Less Is More in the Diagnosis, Treatment, and Prevention of Bronchiolitis

Every winter, the pediatric health care community prepares for its annual battle with viral bronchiolitis. This lower respiratory tract infection is characterized by inflammation, edema, and necrosis of the bronchioles’ lining, which can progress to tachypnea, wheezing, and increased work of breathing. Bronchiolitis is the most common cause of hospitalization of infants younger than 1 year of age.

In November 2014, the American Academy of Pediatrics (AAP) published a revised clinical practice guideline on the diagnosis, management, and prevention of bronchiolitis.¹ This guideline, which had last been updated in 2006,² offers key action statements that indicate the level of evidence, the benefit-harm relationship, and the recommendation strength for measures against pediatric bronchiolitis.

This guideline’s most notable changes from the 2006 version center on paring down the many bronchiolitis therapies that often are tried and focusing on delivering truly supportive care—hydration and, when needed, oxygenation—and identifying which children are at risk for more serious complications.

While respiratory syncytial virus (RSV) is the most common culprit in bronchiolitis cases, the AAP guideline does not recommended testing for specific viruses, since many viruses can be responsible for the infection. And it discourages radiographic and laboratory studies when possible, which often are unnecessary.

Another significant change is that a trial dose of a bronchodilator such as albuterol no longer is recommended; enough evidence (evidence quality B; strong recommendation) demonstrates that these medications are not effective in changing the disease course of bronchiolitis. 

Also on the therapy chopping block is epinephrine (evidence quality B; strong recommendation). Nebulized hypertonic saline can be administered to hospitalized patients (although the recommendation strength is “weak” due to evidence from trials with inconsistent findings), but it is not recommended in the ED setting.

Otherwise healthy infants with a gestational age of 29 weeks or greater should not receive palivizumab to prevent RSV infections, according to the guideline. During the first year of life, infants with hemodynamically significant heart disease or chronic lung disease of prematurity should receive palivizumab (a maximum of 5 monthly doses, 15 mg/kg/dose, during the RSV season). This recommendation is in line with AAP guidelines on pediatric palivizumab prophylaxis and RSV published in August 2014.³

Potential future areas of research noted in the guideline include the development of algorithms for the bronchiolitis illness course, the use of nasogastric tubes for hydration, the use of hypertonic saline in the outpatient setting, the utility of nasopharyngeal suctioning, and the delivery of oxygen via high-flow nasal cannula. And every late fall, we will continue to look to this growing body of literature to assist us in providing children with the best care possible. 

Jessica Tomaszewski, MD, is an assistant clinical professor of pediatrics at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania, and a hospitalist pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.

Charles A. Pohl, MD—Series Editor, is a professor of pediatrics, senior associate dean of student affairs and career counseling, and associate provost for student affairs at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania.

References

1. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502.

2. American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118(4):1774-1793.

3. American Academy of Pediatrics Committee on Infectious Diseases, 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.