EditorialPublication Exclusive

Updates in bronchiolitis treatment based on 2014 AAP guidelines

Although it might seem early to start thinking about bronchiolitis, this seems to be the perfect time to reflect on the 2014 Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis by the AAP. With the 2014/2015 bronchiolitis season fresh in our minds, we can step back, review our practice, look at our outcomes and think about how we will forge ahead this fall.

Since the last iteration of the guidelines in 2006, providers have been challenged to keep up with new evidence affecting diagnosis, management and prevention. Lack of clarity regarding the evidence for treatment has created inconsistency in practice and confusion for providers and health care consumers alike. The goal of the 2014 AAP clinical guideline is to provide an evidence-based approach to care of viral bronchiolitis in children aged 1 through 23 months. Fourteen key action statements are discussed by level of evidence, benefit-harm relationship, and level of recommendation.

Many providers interested in the action statements skipped the important preface to the guideline that talks about the target group for the guideline. While the guideline is directed at prevention of bronchiolitis for all children, the action statements about management of bronchiolitis do not apply to children with immunodeficiencies, underlying respiratory illnesses (including recurrent wheezing, bronchopulmonary dysplasia, or cystic fibrosis), neuromuscular disease or those with significant congenital heart disease.

Anne E. Borgmeyer

Action statements about diagnosis and management seem to encourage nonaction. Assessment of symptoms and severity is recommended for diagnosis, and laboratory and radiology are discouraged. There is no recommendation supporting the administration of albuterol, steroids, or epinephrine. Nebulized hypertonic saline is discouraged in the emergency unit and needs more study to be recommended in the inpatient setting. Antibiotics are not recommended unless there is concomitant infection. While supportive therapy with fluids and supplemental oxygen continue to be mainstays, the guideline encourages more study related to how to monitor oxygen and how to give fluids. Perhaps continuous oxygen monitoring is not needed. Perhaps fluids per nasogastric feeding tube should be utilized instead of IV fluids.

So what are providers to do? Implement prevention in practice. Know the parameters for Synagis (palivizumab, MedImmune). Encourage hand washing and breast-feeding, and discourage smoke exposure. By the way, the guideline says there is measurable effect of counseling about avoidance of smoke in the health care setting. Stay strong. Refrain from treatments that are not supported by evidence. Educate families regarding evidence and recommendations. To effectively implement the guideline requires changing the culture for providers and families, and education is crucial.

But what do providers do when the patient is decompensating and heading to the hospital or heading to the ICU? Perhaps then we should try a management strategy and make certain we evaluate the effectiveness for our patient before we continue unnecessary and expensive therapy. Develop a plan for systematic patient assessment before and after the therapy. Assess effect of treatment based on respiratory assessment that includes respiratory rate, retractions, wheezing, and oxygen saturation. If the patient ends up in the ICU, then treatment with available, potentially lifesaving therapy is warranted. There is a disclaimer with the guideline that states that variations in care, taking into account individual circumstances, may be appropriate.

Providers should remember that the guideline does not apply to the patient with recurrent wheezing. The patient with recurrent wheezing falls into a different category and may benefit from albuterol and/or steroids.

As in all reviews of evidence, the AAP guideline draws attention to gaps in knowledge and generates more questions for further research. Clinical practice guidelines from the AAP automatically expire 5 years after publication. I’m hoping for action statements with more action in the recommendations within the next 5 years. This past year at the Midwest hospital where I practice, we tweaked our hospital guideline as we do every year at the start of bronchiolitis season. In order to successfully impact practice we utilize a multidisciplinary group of key stakeholders from all areas — physicians, nurse practitioners, nurses, and respiratory therapists.

The key stakeholders reviewed our practice in terms of the AAP guideline, updated our practice parameter, changed our standardized electronic order set, and disseminated the information. This year we made changes to more firmly discourage chest X-rays, continuous oximetry and the use of albuterol as a first-line strategy for bronchiolitis. We’ll see what the outcome data shows for the 2014/2015 season, plan for the 2015/2016 season, and watch for the next AAP update.

