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PEDIATRICS Vol. 118 No. 4 October 2006, pp. 1774-1793 (doi:10.1542/peds.2006-2223)
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CLINICAL PRACTICE GUIDELINE |
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ABSTRACT |
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The American Academy of Pediatrics convened a committee composed of primary care physicians and specialists in the fields of pulmonology, infectious disease, emergency medicine, epidemiology, and medical informatics. The committee partnered with the Agency for Healthcare Research and Quality and the RTI International-University of North Carolina Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to the diagnosis, management, and prevention of bronchiolitis. The resulting evidence report and other sources of data were used to formulate clinical practice guideline recommendations.
This guideline addresses the diagnosis of bronchiolitis as well as various therapeutic interventions including bronchodilators, corticosteroids, antiviral and antibacterial agents, hydration, chest physiotherapy, and oxygen. Recommendations are made for prevention of respiratory syncytial virus infection with palivizumab and the control of nosocomial spread of infection. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent comprehensive peer review before it was approved by the American Academy of Pediatrics.
This clinical practice guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with this condition. These recommendations may not provide the only appropriate approach to the management of children with bronchiolitis.
Key Words: bronchiolitis
Abbreviations: CAM—complementary and alternative medicine • LRTI—lower respiratory tract infection • AHRQ—Agency for Healthcare Research and Quality • RSV—respiratory syncytial virus • AAP—American Academy of Pediatrics • AAFP—American Academy of Family Physicians • RCT—randomized, controlled trial • CLD—chronic neonatal lung disease • SBI—serious bacterial infection • UTI—urinary tract infection • AOM—acute otitis media • SpO2—oxyhemoglobin saturation • LRTD—lower respiratory tract disease
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INTRODUCTION |
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The goal of this guideline is to provide an evidence-based approach to the diagnosis, management, and prevention of bronchiolitis in children from 1 month to 2 years of age. The guideline is intended for pediatricians, family physicians, emergency medicine specialists, hospitalists, nurse practitioners, and physician assistants who care for these children. The guideline does not apply to children with immunodeficiencies including HIV, organ or bone marrow transplants, or congenital immunodeficiencies. Children with underlying respiratory illnesses such as chronic neonatal lung disease (CLD; also known as bronchopulmonary dysplasia) and those with significant congenital heart disease are excluded from the sections on management unless otherwise noted but are included in the discussion of prevention. This guideline will not address long-term sequelae of bronchiolitis, such as recurrent wheezing, which is a field with distinct literature of its own.
Bronchiolitis is a disorder most commonly caused in infants by viral lower respiratory tract infection (LRTI). It is the most common lower respiratory infection in this age group. It is characterized by acute inflammation, edema and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm. Signs and symptoms are typically rhinitis, tachypnea, wheezing, cough, crackles, use of accessory muscles, and/or nasal flaring.1 Many viruses cause the same constellation of symptoms and signs. The most common etiology is the respiratory syncytial virus (RSV), with the highest incidence of RSV infection occurring between December and March.2 Ninety percent of children are infected with RSV in the first 2 years of life,3 and up to 40% of them will have lower respiratory infection.4,5 Infection with RSV does not grant permanent or long-term immunity. Reinfections are common and may be experienced throughout life.6 Other viruses identified as causing bronchiolitis are human metapneumovirus, influenza, adenovirus, and parainfluenza. RSV infection leads to more than 90000 hospitalizations annually. Mortality resulting from RSV has decreased from 4500 deaths annually in 1985 in the United States2,6 to an estimated 510 RSV-associated deaths in 19976 and 390 in 1999.7 The cost of hospitalization for bronchiolitis in children less than 1 year old is estimated to be more than $700 million per year.8
Several studies have shown a wide variation in how bronchiolitis is diagnosed and treated. Studies in the United States,9 Canada,10 and the Netherlands11 showed variations that correlated more with hospital or individual preferences than with patient severity. In addition, length of hospitalization in some countries averages twice that of others.12 This variable pattern suggests a lack of consensus among clinicians as to best practices.
In addition to morbidity and mortality during the acute illness, infants hospitalized with bronchiolitis are more likely to have respiratory problems as older children, especially recurrent wheezing, compared with those who did not have severe disease.13–15 Severe disease is characterized by persistently increased respiratory effort, apnea, or the need for intravenous hydration, supplemental oxygen, or mechanical ventilation. It is unclear whether severe viral illness early in life predisposes children to develop recurrent wheezing or if infants who experience severe bronchiolitis have an underlying predisposition to recurrent wheezing.
