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New Bronchiolitis Guidelines

Evidence-based recommendations for diagnosis and management of bronchiolitis

The AAP assembled a committee of primary care physicians and specialists who partnered with the Agency for Healthcare Research and Quality, the American Academy of Family Physicians, the American Thoracic Society, and the American College of Chest Physicians to review the available evidence on the diagnosis, treatment, and prevention of bronchiolitis in children younger than 2 years. The resulting clinical practice guideline consists of 11 recommendations evaluated for strength of recommendation, quality of evidence, and comparison of benefit and harm. Highlights of the recommendations include:

• Diagnosis should be made clinically, without routine use of laboratory or radiologic tests, and should include assessment of risk factors for severe disease (e.g., prematurity, underlying lung or heart disease, and immunodeficiency).
  
• Bronchodilators should not be used routinely for management. An optional trial of an - or ß-agonist should be continued only if objective evaluation indicates a clinical response. Most positive studies of bronchodilators for management of bronchiolitis show transient improvement of unclear clinical significance.
  
• Routine use of corticosteroids is not recommended.
  
• Routine use of ribavirin is not recommended.
  
• Antibiotics should be used only when bacterial infection is clearly present.
  
• Assessment of hydration status and oral intake is strongly recommended. Treatment with intravenous fluids is recommended if necessary.
  
• Routine chest physiotherapy is not recommended.
  
• Supplemental oxygen and continuous monitoring are not routinely recommended unless oxyhemoglobin saturation (Spo2) persistently falls below 90%. At that point, oxygen should be used to maintain Spo2 at 90% or greater. The infant’s clinical work of breathing may also be considered in the decision to use supplemental oxygen. Careful oxygen weaning is strongly recommended in infants with prematurity or hemodynamically significant heart or lung disease.
  
• Prophylactic palivizumab is recommended in selected high-risk children with prematurity or heart or lung disease. It should be administered in five monthly doses during the respiratory syncytial virus (RSV) season. Palivizumab’s benefits outweigh its costs.
  
• Hand washing is strongly recommended, preferably with alcohol-based rubs or antimicrobial soaps, to prevent the spread of nosocomial RSV.
  
• Infants should not be exposed to passive smoking (strong recommendation). Breast-feeding is recommended to decrease the risk for RSV and other lower respiratory tract illnesses.
  
• Asking parents about their use of complementary and alternative therapies is optional.
  

Comment: The new bronchiolitis guidelines address key controversial areas, including many interventions that are still widely used. Routine chest radiographs as well as use of bronchodilators, corticosteroids, and antibiotics are not recommended. Use of supplemental oxygen is not supported by evidence and may be associated with prolonged hospitalization. The authors note the lack of practical, objective clinical measures for evaluating children with bronchiolitis and point out that much of the evidence comes from inpatient studies and may not apply to most children with bronchiolitis. They call for future research to determine whether selected children with bronchiolitis might benefit from some interventions that currently are not recommended.

— Cornelius W. Van Niel, MD

Published in Journal Watch Pediatrics and Adolescent Medicine January 10, 2007

Citation(s):

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

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