Bronchiolitis: A Reintroduction to an Old FriendJaime Pittenger, MD, FAAPPediatric HospitalistAssistant ProfessorDepartment of PediatricsUniversity of Kentucky

Disclosures I have no disclosure to make at this

time.

Objectives Briefly review basic information about

bronchiolitis

Discuss current trends in management of bronchiolitis

Evaluate the evidence for evidence based medicine

“Since acute viral bronchiolitis is thus a self-limited disease of relatively good prognosis, the principle of primum non nocere should temper frustrated anxiety to do something-anything-to relieve severe dyspnea. Simple physical exhaustion may determine the fate of an infant laboring to meet his metabolic requirements for oxygen. His energies should not be frittered away by the annoyance of unnecessary or futile medications and procedures. Rest should be treasured.”

Pediatrics, 1965

Is This New?

A Case 2 month old previously healthy male infant is

brought to the Emergency Department with clinical bronchiolitis Wheezing, nasal congestion, and poor feeding

reported by parent; low grade fever noted at home T 101°F, HR 175, RR 65, SaO2 92% on RA Infant in moderate respiratory distress, IC and SC

retractions, wheezing in all lung fields, CR<3 sec

What would you do? The next step in management should

be:A. Place nasal cannula and provide

supplemental oxygenB. Provide albuterol by nebulizerC. Provide racemic epinephrine by

nebulizerD. Provide nasal suction

Risk Factors For Severe Disease

Prematurity Chronic lung disease of infancy (BPD) Congenital heart disease Pulmonary hypertension Neuromuscular disease Cystic fibrosis Immunocompromised infant

Hospitalization Children with severe disease Toxic with poor feeding, lethargy,

dehydration Moderate to severe respiratory distress

(RR > 70, dyspnea, cyanosis) Apnea Hypoxemia Parent unable to care for child at home

Prevention Good hand washing

Avoidance of cigarette smoke

Avoiding contact with individuals with viral illnesses

Influenza vaccine for children > 6 months and household contacts of those children

So if all the information is the same, why are we still talking about it?....

Shay DK, et al. JAMA. 1999;282:1440-6.

Among U.S. Children Less Than 1-Year Old, 1980-1996Annual Bronchiolitis Hospitalizations

40,00050,00060,000

70,00080,00090,000

100,000110,000120,000130,000140,000

1980

1982

1984

1986

1988

1990

1992

1994

1996

Hos

pita

lizat

ions

0

10,00020,000

30,000

Is It Getting Worse? Maybe…. Changes in trends:

Routine use of pulse oximetry 1980 vs. Today Routine use of chest x-ray 1980 vs. Today Routine utilization of ED services 1980 vs.

Today

Flat mortality rate 1979-1996 Shay DK, et al. J Infect Dis 2001;183:16–22

Bronchiolitis Management Preferences and the Influence of Pulse Oximetry and Respiratory Rate on the Decision to Admit Mallory MD, et al. Pediatrics 2003;111:e45–e51.

Members of AAP Section of Emergency Medicine 76% Board Certified in Pediatric EM Mean post-training experience = 10 years

Randomized into 4 groups and sent different questionnaires

Bronchiolitis Management Preferences and the Influence of Pulse Oximetry and Respiratory Rate on the Decision to AdmitMallory MD, et al. Pediatrics 2003;111:e45–e51.Measured Outcome Oxygen sat = 94% Oxygen sat = 92%

RR=50(n=119)

RR=65(n=125)

RR=50(n=124)

RR=65(n=117)

Decision to admit 43% 58% 83% 85% (Χ2 = 5.021;P = .025) (Χ2 = 0.126;P = 0.723)

Treat with bronchodilator

92% 95% 97% 98%

2nd neb if no benefit 60% 56% 62% 62%Supplemental Oxygen

34% 39% 75% 81%

Nasal Suction 80% 82% 85% 80%Chest x-ray 55% 58% 64% 67%

Here’s the Punch Line…

The Baby Goes with the NOSE!

Nose suction is the most

common, yet unstudied,

intervention for

bronchiolitis

Bronchiolitis ALWAYS affects the nose

FIX MY nose!!!!

23

The diagnosis should be made clinicallyBronchodilators are not recommendedCorticosteroids are not recommendedRibavirin is not recommendedAntibiotics are not recommendedChest physiotherapy is not

recommended, oral rehydration is preferred

AAP practice guideline: Diagnosis and management of bronchiolitis. Pediatrics 2006;118(4):1774-93.