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METHODS |
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The AAP and AAFP partnered with the AHRQ and the RTI International-University of North Carolina Evidence-Based Practice Center (EPC) to develop an evidence report, which served as a major source of information for these practice guideline recommendations.1 Specific clinical questions addressed in the AHRQ evidence report were the (1) effectiveness of diagnostic tools for diagnosing bronchiolitis in infants and children, (2) efficacy of pharmaceutical therapies for treatment of bronchiolitis, (3) role of prophylaxis in prevention of bronchiolitis, and (4) cost-effectiveness of prophylaxis for management of bronchiolitis. EPC project staff searched Medline, the Cochrane Collaboration, and the Health Economics Database. Additional articles were identified by review of reference lists of relevant articles and ongoing studies recommended by a technical expert advisory group. To answer the question on diagnosis, both prospective studies and randomized, controlled trials (RCTs) were used. For questions related to treatment and prophylaxis in the AHRQ report, only RCTs were considered. For the cost-effectiveness of prophylaxis, studies that used economic analysis were reviewed. For all studies, key inclusion criteria included outcomes that were both clinically relevant and able to be abstracted. Initially, 744 abstracts were identified for possible inclusion, of which 83 were retained for systematic review. Results of the literature review were presented in evidence tables and published in the final evidence report.1
An additional literature search of Medline and the Cochrane Database of Systematic Reviews was performed in July 2004 by using search terms submitted by the members of the Subcommittee on the Diagnosis and Management of Bronchiolitis. The methodologic quality of the research was appraised by an epidemiologist before consideration by the subcommittee.
The evidence-based approach to guideline development requires that the evidence in support of a policy be identified, appraised, and summarized and that an explicit link between evidence and recommendations be defined. Evidence-based recommendations reflect the quality of evidence and the balance of benefit and harm that is anticipated when the recommendation is followed. The AAP policy statement "Classifying Recommendations for Clinical Practice Guidelines"16 was followed in designating levels of recommendation (Fig 1; Table 1).
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This clinical practice guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with this condition. These recommendations may not provide the only appropriate approach to the management of children with bronchiolitis.
All AAP guidelines are reviewed every 5 years.
Definitions used in the guideline are:
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RECOMMENDATION 1a |
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RECOMMENDATION 1b |
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The 2 goals in the history and physical examination of infants presenting with cough and/or wheeze, particularly in the winter season, are the differentiation of infants with probable bronchiolitis from those with other disorders and the estimation of the severity of illness. Most clinicians recognize bronchiolitis as a constellation of clinical symptoms and signs including a viral upper respiratory prodrome followed by increased respiratory effort and wheezing in children less than 2 years of age. Clinical signs and symptoms of bronchiolitis consist of rhinorrhea, cough, wheezing, tachypnea, and increased respiratory effort manifested as grunting, nasal flaring, and intercostal and/or subcostal retractions.
Respiratory rate in otherwise healthy children changes considerably over the first year of life, decreasing from a mean of approximately 50 breaths per minute in term newborns to approximately 40 breaths per minute at 6 months of age and 30 breaths per minute at 12 months.18–20 Counting respiratory rate over the course of 1 minute may be more accurate than measurements extrapolated to 1 minute but observed for shorter periods.21 The absence of tachypnea correlates with the lack of LRTIs or pneumonia (viral or bacterial) in infants.22,23
The course of bronchiolitis is variable and dynamic, ranging from transient events such as apnea or mucus plugging to progressive respiratory distress from lower airway obstruction. Important issues to assess include the impact of respiratory symptoms on feeding and hydration and the response, if any, to therapy. The ability of the family to care for the child and return for further care should be assessed. History of underlying conditions such as prematurity, cardiac or pulmonary disease, immunodeficiency, or previous episodes of wheezing should be identified.
The physical examination reflects the variability in the disease state and may require serial observations over time to fully assess the child's status. Upper airway obstruction may contribute to work of breathing. Nasal suctioning and positioning of the child may affect the assessment. Physical examination findings of importance include respiratory rate, increased work of breathing as evidenced by accessory muscle use or retractions, and auscultatory findings such as wheezes or crackles.
