Bronchiolitis: The Rationale Behind the New AAP Guideline

Ricardo A. Quinonez, MD; Shawn L. Ralston, MD


November 13, 2014

Editor's Note:The American Academy of Pediatrics (AAP) recently released an updated Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis,[1] just in time for this winter's upcoming cold and flu season. The guideline offers a number of strong recommendations for both diagnosis and management. Ricardo Quinonez, MD, chief of the division of pediatric hospital medicine at Children's Hospital of San Antonio, and a member of the Medscape Pediatrics Advisory Board, spoke with Shawn L. Ralston, MD, lead author of the guideline and section chief, visiting associate professor and instructor in pediatrics at the Geisel School of Medicine at Dartmouth, about the clinical implications of this new guideline.

Dr Quinonez: My overall assessment of this guideline is that it could easily be called a negative or a non-interventional guideline. The 2006 guideline already discouraged many commonly employed diagnostic tools and treatments. This one even more so. Was this a purposeful intention of the committee?

Dr Ralston: The guiding principle for the AAP is that guidelines be evidence based. While there was a desire to address many topics related to bronchiolitis, there was, unfortunately, only evidence on a certain amount of the questions. In this particular case the evidence was overwhelmingly negative. There really was no choice in making recommendations in the guideline. We recommended what the evidence supported.

Dr Quinonez: The guideline clearly discourages diagnostic imaging or labs. Rather, the document states that a history and physical should focus first on distinguishing viral bronchiolitis from other disorders, and then on estimating disease severity. If we can't use labs or imaging studies, how are estimates of disease severity best made?

Dr Ralston: This was a topic that we spent a great deal of time on because people want advice on what's going to help them manage bronchiolitis. However, there is some conflicting evidence on what predicts disease severity. As with anything in pediatrics, there's a plethora of small studies. Because of this, we did not think we could issue a specific set of risk factors or an algorithm for disease severity. However, I think there are some lessons to be gleaned from the literature. We know that the younger the patient, the more potentially severe the disease. However, this doesn't mean that all young patients will have severe bronchiolitis. We know that if patients have been born prematurely they may have more severe bronchiolitis, but again, there are plenty of premature infants who have relatively nonsevere bronchiolitis. The same is true for patients with other complicating illnesses, particularly neuromuscular disorders, disorders that impair their ability to cough and their general muscle tone. In general, babies have low tone, and the ability to cough is a key skill in weathering bronchiolitis.

Dr Quinonez: So even if we did have a good way of distinguishing disease severity, it would not necessarily mean that there would be much more to offer in the way of therapeutics.

Dr Ralston: Unfortunately, no. The guideline is intended to address the issue of typical bronchiolitis. In most cases we exclude patients who appear to require intensive care therapy. However, there really aren't any specific therapies in the intensive care setting that have been proven to be particularly effective either. Unfortunately, bronchiolitis is a frustrating disease for physicians because of the lack of any truly effective therapy.


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