Oxygen saturation threshold is 90% and continuous monitoring not necessary

Prophylaxis is recommended for particular subsets of patients

Hand hygiene with alcohol hand gel is preferred

Secondhand smoke exposure is bad and should be addressed

Ask about use of alternative medicine

New meta-analyses since last guideline

Beta-agonists: Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010; (12):CD001266.

Epinephrine: Hartling L, Bialy LM, Vandermeer B. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2011;(6):CD003123.

Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010; (12):CD001266.

Authors’ conclusions: Bronchodilators do not improve oxygen

saturation, do not reduce hospital admission after outpatient treatment, do not shorten the duration of hospitalization and do not reduce the time to resolution of illness at home.

The small improvements in clinical scores for outpatients must be weighed against the costs and adverse effects of bronchodilators.

Hartling L, Bialy LM, Vandermeer B. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2011;(6):CD003123.

Author’s Conclusions: This review demonstrates the superiority of

epinephrine compared to placebo for short-term outcomes for outpatients, particularly in the first 24 hours of care.

Exploratory evidence from a single study suggests benefits of epinephrine and steroid combined for later time points. More research is required to confirm the benefits of combined epinephrine and steroids among outpatients.

There is no evidence of effectiveness for repeated dose or prolonged use of epinephrine or epinephrine and dexamethasone combined among inpatients.

29

1. Randomized, double-blind, placebo controlled trial2. 5 day course of prednisolone or placebo3. 700 enrolled , ages 10 months- 60months4. Primary outcome: LOS5. Secondary outcomes: Score on Preschool Respiratory

Assessment Measure ; Albuterol use; 7 day symptom score

Author’s Conclusions:

Current evidence does not support a clinically relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalization.

Combined dexamethasone and epinephrine may reduce outpatient admissions, but results are exploratory and safety data limited.

Fernandes RM, Bialy LM, Vandermeer B. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2010;(10):CD004878.

So why bother?

Berwick, D. M. et al. JAMA doi:10.1001/jama.2012.362

Waste in US Healthcare

Choosing Wisely Don’t order chest radiographs in children with

uncomplicated asthma or bronchiolitis. Don’t routinely use bronchodilators in children with

bronchiolitis. Don’t use systemic corticosteroids in children under 2

years of age with an uncomplicated lower respiratory tract infection.

Don’t treat gastroesophageal reflux in infants routinely with acid suppression therapy.

Don’t use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.

Airway clearance: suction first, last, and as needed

Nutritional Support: Often overlooked Oxygen: recommendations for its use and

clear guidelines for its discontinuation. Eliminate the utilization of unnecessary

resources with the implementation of an objective scoring tool to validate the effectiveness and the need for continuation of an intervention.

Basic Elements of Evidence –based care for Bronchiolitis.

34

Author Intervention/Location Outcomes

Adcock 1998Local Guideline,Kosair Children’s Hospital,Louisville, Kentucky

RSV testing Bronchodilator utilization Isolation precautions Readmission rates Antibiotic utilization LOS

Perlstein 1999Local Guideline,Children’s Hospital Medical Center Cincinnati, Ohio

Admission rates LOS Beta-agonist utilization RSV testing Chest radiographs Cost

Perlstein 2000Local Guideline (same as above),Children’s Hospital Medical Center Cincinnatti, Ohio

Admission rates LOS Beta-agonist utilization RSV testing Chest radiographs Cost

Harrison 2001 Local Guideline,Syracuse, NY

Albuterol utilization Documentation of response

to albuterol Discharged on albuterol Utilization of oxygen Utilization of

cardiorespiratory monitoring

Study Intervention/Location Outcomes

Kotagal 2002

Local Guidelines,Eleven children’s hospitals in the Child Health Accountability Initiative

Bronchodilator usage Steroid use LOS

Todd 2002Local Guideline and Respiratory Distress Score, The Children’s Hospital, Denver, Colorado

Bronchodilator utilization Antibiotic utilization Chest physiotherapy RSV testing Ribavirin utilization Nosocomial infection rate

Muething 2004ED care algorithm, admission order set, respiratory score;Children’s Hospital Medical Center Cincinnatti, Ohio

Bronchodilator Utilization RSV testing Chest radiographs LOS

Cheney 2005 Multi-center Pathway,Four hospitals in Australia

Readmission rates IV fluid utilization Steroid utilization

King 2007CPOE decision support,Children’s Hospital of Eastern Ontario

Albuterol utilization Antibiotic utilization

Respiratory Assessment Score0 - Normal 1 – Mild 2 - Moderate 3 - Severe

Resp Rate < 40 40 – 50 50 – 60 > 60

ColorO2 Sat on RA

Cap Refill

Normal>97%

< 2 sec.