The evidence relating the presence of specific findings in the assessment of bronchiolitis to clinical outcomes is limited. Most studies are retrospective and lack valid and unbiased measurement of baseline and outcome variables. Most studies designed to identify the risk of severe adverse outcomes such as requirement for intensive care or mechanical ventilation have focused on inpatients.24–26 These events are relatively rare among all children with bronchiolitis and limit the power of these studies to detect clinically important risk factors associated with disease progression.
Several studies have associated premature birth (less than 37 weeks) and young age of the child (less than 6–12 weeks) with an increased risk of severe disease.26–28 Young infants with bronchiolitis may develop apnea, which has been associated with an increased risk for prolonged hospitalization, admission to intensive care, and mechanical ventilation.26 Other underlying conditions that have been associated with an increased risk of progression to severe disease or mortality include hemodynamically significant congenital heart disease,26,29 chronic lung disease (bronchopulmonary dysplasia, cystic fibrosis, congenital anomaly),26 and the presence of an immunocompromised state.26,30
Findings on physical examination have been less consistently associated with outcomes of bronchiolitis. Tachypnea, defined as a respiratory rate of 70 or more breaths per minute, has been associated with increased risk for severe disease in some studies24,27,31 but not others.32 An AHRQ report1 found 43 of 52 treatment trials that used clinical scores, all of which included measures of respiratory rate, respiratory effort, severity of wheezing, and oxygenation. The lack of uniformity of scoring systems made comparison between studies difficult.1 The most widely used clinical score, the Respiratory Distress Assessment Instrument,33 is reliable with respect to scoring but has not been validated for clinical predictive value in bronchiolitis. None of the other clinical scores used in the various studies have been assessed for reliability and validity. Studies that have assessed other physical examination findings have not found clinically useful associations with outcomes.27,32 The substantial temporal variability in physical findings as well as potential differences in response to therapy may account for this lack of association. Repeated observation over a period of time rather than a single examination may provide a more valid overall assessment.
Pulse oximetry has been rapidly adopted into clinical assessment of children with bronchiolitis on the basis of data suggesting that it can reliably detect hypoxemia that is not suspected on physical examination.27,34 Few studies have assessed the effectiveness of pulse oximetry to predict clinical outcomes. Among inpatients, perceived need for supplemental oxygen that is based on pulse oximetry has been associated with higher risk of prolonged hospitalization, ICU admission, and mechanical ventilation.24,26,35 Among outpatients, available evidence differs on whether mild reductions in pulse oximetry (less than 95% on room air) predict progression of disease or need for a return visit for care.27,32
Radiography may be useful when the hospitalized child does not improve at the expected rate, if the severity of disease requires further evaluation, or if another diagnosis is suspected. Although many infants with bronchiolitis have abnormalities that show on chest radiographs, data are insufficient to demonstrate that chest radiograph abnormalities correlate well with disease severity.16 Two studies suggest that the presence of consolidation and atelectasis on a chest radiograph is associated with increased risk for severe disease.26,27 One study showed no correlation between chest radiograph findings and baseline severity of disease.36 In prospective studies including 1 randomized trial, children with suspected LRTI who received radiographs were more likely to receive antibiotics without any difference in time to recovery.37,38 Current evidence does not support routine radiography in children with bronchiolitis.
The clinical utility of diagnostic testing in infants with suspected bronchiolitis is not well supported by evidence.39–41 The occurrence of serious bacterial infections (SBIs; eg, urinary tract infections [UTIs], sepsis, meningitis) is very low.42,43 The use of complete blood counts has not been shown to be useful in either diagnosing bronchiolitis or guiding its therapy.1
Virologic tests for RSV, if obtained during peak RSV season, demonstrate a high predictive value. However, the knowledge gained from such testing rarely alters management decisions or outcomes for the vast majority of children with clinically diagnosed bronchiolitis.1 Virologic testing may be useful when cohorting of patients is feasible.
Evidence Profile 1a: Diagnosis
Evidence Profile 1b: Risk Factors
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RECOMMENDATION 2a |
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RECOMMENDATION 2b |
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-adrenergic or ß-adrenergic medication is an option. Inhaled bronchodilators should be continued only if there is a documented positive clinical response to the trial using an objective means of evaluation (option: evidence level B; RCTs with limitations and expert opinion; balance of benefit and harm).
