Children in ED Get Unnecessary Imaging for Bronchiolitis

Lara C. Pullen, PhD

October 16, 2018

Although numerous guidelines recommend against imaging for diagnosis of bronchiolitis, there was no decrease in the use of radiography for these patients in US emergency departments (EDs) between 2007 and 2015, according to an analysis published online October 16th in JAMA. The recommendations against imaging have come from the American Academy of Pediatrics (AAP) in their 2006 and 2014 bronchiolitis guidelines and the Choosing Wisely recommendations in 2013.

Overall, there was no change by year in the proportion of infants who underwent radiography for acute bronchiolitis, according to Brett Burstein, PhD, MPH, assistant professor, Division of Emergency Medicine, Montreal Children's Hospital in Canada, and colleagues.

The National Center for Health Statistics, Centers for Disease Control and Prevention, collects data about EDs, outpatient departments, and ambulatory surgery locations in the United States in the National Hospital Ambulatory Medical Care Survey (NHAMC).

The NHAMC identified 269,721 ED visits between 2007 and 2015. Of these, 59,921 ED visits were by patients younger than 18 years. Of these patients, 1.1% (95% confidence interval [CI], 0.9% - 1.3%) received an ED diagnosis of bronchiolitis.

The median age of children with a diagnosis of bronchiolitis was 8 months (interquartile range, 5 - 12 months), 58.8% were male, 66.9% were white, and the majority presented to nonteaching and nonpediatric hospitals.

Approximately half (46.1%; 95% CI, 39.5% - 52.8%) of those who had bronchiolitis underwent radiography. The majority (89.7%) of these patients were discharged, and 10.3% were admitted to the hospital.

When the investigators specifically analyzed patients who were discharged from the ED, they saw that these patients were as likely to have undergone radiography as patients who were admitted: 46.2% for discharged children (95% CI, 39.4% - 53.2%), compared with 44.8% for admitted children (95% CI, 29.2% - 61.6%).

The AAP clinical practice guidelines specifically recommend imaging only in severe cases that warrant intensive care and in which there is the possibility of airway complication.

The AAP guidelines explain that clinicians should diagnose bronchiolitis primarily on the basis of history and physical examination. They detail that, when infants present with wheeze or other lower respiratory tract symptoms, history and physical examination should be able to differentiate between infants with probable viral bronchiolitis and those with other disorders. Thus, radiographic and/or laboratory studies should not be obtained routinely.

Bronchiolitis can present variably, from transient events such as apnea to progressive respiratory distress from lower airway obstruction. In their guideline, the AAP notes that because the course of bronchiolitis is variable and dynamic, the clinician may need to perform serial observations over time to fully understand the child's status.

The AAP also notes that, while many infants with bronchiolitis have abnormalities on chest radiography, it is not clear that chest radiography correlates well with disease severity.

Worldwide, bronchiolitis is an important health burden among young children and is the most common cause of hospitalization in the first year of life in the United States. As such, experts have stated that it is important to guide investment of resources and follow informed policies when addressing the diagnosis and management of bronchiolitis.

"These results suggest that nationwide quality initiatives are still needed to translate bronchiolitis guidelines into practice," the authors write.

One of the authors has received grants from BD Diagnostics, AbbVie, and MedImmune and personal fees from BD Diagnostics, Cepheid, AbbVie, and Merck. The remaining authors have disclosed no relevant financial relationships.

JAMA. 2018;320:1598-1600. Abstract

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