status, and respiratory effort. In addition, as bronchiolitis is known to be a dynamic and rapidly changing disease process, assessing the ability of the family to provide supportive care, understand concerning signs and symptoms, and return for follow-up is critical.

How Can Patients at High Risk for Severe Disease Be Better Protected?

One tool available to the outpatient pediatrician for the prevention of RSV infection is palivizumab. The AAP Committee on Infectious Diseases published guidelines in 2014 on the use of palivizumab for prophylaxis of RSV infection.10 This policy statement recommends restricting use of palivizumab to a specific group of high-risk infants, including premature infants with a gestational age of less than 29 weeks, preterm infants with a diagnosis of chronic lung disease of prematurity (defined as gestational age <32 weeks requiring supplemental oxygen >21% for at least 28 days after birth), and infants younger than age 12 months with hemodynamically significant congenital heart disease. Other subsets of infants, including those with pulmonary abnormalities, neuromuscular disease, or severely immunocompromised states, may also be considered for prophylaxis in some situations.

Additionally, preventive care for all patients should include counseling on hand hygiene, breast-feeding promotion, and avoidance of tobacco smoke.1

Are There Treatments for Bronchiolitis in the Office?

The mainstay of treatment is routine supportive care including ensuring adequate hydration and educating the family about signs and symptoms that signal worsening disease and need for re-evaluation. Frequent nasal suctioning to remove secretions is helpful, although “deep” suctioning of the nasopharynx has been associated with increased length of stay in hospitalized children, possibly due to edema of the upper airway.11 Chest physiotherapy with vibration or percussion is also not recommended as it has not been shown to be beneficial.1

A notable change between an earlier version of the AAP bronchiolitis clinical practice guideline and the current guideline relates to the use of bronchodilators. Although some studies show an improvement in clinical symptom scores with the use of albuterol,12,13 evidence does not support their use in decreasing need for hospitalization, shortening length of stay, or improving oxygen saturation. Therefore, there is a strong recommendation in the 2014 AAP guidelines against using albuterol in patients with bronchiolitis.1 This recommendation relies heavily on a Cochrane review from 2014 that included 30 studies of both outpatients and inpatients,14 and included the consideration that albuterol use can cause side effects such as tremor and tachycardia. Despite the strong recommendation against the use of bronchodilators for patients with bronchiolitis, some clinicians might still consider a trial of albuterol for a patient who is wheezing for the first time and has a strong family history of asthma. It is important to note that although a small number of children with viral-induced wheezing may respond to bronchodilators, there is no reliable way to determine which patients will have reversible airway obstruction, nor whether the effect of the medication will be sustained with repeat administration.

Nebulized epinephrine is also not recommended.1 In the inpatient setting, epinephrine use has been associated with increased length of stay.15,16 In the outpatient setting, a Cochrane review suggested a benefit in reducing admission on the first day after an emergency department visit but not at 7 days.17 Given that epinephrine is not generally administered at home and that prolonged observation after administration in the outpatient setting is problematic, the authors of the 2014 clinical practice guideline1 strongly recommend against using epinephrine for the treatment of bronchiolitis.

Similarly, corticosteroids are not recommended due to evidence showing no improvements in admission rates or length of stay, most notably from a 2013 Cochrane review.1,18

If My Patient Requires Hospitalization, What Care Will They Receive in the Inpatient Setting?

When infants with bronchiolitis are hospitalized, the goals of care remain supportive while the acute illness resolves. For infants who cannot hydrate themselves orally, nasogastric or intravenous hydration will be used. Several studies have compared nasogastric and intravenous hydration and found that clinical outcomes (including duration of oxygen requirement, need for escalation of respiratory support, and length of stay) and parental satisfaction are similar.1 Due to the evidence discussed in the previous section, infants are not routinely treated with albuterol, epinephrine, or corticosteroids.12–14 Earlier evidence showed a possible decrease in length of stay when nebulized hypertonic saline treatments were used in hospitalized infants; however, a reanalysis of this data in 2016 did not show benefit after accounting for heterogeneity of the included patient populations.19 Therefore, infants hospitalized for bronchiolitis are often not treated with any respiratory medications at all.