Normal94-96% on RA

< 2 sec.

Normal90-93% on RA

< 2 sec.

Dusky, Mottled< 90%

= > 3 sec.

Retractions / WOB

None Subcostal Intercostal & Subcostal when

Quiet

SupraclavicularSternal

Paradoxical respiration

Air EntryWheezing

Breath Sounds Clear / Good

Good EntryEnd Exp. Wheeze

+/- Rales

Fair Air EntryInsp and Exp

Wheeze +/- Rales

Poor / GruntingInsp and Exp

Wheeze +/- RalesLOC Normal / Alert Mild Irritability Restless When

Disturbed - Agitated

Lethargic, Hard to Arouse

Dayton Children’s Medical Center, by permission.

Nebulizer TrialSCORE RESPIRATORY TREATMENT OTHER THERAPY

0-2 NORMAL Assess Q6 PRN Normal Saline Nose Drops; Bulb Syringe Suction for Home

3-6 MILD Aerosol Trial with Racemic Epinephrine or Albuterol; If response is positive continue aerosol Q6; If not responsive assess Q6 PRN

Oxygen per Protocol (SpO2>91%); Suction PRN with Bulb Syringe, Neotech Little Sucker™ or Catheter

7-10 MODERATE Aerosol Trial with Racemic Epi or Albuterol; If response is positive continue aerosol Q4. If not responsive, trial alternate medication. Assess Q4 PRN

Consider Chest X-ray; consider capillary blood gas; Normal Saline Nose Drops; Suction PRN with Bulb Syringe, Neotech Little Sucker™ or Catheter; IV fluids if patient exhibits dehydration or failure to feed; Oxygen per Protocol

11-15 SEVERE Aerosol Trial with Racemic Epi or Albuterol, If response is positive continue aerosol Q2-4, If not responsive trial alternate medication. Assess Q2 PRN

Chest X-Ray; IV fluids; Blood Gas; Excessive PCO2, acidosis orhypoxia should be transferred to ICU; Oxygen per Protocol

ED Algorithm

Admit as 23-hr Observation Admit as Inpatient Admit to PICU

DC Home

Nebulizer Trial

Admit to PICU Assess Clinical Symptoms, including Respiratory Score

Pt < 24 months presents with upper respiratory infection symptoms & wheezing

Meets DC Criteria?

Does PtRequire IV

FluidsOr O2?

Symptoms Improve?

SymptomsResolve with

Nasal Suctioning?

WitnessedApnea?

Yes

Yes

Yes

Yes

Yes

Yes

No

Meets ICUCriteria?

No

No

No

No No

No

Modified from Bronchiolitis CPG, Children’s Medical Center, Dayton, OH

Nebulizer Trial is Recommended For a Post Suction Score of 3 or Higher(Racemic Epinephrine if no history of wheezing; Albuterol if history of wheezing)

BRONCHIOLITIS SCORING SHEET

Pre Suction Score

Post Suction Score (Pre

Nebulizer)

Post Nebulizer Score

Pre Suction Score

Post Suction Score (Pre

Nebulizer)

Post Nebulizer

Score

Respiratory Rate0),<40 2)50-601)40-50 3)>60Color, Room Air Saturation, Capillary Refill0),>97,<2seconds 2),90-93,<2seconds1),94-96,<2seconds 3)Dusky/mottled,<90,>3secondsRetractions0)None 2)Intercostal and subcostal when quiet1)Subcostal 3)Supraclavicular,sternal,paradoxical respirationAir Entry, Breath Sounds (insp=inspiratory, exp=expiratory)0)Good,clear 2)Fair,insp and exp wheeze +/- rales1)Good,exp wheeze 3)Poor,insp and exp wheeze +/- ralesLOC0)Normal/alert 2)Restless when disturbed/agitated1)Mild irritability 3)Lethargic/hard to arouseTotalNebulizer trial recommended Yes____ No____Medication Used: Albuterol or Racemic Epinephrine

Date/Time___________ Initials_______ Date/Time__________ Initials_______Positive Response Yes___ No___ Positive Response Yes___ No___

(A positive response is defined as a decrease in the post nebulizer score by 2 or more.)Continued Management/Education/Comments:

______________________________________________________________________________________________________________________________________________________________________________________

New AAP guideline currently being developed and will be published in mid to late 2014 Will not change the basic

recommendations in the 2006 guideline but will be a little clearer about not routine using albuterol and what to trial – evidence favors epi over albuterol

Will not recommend hypertonic saline

Evidence on the horizon

41

~2900 Studies later….