The use of bronchodilator agents continues to be controversial. RCTs have failed to demonstrate a consistent benefit from -adrenergic or ß-adrenergic agents. Several studies and reviews have evaluated the use of bronchodilator medications for viral bronchiolitis. A Cochrane systematic review44 found 8 RCTs involving 394 children.33,45–50 Some of the studies included infants who had a history of previous wheezing. Several used agents other than albuterol/salbutamol or epinephrine/adrenaline (eg, ipratropium and metaproterenol). Overall, results of the meta-analysis indicated that, at most, 1 in 4 children treated with bronchodilators might have a transient improvement in clinical score of unclear clinical significance. This needs to be weighed against the potential adverse effects and cost of these agents and the fact that most children treated with bronchodilators will not benefit from their use. Studies assessing the impact of bronchodilators on long-term outcomes have found no impact on the overall course of the illness.1,44,51
Albuterol/Salbutamol
Some outpatient studies have demonstrated modest improvement in oxygen saturation and/or clinical scores. Schweich et al52 and Schuh et al53 evaluated clinical scores and oxygen saturation after 2 treatments of nebulized albuterol. Each study showed improvement in the clinical score and oxygen saturation shortly after completion of the treatment. Neither measured outcomes over time. Klassen et al47 evaluated clinical score and oxygen saturation 30 and 60 minutes after a single salbutamol treatment. Clinical score, but not oxygen saturation, was significantly improved at 30 minutes, but no difference was demonstrated 60 minutes after a treatment. Gadomski et al54 showed no difference between those in groups on albuterol or placebo after 2 nebulized treatments given 30 minutes apart.
Studies of inpatients have not shown a clinical change that would justify recommending albuterol for routine care. Dobson et al55 conducted a randomized clinical trial in infants who were hospitalized with moderately severe viral bronchiolitis and failed to demonstrate clinical improvement resulting in enhanced recovery or an attenuation of the severity of illness. Two meta-analyses1,56 could not directly compare inpatient studies of albuterol because of widely differing methodology. Overall, the studies reviewed did not show the use of albuterol in infants with bronchiolitis to be beneficial in shortening duration of illness or length of hospital stay.
Epinephrine/Adrenaline
The AHRQ evidence report1 notes that the reviewed studies show that nebulized epinephrine has "some potential for being efficacious." In contrast, a later multicenter controlled trial by Wainwright et al51 concluded that epinephrine did not impact the overall course of the illness as measured by hospital length of stay. Analysis of outpatient studies favors nebulized epinephrine over placebo in terms of clinical score, oxygen saturation, and respiratory rate at 60 minutes57 and heart rate at 90 minutes.58 However, the differences were small, and it could not be established that they are clinically significant in altering the course of the illness. One study59 found significant improvement in airway resistance (but no change in oxygen need), suggesting that a trial of this agent may be reasonable for such infants.
Several studies have compared epinephrine to albuterol (salbutamol) or epinephrine to placebo. Racemic epinephrine has demonstrated slightly better clinical effect than albuterol. It is possible that the improvement is related to the effect of the medication.60 Hartling et al61 performed a meta-analysis of studies comparing epinephrine to albuterol and also participated in the Cochrane review of epinephrine.62 The Cochrane report concluded: "There is insufficient evidence to support the use of epinephrine for the treatment of bronchiolitis among inpatients. There is some evidence to suggest that epinephrine may be favorable to salbutamol (albuterol) and placebo among outpatients."
Although there is no evidence from RCTs to justify routine use of bronchodilators, clinical experience suggests that, in selected infants, there is an improvement in the clinical condition after bronchodilator administration.47,52,53,57,58 It may be reasonable to administer a nebulized bronchodilator and evaluate clinical response. Individuals and institutions should assess the patient and document pretherapy and posttherapy changes using an objective means of evaluation. Some of the documentation tools that have been used can be found in articles by Alario et al,45 Bierman and Pierson,63 Gadomski et al,54 Lowell et al,33 Wainwright et al,51 Schuh et al,64 and Gorelick et al.65 In addition, a documentation tool has been developed by Cincinnati Children's Hospital (Cincinnati, OH).66
Extrapolation from the studies discussed above suggests that epinephrine may be the preferred bronchodilator for this trial in the emergency department and in hospitalized patients. In the event that there is documented clinical improvement, there is justification for continuing the nebulized bronchodilator treatments. In the absence of a clinical response, the treatment should not be continued.
