AAP's Bronchiolitis Guidelines Praised, but Contentious

Diana Phillips

April 07, 2015

It's back to the future for the diagnosis and management of bronchiolitis in infants aged 1 to 23 months, experts note in an editorial published online April 6 in Pediatrics. The recently updated bronchiolitis guideline from the American Academy of Pediatrics (AAP) emphasized the need to avoid unnecessary or unproven interventions, harking back to recommendations put forth half a century ago.

Ricardo A. Quinonez, MD, from the Division of Pediatric Hospital Medicine in the Department of Pediatrics at Baylor College of Medicine, Children's Hospital of San Antonio, Texas, and Alan R. Schroeder, MD, from the Department of Pediatrics at Santa Clara Valley Medical Center in San Jose, California, liken the revised guidelines, issued in October 2014, to advice published in the same journal in 1965 by F. Howell Wright, MD, and Marc O. Beem, MD, supporting the principle of primum non nocere: first, do no harm.

Dr Wright and Dr Beem described acute viral bronchiolitis as a "self-limited disease of relatively good prognosis." For this reason, they suggested, "the principle of primum non nocere should temper frustrated anxiety to do something — anything — to relive severe dyspnea."

Based on modern evidence, the new AAP guidelines take a similar tack, recommending against the use of albuterol, epinephrine, systemic corticosteroids, chest physiotherapy, and antibiotics. Further, they defer to clinician judgment regarding the administration of supplemental oxygen or the use of continuous pulse oximetry.

The new guidelines, based on a review of the evidence published since the original evidence review in 2004, upend some of the management practices that have become routine. In recent years, Dr Quinonez and Dr Schroeder write, " 'Doing something' has trumped watchful waiting. Medications, tests, and procedures continue to be used profusely in spite of decades of research confirming their futility."

In contrast, the new guidelines, which the authors call "courageous and bold," emphasize avoiding interventions that lack a favorable risk–benefit ratio and "focus on meaningful outcomes, such as hospitalization, length of stay, and symptom duration."

Of the 14 recommendations in the new document, 10 focus on tests or treatments to avoid, the authors note. "Two recommendations in particular, 1 regarding trials of bronchodilators and 1 regarding continuous pulse oximetry, are sure to spark controversy."

At this time, nearly two thirds of patients hospitalized with bronchiolitis receive an average of four to seven doses each of albuterol in the inpatient setting, despite evidence that doing so has only marginal clinical effect, the authors write. Moreover, evidence suggests that frequent nebulized treatments can increase length of stay and oxygen requirements, "highlighting the idea that excessive treatments of any kind can cause meaningful harm," they note. "Whether infants are harmed directly by the well-documented pharmacologic effects of bronchodilators (tachycardia, tremors, and hypoxemia), or simply by rest disruption and the '...annoyance of unnecessary or futile medications and procedures,' avoidance of an albuterol trial stays true to the principles espoused by Wright and Beem nearly half a century ago."

Similarly, although some clinicians "will be reluctant to avoid pulse oximetry, which is seen by many as a potentially life-saving device," the authors write, "this technology introduces the potential for overdiagnosis of hypoxemia, which can be the main determinant for admission and an important driver for length of stay in bronchiolitis."

Consistent with the authors' prediction that some of the revised recommendations might be controversial, in a paper assessing the medical education ramifications of the revised recommendations published online in Emergency Physicians Monthly on January 30, Amy Levine, MD, professor of pediatrics in the Division of Pediatric Medicine at the University of North Carolina, and April Edwards, MD, a medicine-pediatrics resident at the university, describe pushback among pediatric emergency physicians regarding the recommendation against albuterol.

"The AAP's position is that the literature on patients with bronchiolitis has not supported a significant clinical benefit from bronchodilators. However, some ED providers have noted that an undifferentiated wheezing child under 24 months of age may not have bronchiolitis," Dr Levine and Dr Edwards write. "In the discussion accompanying the guidelines, it is acknowledged that a subset of patients may have reversible bronchospasm but attempts to define this subset or objectively measure their response have been unsuccessful. It is reasonable to conclude that if you are sure that this child has bronchiolitis then albuterol won't help." In contrast, they contend, "If you are not sure, a trial of albuterol may be justified."

Jean Ogborn, MD, an emergency medicine pediatrician at Johns Hopkins Children's Center and assistant professor of pediatrics at the Johns Hopkins School of Medicine, Baltimore, Maryland, agrees with the editorialists that the AAP guidelines are on the right track, but cautions that implementation is going to be a challenge. "I think that the AAP guidelines, which recommend doing less for infants with bronchiolitis, are going to be difficult for some practitioners to implement because physicians of today and parents of today are less comfortable watching and providing supportive care (nasal suctioning, oxygen if needed, [intravenous] fluids) for these babies than prior generations may have been. Our culture is very attuned to 'doing something' about every problem and expecting that an instant cure can be accomplished if we only 'do the right thing.'

"I agree that supportive care rather than steroids and albuterol for babies with bronchiolitis is the most appropriate therapy," Dr Ogborn told Medscape Medical News. "This must also be coupled with vigilant observation and reassessment so that we can detect the small, but important, percentage of infants who are reaching a state of exhaustion or respiratory failure in time to intervene with more aggressive management, such as respiratory support with [continuous positive airway pressure] or high-flow oxygen or even mechanical ventilation."

She continues, "Encouraging physicians to do careful physical exams with frequent re-exams, and to closely monitor the hydration status of and metabolic demands on the infant will be important parts of re-education. There will be pushback as people become more comfortable with these less aggressive forms of providing good clinical care. There will be variation in how clinicians treat bronchiolitis for some time to come as clinicians reorient their thinking and gain experience with this practice."

For their part, Dr Quinonez and Dr Schroeder emphasize that the guideline "is a true reflection of the past 50 years of research and clinical practice.... We hope that clinicians embrace these new recommendations that put the focus back on the patient and encourage practitioners to safely do less."

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online April 6, 2015.

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