Disclosure: Borgmeyer reports no relevant financial disclosures.

Although it might seem early to start thinking about bronchiolitis, this seems to be the perfect time to reflect on the 2014 Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis by the AAP. With the 2014/2015 bronchiolitis season fresh in our minds, we can step back, review our practice, look at our outcomes and think about how we will forge ahead this fall.

Since the last iteration of the guidelines in 2006, providers have been challenged to keep up with new evidence affecting diagnosis, management and prevention. Lack of clarity regarding the evidence for treatment has created inconsistency in practice and confusion for providers and health care consumers alike. The goal of the 2014 AAP clinical guideline is to provide an evidence-based approach to care of viral bronchiolitis in children aged 1 through 23 months. Fourteen key action statements are discussed by level of evidence, benefit-harm relationship, and level of recommendation.

Many providers interested in the action statements skipped the important preface to the guideline that talks about the target group for the guideline. While the guideline is directed at prevention of bronchiolitis for all children, the action statements about management of bronchiolitis do not apply to children with immunodeficiencies, underlying respiratory illnesses (including recurrent wheezing, bronchopulmonary dysplasia, or cystic fibrosis), neuromuscular disease or those with significant congenital heart disease.

Anne E. Borgmeyer

Action statements about diagnosis and management seem to encourage nonaction. Assessment of symptoms and severity is recommended for diagnosis, and laboratory and radiology are discouraged. There is no recommendation supporting the administration of albuterol, steroids, or epinephrine. Nebulized hypertonic saline is discouraged in the emergency unit and needs more study to be recommended in the inpatient setting. Antibiotics are not recommended unless there is concomitant infection. While supportive therapy with fluids and supplemental oxygen continue to be mainstays, the guideline encourages more study related to how to monitor oxygen and how to give fluids. Perhaps continuous oxygen monitoring is not needed. Perhaps fluids per nasogastric feeding tube should be utilized instead of IV fluids.

So what are providers to do? Implement prevention in practice. Know the parameters for Synagis (palivizumab, MedImmune). Encourage hand washing and breast-feeding, and discourage smoke exposure. By the way, the guideline says there is measurable effect of counseling about avoidance of smoke in the health care setting. Stay strong. Refrain from treatments that are not supported by evidence. Educate families regarding evidence and recommendations. To effectively implement the guideline requires changing the culture for providers and families, and education is crucial.

But what do providers do when the patient is decompensating and heading to the hospital or heading to the ICU? Perhaps then we should try a management strategy and make certain we evaluate the effectiveness for our patient before we continue unnecessary and expensive therapy. Develop a plan for systematic patient assessment before and after the therapy. Assess effect of treatment based on respiratory assessment that includes respiratory rate, retractions, wheezing, and oxygen saturation. If the patient ends up in the ICU, then treatment with available, potentially lifesaving therapy is warranted. There is a disclaimer with the guideline that states that variations in care, taking into account individual circumstances, may be appropriate.

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Providers should remember that the guideline does not apply to the patient with recurrent wheezing. The patient with recurrent wheezing falls into a different category and may benefit from albuterol and/or steroids.

As in all reviews of evidence, the AAP guideline draws attention to gaps in knowledge and generates more questions for further research. Clinical practice guidelines from the AAP automatically expire 5 years after publication. I’m hoping for action statements with more action in the recommendations within the next 5 years. This past year at the Midwest hospital where I practice, we tweaked our hospital guideline as we do every year at the start of bronchiolitis season. In order to successfully impact practice we utilize a multidisciplinary group of key stakeholders from all areas — physicians, nurse practitioners, nurses, and respiratory therapists.

The key stakeholders reviewed our practice in terms of the AAP guideline, updated our practice parameter, changed our standardized electronic order set, and disseminated the information. This year we made changes to more firmly discourage chest X-rays, continuous oximetry and the use of albuterol as a first-line strategy for bronchiolitis. We’ll see what the outcome data shows for the 2014/2015 season, plan for the 2015/2016 season, and watch for the next AAP update.

Disclosure: Borgmeyer reports no relevant financial disclosures.