Because of a lack of studies, short duration of action, and potential adverse effects, epinephrine is usually not used in the home setting. Therefore, it would be more appropriate that a bronchodilator trial in the office or clinic setting use albuterol/salbutamol rather than racemic epinephrine. Parameters to measure its effectiveness include improvements in wheezing, respiratory rate, respiratory effort, and oxygen saturation.
Anticholinergic agents such as ipratropium have not been shown to alter the course of viral bronchiolitis. Although a minority of individual patients may show a positive clinical response to anticholinergic agents, studies have shown that the groups as a whole showed no significant improvement. At this point there is no justification for using anticholinergic agents, either alone or in combination with ß-adrenergic agents, for viral bronchiolitis.67–69
Evidence Profile 2a: Routine Use of Bronchodilators
Evidence Profile 2b: Trial of Bronchodilators
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RECOMMENDATION 3 |
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Reports indicate that up to 60% of infants admitted to the hospital for bronchiolitis receive corticosteroid therapy.9,12,70 Systematic review and meta-analyses of RCTs involving close to 1200 children with viral bronchiolitis have not shown sufficient evidence to support the use of steroids in this illness.1,71,72
A Cochrane database review on the use of glucocorticoids for acute bronchiolitis71 included 13 studies.37,50,64,73–82 The 1198 patients showed a pooled decrease in length of stay of 0.38 days. However, this decrease was not statistically significant. The review concluded: "No benefits were found in either LOS [length of stay] or clinical score in infants and young children treated with systemic glucocorticoids as compared with placebo. There were no differences in these outcomes between treatment groups; either in the pooled analysis or in any of the sub analyses. Among the three studies evaluating hospital admission rates following the initial hospital visit there was no difference between treatment groups. There were no differences found in respiratory rate, hemoglobin oxygen saturation, or hospital revisit or readmission rates. Subgroup analyses were significantly limited by the low number of studies in each comparison. Specific data on the harm of corticosteroid therapy in this patient population are lacking. Available evidence suggests that corticosteroid therapy is not of benefit in this patient group."71
The 2 available studies that evaluated inhaled corticosteroids in bronchiolitis83,84 showed no benefit in the course of the acute disease. Because the safety of high-dose inhaled corticosteroids in infants is still not clear, their use should be avoided unless there is a clear likelihood of benefit.
There are insufficient data to make a recommendation regarding the use of leukotriene modifiers in bronchiolitis. Until additional randomized clinical trials are completed, no conclusions can be drawn.
Evidence Profile 3: Corticosteroids
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RECOMMENDATION 4 |
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The indications for specific antiviral therapy for bronchiolitis are controversial. A recent review of 11 randomized clinical trials of ribavirin therapy for RSV LRTIs, including bronchiolitis, summarized the reported outcomes.85 Nine of the studies measured the effect of ribavirin in the acute phase of illness.86–94 Two evaluated the effect on long-term wheezing and/or pulmonary function.95,96 Three additional studies were identified with similar results. Two of these evaluated effectiveness in the acute phase97,98 and one on subsequent respiratory status.99
Each of the 11 studies that addressed the acute treatment effects of ribavirin included a small sample size ranging from 26 to 53 patients and cumulatively totaling 375 subjects. Study designs and outcomes measured were varied and inconsistent. Seven of the trials demonstrated some improvement in outcome attributed to ribavirin therapy, and 4 did not. Of those showing benefit, 4 documented improved objective outcomes (eg, better oxygenation, shorter length of stay), and 3 reported improvement in subjective findings such as respiratory scores or subjective clinical assessment. The quality of the studies was highly variable.
Of the studies that focused on long-term pulmonary function, one was an RCT assessing the number of subsequent wheezing episodes and LRTIs over a 1-year period.96 Two others were follow-up studies of previous randomized trials and measured subsequent pulmonary function as well as wheezing episodes.95,99 The first study96 found fewer episodes of wheezing and infections in the ribavirin-treated patients, and the latter 2 studies95,99 found no significant differences between groups. No randomized studies of other antiviral therapies of bronchiolitis were identified.
Specific antiviral therapy for RSV bronchiolitis remains controversial because of the marginal benefit, if any, for most patients. In addition, cumbersome delivery requirements,100 potential health risks for caregivers,101 and high cost102 serve as disincentives for use in the majority of patients. Nevertheless, ribavirin may be considered for use in highly selected situations involving documented RSV bronchiolitis with severe disease or in those who are at risk for severe disease (eg, immunocompromised and/or hemodynamically significant cardiopulmonary disease).