Infants will be treated with oxygen for sustained hypoxia, although increasing oxygen saturations above 90% are generally accepted, so those infants are not treated with supplemental oxygen. This is due to an analysis of the oxyhemoglobin dissociation curve, which shows that increasing oxygen saturation above 90% requires large elevations in arterial pressure of oxygen. Furthermore, there is no evidence that increasing oxygen saturations above 90% affects clinical outcomes.1

Another change in the 2014 clinical practice guidelines is the option not to monitor hospitalized infants with continuous pulse oximetry. Studies have found that a perceived need for oxygen is a key driver of length of stay in bronchiolitis,20 and that transient hypoxemia is common even in healthy infants.21 A 2016 study22 showed that most infants evaluated in the emergency department for bronchiolitis who were determined to be stable for discharge home had either transient or sustained oxygen desaturations. There were no differences between those with and without desaturations in terms of unscheduled follow-up visits or delayed hospitalizations;22 therefore, intermittent oxygen saturation monitoring is considered to be safe.

Children who have significant respiratory distress may be treated with high-flow nasal cannula, which is a relatively new mode of respiratory support that supplies humidified, heated, high flow of an air-oxygen mixture via a nasal cannula. This therapy is increasingly being used in all clinical settings, including the emergency department, intensive care unit, and some inpatient units. It has been shown to improve respiratory effort, generate positive airway pressure, and may decrease the need for intubation.1

Once an infant demonstrates an improvement of symptoms, no longer has significant respiratory distress, and is able to maintain oral hydration, they may be discharged home with close follow-up with their outpatient pediatrician. There should be close communication between the discharging hospital and the primary pediatrician, and families should receive education about the expected course of symptoms as well as signs and symptoms that should prompt a return visit.

Should Parents Expect Their Child to Experience Recurrent Wheezing After An Episode of Bronchiolitis?

Many parents worry about the likelihood of recurrent wheezing or the development of asthma later in life after an episode of bronchiolitis. Some studies do show an association between severe bronchiolitis and childhood asthma, particularly with RSV and rhinovirus, but the causality is unclear.23,24 It is not yet known whether some infants have a predisposition to both severe bronchiolitis and recurrent wheezing later in life due to epidemiologic or genetic factors, or whether there is injury or altered development of the lungs during the acute illness that later causes recurrent wheezing.5 In other words, as pediatricians, our best answer to this question may only be “time will tell.”

Conclusion

We have presented a series of questions that can guide pediatricians in caring for children with bronchiolitis, and these recommendations are summarized in Table 1. When caring for patients in the outpatient setting, pediatricians should carefully assess patients for risk factors for severe disease, assess current respiratory and hydration status, and assess the family's ability to care for the patient at home. If hospitalization is indicated, pediatricians and families should expect infants to receive supportive care until the acute illness has resolved. Increasingly, evidence is suggesting that medical interventions such as diagnostic testing, respiratory medications other than oxygen, and continuous monitoring do not alter the course of bronchiolitis. In general, less is more when caring for infants with bronchiolitis.

Summary of Recommendations for Children with Bronchiolitis

Table 1:

