Bronchiolitis: The Rationale Behind the New AAP Guideline

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

Disclosures

November 13, 2014

Dr Quinonez: Let's talk about home oxygen. The guideline discusses the option but does not make a recommendation. What is your opinion on it?

Dr Ralston: This is a very interesting trend. I once worked in a city that was at high altitude—Albuquerque, New Mexico. We certainly provided oxygen to infants at home frequently. The other two cities where this practice has been studied (and data published) are Denver[11] and Salt Lake City,[12] both high-altitude cities. We were interested in this phenomenon. However, the only place where it's been studied at sea level is Australian.[13] So we felt like there really wasn't a preponderance of applicable evidence in order to be able to make a clear recommendation. But we also felt like it was a topic that at least needed to be acknowledged in the guideline. Along with hypertonic saline, this is an area where some significant research is still needed.

We also hesitated to make a recommendation about home oxygen in that, while we certainly can see its benefit, we also felt like the more relevant conversation was about our obsession with the pulse ox and our inability to wean ourselves off pulse oximetry and pay closer attention to the patient. On some level, home oxygen is a Band-Aid. The real question is putting pulse oximetry in context.

Dr Quinonez: Let's switch now to hydration. The guideline says that clinicians should administer nasogastric (NG) or intravenous (IV) fluids for infants diagnosed with bronchiolitis who cannot maintain hydration orally. I'm really interested in the fact that you included NG fluids for these infants. What's the evidence for that?

Dr Ralston: There is one randomized controlled trial from Australia[14] which finds the two approaches to be basically equivalent. The gut is functional in bronchiolitis. We all know that nutrition is probably even more important in the long run. There is at least some small amount of literature to suggest that early nutrition in bronchiolitis may improve the general condition, especially in hospitalized children. So we felt that it was worth addressing.

The other issue that we wanted to address with the IV fluid recommendation is that bronchiolitis is a disease with significant risk for iatrogenic hyponatremia. The idea that IV fluids in general are a benign intervention is one we wanted to at least question. The idea that one wouldn't want to use a functional gut is one that we strongly wanted to question as well. Again, there's a small amount of evidence. There's not a preponderance of evidence in this particular case, but there are certainly some risks of maintenance IV fluids in the traditional fashion using a hypotonic solution. There isn't any compelling reason not to use a patient's gut. We didn't get into the issue of IV access, harm from IV infiltration, cost, and difficulty of IV placement in pediatric patients, but there is a literature on that as well. I personally strongly prefer NG hydration to IV hydration in bronchiolitis if I'm given the choice.

Dr Quinonez: Finally, the guideline committee spent a significant amount of time addressing prevention infection control measures that we can all do to prevent dissemination of bronchiolitis. I think clinicians are going to be particularly interested in the palivizumab recommendation. While I realize that this wasn't a recommendation that was made only by this guideline committee, it is a supplement to the earlier palivizumab guideline.[15] It increases the recommended gestational age for administration of palivizumab and it gets rid of some of the criteria of who can receive it to make it more specific. It seems that many fewer infants will be getting this medication. Why is this a good thing?

Dr Ralston: There are two important things. These recommendations are much clearer. They are much easier to understand and they are much more strongly evidence based. They identify the group of infants with the greatest likelihood of benefiting from prophylaxis. I think it's important to remember, when thinking about palivizumab, that the original palivizumab trial suggested that at-risk premature infants had about a 10% risk for hospitalization with RSV infection. Again, hospitalization was the outcome in the trial. Administration of palivizumab decreased that risk to 5%, so that's an absolute risk reduction of 5%—from a 10% risk for hospitalization to a 5% risk. This is not a profound treatment effect for an intramuscular injection that needs to be given monthly and is also quite expensive. It's also important to remember that mortality has never been shown to be affected by the medication. I think directing the medication to the patient population that is most likely to benefit is undoubtedly a good thing.

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