Evidence Profile 4: Ribavirin
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RECOMMENDATION 5 |
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Children with bronchiolitis frequently receive antibacterial therapy because of fever,103 young age,104 or the concern over secondary bacterial infection.105 Early RCTs106,107 showed no benefit from antibacterial treatment of bronchiolitis. However, concern remains regarding the possibility of bacterial infections in young infants with bronchiolitis; thus, antibacterial agents continue to be used.
Several retrospective studies41,108–113 identified low rates of SBI (0%–3.7%) in patients with bronchiolitis and/or infections with RSV. When SBI was present, it was more likely to be a UTI than bacteremia or meningitis. In a study of 2396 infants with RSV bronchiolitis, 69% of the 39 patients with SBI had a UTI.110
Three prospective studies of SBI in patients with bronchiolitis and/or RSV infections also demonstrated low rates of SBI (1%–12%).42,43,114 One large study of febrile infants less than 60 days of age43 with bronchiolitis and/or RSV infections demonstrated that the overall risk of SBI in infants less than 28 days of age, although significant, was not different between RSV-positive and RSV-negative groups (10.1% and 14.2%, respectively). All SBIs in children between 29 and 60 days of age with RSV-positive bronchiolitis were UTIs. The rate of UTIs in RSV-positive patients between 28 and 60 days old was significantly lower than those who were RSV-negative (5.5% vs 11.7%).
Approximately 25% of hospitalized infants with bronchiolitis will have radiographic evidence of atelectasis or infiltrates, often misinterpreted as possible bacterial infection.115 Bacterial pneumonia in infants with bronchiolitis without consolidation is unusual.116
Although acute otitis media (AOM) in bronchiolitic infants may be caused by RSV alone, there are no clinical features that permit viral AOM to be differentiated from bacterial. Two studies address the frequency of AOM in patients with bronchiolitis. Andrade et al117 prospectively identified AOM in 62% of 42 patients who presented with bronchiolitis. AOM was present in 50% on entry to the study and developed in an additional 12% within 10 days. Bacterial pathogens were isolated from 94% of middle-ear aspirates, with Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis being the most frequent isolates. A subsequent report118 followed 150 children hospitalized for bronchiolitis for the development of AOM. Seventy-nine (53%) developed AOM, two thirds within the first 2 days of hospitalization. Tympanocentesis was performed on 64 children with AOM, and 33 middle-ear aspirates yielded pathogens. H influenzae, S pneumoniae, and M catarrhalis were the ones most commonly found. AOM did not influence the clinical course or laboratory findings of bronchiolitis. When found, AOM should be managed according to the AAP/AAFP guidelines for diagnosis and management of AOM.119
Evidence Profile 5: Antibacterial Therapy
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RECOMMENDATION 6a |
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RECOMMENDATION 6b |
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The level of respiratory distress caused by bronchiolitis guides the indications for use of other treatments.
Intravenous Fluids
Infants with mild respiratory distress may require only observation, particularly if feeding remains unaffected. When the respiratory rate exceeds 60 to 70 breaths per minute, feeding may be compromised, particularly if nasal secretions are copious. Infants with respiratory difficulty may develop nasal flaring, increased intercostal or sternal retractions, and prolonged expiratory wheezing and be at increased risk of aspiration of food into the lungs.120 Children who have difficulty feeding safely because of respiratory distress should be given intravenous fluids. The possibility of fluid retention related to production of antidiuretic hormone has been reported in patients with bronchiolitis.121,122 Clinicians should adjust fluid management accordingly.
Airway Clearance
Bronchiolitis is associated with airway edema and sloughing of the respiratory epithelium into airways, which results in generalized hyperinflation of the lungs. Lobar atelectasis is not characteristic of this disease, although it can be seen on occasion. A Cochrane review123 found 3 RCTs that evaluated chest physiotherapy in hospitalized patients with bronchiolitis.124–126 No clinical benefit was found using vibration and percussion techniques. Suctioning of the nares may provide temporary relief of nasal congestion. There is no evidence to support routine "deep" suctioning of the lower pharynx or larynx.
Evidence Profile 6a: Fluids
Evidence Profile 6b: Chest Physiotherapy
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RECOMMENDATION 7a |
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RECOMMENDATION 7b |
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RECOMMENDATION 7c |
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ABSTRACT
INTRODUCTION