The Bottom Line“Ascertainment of optimal care is difficult

because our therapies are supportive, not curative, and most children do well irrespective of differences in therapy. Consequently, there is a propensity to persist in care practices that may offer little or marginal benefit.”

Willson, et al. Pediatr 2001;108(4):851

16

A Case 2 month old previously healthy male infant is

brought to the Emergency Department with clinical bronchiolitis Wheezing, nasal congestion, and poor feeding

reported by parent; low grade fever noted at home T 101°F, HR 175, RR 65, SaO2 92% on RA Infant in moderate respiratory distress, IC and SC

retractions, wheezing in all lung fields, CR<3 sec

What would you do? The next step in management should

be:A. Place nasal cannula and provide

supplemental oxygenB. Provide albuterol by nebulizerC. Provide racemic epinephrine by

nebulizerD. Provide nasal suctionE. Obtain a chest x-ray

MUST READ! Diagnosis and Management of

BronchiolitisSubcommittee on Diagnosis and Management of BronchiolitisPediatrics 2006;118;1774-1793

Further Reading McBride. RSV and Asthma: Is There a Link? 1998;34. Lowell et al. Pediatrics. 1987;79:939. Menon et al. J Pediatr. 1995;126:1004. Infants have airway tone and responsiveness to ß-agonists similar to older

children & adultsGoldstein A, et al. Am J Resp Crit Care Med 2001;164:447-54 Responsiveness to bronchodilators in bronchiolitis is not age dependent

Modl M et al. J Pediatr 2005;147:617-21 Short acting beta-agonists have no clear benefit in children less than 2 years

oldChavasse R, et al. Cochrane Rev 2009 1-2% of nebulized dose reaches lungs of infants

Amirav I, et al. J Nucl Med 2002;43(4):487-91

α / β-agonist epinephrine has no clear benefit in inpatients with bronchiolitisHarding L, et al. The Cochrane Database of Systematic Reviews 2004;1.

RSV may reduce β-agonist responsiveness of human airway smooth muscleMoore P, et al. Am J Resp Cell Molec Biol 2006;35:559-64.

1. Al-Shehri MA, Sadeq A, Quli K: Bronchiolitis in Abha, Southwest Saudi Arabia: viral etiology and predictors for hospital admission. West Afr J Med 2005, 24:299-3042. Anderson LJ, Parker RA, Strikas RA, Farrar JA, Gangarosa EJ, Keyserling HL, Sikes RK: Day-care center attendance and hospitalization for lower respiratory tract illness. Pediatrics 1988, 82:300-3083. Breese Hall C, Hall WJ, Gala CL, MaGill FB, Leddy JP: Long-term prospective study in children after respiratory syncytial virus infection. J Pediatr 1984, 105:358-3644. Gurkan F, Kiral A, Dagli E, Karakoc F: The effect of passive smoking on the development of respiratory syncytial virus bronchiolitis. Eur J Epidemiol 2000, 16:465-468.5. Hayes EB, Hurwitz ES, Schonberger LB, Anderson LJ: Respiratory syncytial virus outbreak on American Samoa. Evaluation of risk factors. Am J Dis Child 1989, 143:316-3216. McConnochie KM, Roghmann KJ: Parental smoking, presence of older siblings, and family history of asthma increase risk of bronchiolitis. Am J Dis Child 1986, 140:806-8127. Sims DG, Downham MA, Gardner PS, Webb JK, Weightman D: Study of 8-year-old children with a history of respiratory syncytial virus bronchiolitis in infancy. BMJ 1978, 1:11-148. Chatzimichael A, Tsalkidis A, Cassimos D, Gardikis S, Tripsianis G, Deftereos S, Ktenidou-Kartali S, Tsanakas I: The role of breastfeeding and passive smoking on the development of severe bronchiolitis in infants. Minerva Pediatr 2007, 59:199-2069. Reese AC, James IR, Landau LI, Lesouef PN: Relationship between urinary cotinine level and diagnosis in children admitted to hospital. Am Rev Respir Dis 1992, 146:66-70

Any Questions?