Summary of Recommendations for Children with Bronchiolitis

References

  1. Ralston SL, Lieberthal AS, Meissner HC, et al. American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474–1502. doi: . doi:10.1542/peds.2014-2742 [CrossRef]
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  3. Mansbach JM, Pelletier AJ, Camargo CA. US outpatient office visits for bronchiolitis, 1993–2004. Ambul Pediatr. 2007;7(4):304–307. doi: . doi:10.1016/j.ambp.2007.03.006 [CrossRef]
  4. Miller EK, Gebretsadik T, Carroll KN, et al. Viral etiologies of infant bronchiolitis, croup and upper respiratory illness during 4 consecutive years. Pediatr Infect Dis J. 2013;32(9):950–955. doi: . doi:10.1097/INF.0b013e31829b7e43 [CrossRef]
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  7. Macias CG, Mansbach JM, Fisher ES, et al. Variability in inpatient management of children hospitalized with bronchiolitis. Acad Pediatr. 2015;15(1):69–76. doi: . doi:10.1016/j.acap.2014.07.005 [CrossRef]
  8. Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007;150(4):429–433. doi: . doi:10.1016/j.jpeds.2007.01.005 [CrossRef]
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  10. American Academy of Pediatrics Committee on Infectious DiseasesAmerican Academy of Pediatrics Bronchiolitis Guidelines Committee. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics. 2014;134(2):415–420. doi: . doi:10.1542/peds.2014-1665 [CrossRef]
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  13. Flores G, Horwitz RI. Efficacy of beta2-agonists in bronchiolitis: a reappraisal and meta-analysis. Pediatrics. 1997;100(2 Pt 1):233–239. doi:10.1542/peds.100.2.233 [CrossRef]
  14. Gadomski AM, Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2014(6):CD001266. doi:10.1002/14651858.CD001266.pub4 [CrossRef].
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  21. Hunt CE, Corwin MJ, Lister G, et al. Longitudinal assessment of hemoglobin oxygen saturation in healthy infants during the first 6 months of age. Collaborative Home Infant Monitoring Evaluation (CHIME) study group. J Pediatr. 1999;135(5):580–586. doi:10.1016/S0022-3476(99)70056-9 [CrossRef]
  22. Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S. Effect of oxygen desaturations on subsequent medical visits in infants discharged from the emergency department with bronchiolitis. JAMA Pediatr. 2016;170(6):602–608. doi: . doi:10.1001/jamapediatrics.2016.0114 [CrossRef]
  23. Sigurs N, Aljassim F, Kjellman B, et al. Asthma and allergy patterns over 18 years after severe RSV bronchiolitis in the first year of life. Thorax. 2010;65(12):1045–1052. doi: . doi:10.1136/thx.2009.121582 [CrossRef]
  24. Caliskan M, Bochkov YA, Kreiner-Møller E, et al. Rhinovirus wheezing illness and genetic risk of childhood-onset asthma. N Engl J Med. 2013;368(15):1398–1407. doi: . doi:10.1056/NEJMoa1211592 [CrossRef]

Summary of Recommendations for Children with Bronchiolitis

Diagnostic Test/Treatment Recommendation Based on 2014 AAP Clinical Practice Guideline1
Laboratory studies, including viral testing Not routinely recommended
Radiographic studies (chest X-ray) Not routinely recommended
Nasal suctioning Often helpful
“Deep” nasopharyngeal suctioning Insufficient evidence to make a recommendation (but unlikely to be beneficial)
Chest physiotherapy Not recommended
Albuterol Not recommended
Epinephrine Not recommended
Corticosteroids Not recommended
History to identify risk factors for severe disease Recommendation to assess for risk factors including <list-item>

Age <12 weeks

</list-item><list-item>

Underlying medical conditions such as prematurity, cardiopulmonary disease, and immunodeficiency

</list-item>
Preventive measures Recommendation to disinfect hands before and after patient contact, contact with objects near patient, and after removing gloves using alcohol-based rubs or soap and water if alcohol rubs not available Recommendation to encourage breast-feeding Recommendation to assess for and counsel against environmental smoke exposure Recommend administering palivizumab during RSV season to infants who qualify
Support for patients who cannot maintain oral hydration Recommendation to provide nasogastric or intravenoushydration
Supplemental oxygen Option not to administer supplemental oxygen if saturation exceeds 90%
Continuous pulse oximetry Option not to use continuous pulse oximetry
Authors

Elisa Hampton, MD, is an Assistant Professor of Clinical Pediatrics, Weill Cornell Medicine. Erika Abramson, MD, MS, is an Associate Professor of Pediatrics and Healthcare Policy & Research, Weill Cornell Medicine.

Address correspondence to Elisa Hampton, MD, Weill Cornell Medicine, 505 E. 70th Street, 5th Floor, New York, NY 10021; email: elp9047@med.cornell.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20170620-02

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