Bronchiolitis: recent evidence on diagnosis and management. Continuous pulse oximetry is optional for infants and children with bronchiolitis. Bronchiolitis may present with a wide range of symptoms and severity, from a mild upper respiratory tract infection (URTI) to impending respiratory failure (Table 1). Alarm fatigue is recognized by The Joint Commission as a contributor toward in-hospital morbidity and mortality.114 One adult study demonstrated very poor documentation of hypoxemia alerts by pulse oximetry, an indicator of alarm fatigue.115 Pulse oximetry probes can fall off easily, leading to inaccurate measurements and alarms.116 False reliance on pulse oximetry may lead to less careful monitoring of respiratory status. The AAP policy statement “Classifying Recommendations for Clinical Practice”14 was followed in designating levels of recommendation (Fig 2; Table 1). How is bronchiolitis treated? Depending on the month of birth, fewer than 5 monthly doses will provide protection for most infants for the duration of the season. Clinical Guideline Acute Bronchitis 3 | P a g e CHC Acute Bronchitis Clinical Guideline Workgroup 2018 CHC Workgroup: 1. Effectiveness of chest physiotherapy in infants hospitalized with acute bronchiolitis: a multicenter, randomized, controlled trial. Bronchodilators (albuterol, salbutamol), epinephrine, and corticosteroids should, Supplemental oxygen is not necessary in children and infants with a diagnosis of bronchiolitis if SpO. A major addition to the evidence base came from the Canadian Bronchiolitis Epinephrine Steroid Trial.68 This multicenter randomized trial enrolled 800 patients with bronchiolitis from 8 EDs and compared hospitalization rates over a 7-day period. 6b. Intravenous fluids versus gastric-tube feeding in hospitalized infants with viral bronchiolitis: a randomized, prospective pilot study. Clinicians may administer nebulized hypertonic saline to infants and children hospitalized for bronchiolitis (Evidence Quality: B; Recommendation Strength: Weak Recommendation [based on randomized controlled trials with inconsistent findings]). Nosocomial respiratory syncytial virus infections: the cost-effectiveness and cost-benefit of infection control. The evidence-based approach to guideline development requires that the evidence in support of a policy be identified, appraised, and summarized and that an explicit link between evidence and recommendations be defined. If a clinical trial of bronchodilators is undertaken, clinicians should note that the variability of the disease process, the host’s airway, and the clinical assessments, particularly scoring, would limit the clinician’s ability to observe a clinically relevant response to bronchodilators. The largest and most rigorous retrospective study to date was from Australia,138 which showed a decline in intubation rate in the subgroup of infants with bronchiolitis (n = 330) from 37% to 7% after the introduction of high-flow nasal cannula, while the national registry intubation rate remained at 28%. Families of infants hospitalized with continuous pulse oximeters are exposed to frequent alarms that may negatively affect sleep. Concurrent serious bacterial infections in 2396 infants and children hospitalized with respiratory syncytial virus lower respiratory tract infections. Empiric antibiotics are justified for infants with RSV presenting with respiratory failure. OR exp EPINEPHRINE/ OR exp Cholinergic Antagonists/ OR exp IPRATROPIUM/ OR exp Anti-Inflammatory Agents/ OR ics.mp. All people should use alcohol-based rubs for hand decontamination when caring for children with bronchiolitis. This is based on bulging being the best indicator for the presence of bacteria in multiple tympanocentesis studies and on 2 articles comparing antibiotic to placebo therapy that used a bulging tympanic membrane as a necessary part of the diagnosis.178,179 New studies are needed to determine the incidence of AOM in bronchiolitis by using the new criterion of bulging of the tympanic membrane. Low incidence of respiratory syncytial virus hospitalisations in haemodynamically significant congenital heart disease. Stay Dialed In on the Fight for Family Medicine, AAFP Digital Assistant Pilot Opportunities Available. Since no definitive antiviral therapy exists for most causes of bronchiolitis, management of these infants should be directed toward symptomatic relief and maintenance of hydration and oxygenation. Yanney M, Vyas H; The treatment Use of high-flow nasal cannula support in the emergency department reduces the need for intubation in pediatric acute respiratory insufficiency. Bronchiolitis management preferences and the influence of pulse oximetry and respiratory rate on the decision to admit. The goal of this guideline is to provide an evidence-based approach to the diagnosis, management, and prevention of bronchiolitis in children from 1 month through 23 months of age. When diagnosing bronchiolitis, take into account that symptoms usually peak between 3 and 5 days, and that cough resolves in 90% of infants within 3 weeks. View Issue. MMWR Morb Mortal Wkly Rep. 2013;62(8):141–144. Children’s Hospital of Orange County (April, 2014) Bronchiolitis: Clinical guidelines from the Stanford University Emergency Department, (May, 2015) Bronchiolitis … Nebulized hypertonic saline for bronchiolitis in the emergency department: a randomized clinical trial. Guideline for Hand Hygiene in Health-Care Settings. Pneumothorax is a reported complication. Airway edema, sloughing of respiratory epithelium into airways, and generalized hyperinflation of the lungs, coupled with poorly developed collateral ventilation, put infants with bronchiolitis at risk for atelectasis. How Bronchiolitis Is Treated. When alcohol-based rubs are not available, individuals should wash their hands with soap and water (Evidence Quality: B; Recommendation Strength: Strong Recommendation). Refer to the AOM guideline180 for recommendations regarding the management of AOM. Oxygen therapy for lower respiratory tract infections in children between 3 months and 15 years of age. Clinical and therapeutic variables influencing hospitalisation for bronchiolitis in a community-based paediatric group practice. Sepsis evaluations in hospitalized infants with bronchiolitis. These recommendations may not provide the only appropriate approach to the management of children with bronchiolitis. Exclusive breastfeeding for at least 6 months is recommended to decrease the morbidity of respiratory infections. How can I manage my child's symptoms? High incidence of pulmonary bacterial co-infection in children with severe respiratory syncytial virus (RSV) bronchiolitis. The therapy has been studied in the ED136,137 and the general inpatient setting,134,138 as well as the ICU. The potential adverse effects (tachycardia and tremors) and cost of these agents outweigh any potential benefits. There were 6 studies involving 500 inpatients providing data for the analysis of LOS with an aggregate 1-day decrease reported, a result largely driven by the inclusion of 3 studies with relatively long mean length of stay of 5 to 6 days. In most cases, no investigations are required, and treatment is supportive. Other possible viral causative agents include human metapneumovirus (hMPV), adenovirus, rhinovirus, and parainfluenza and influenza viruses. Children with severe disease or with respiratory failure were generally excluded from these trials, and this evidence cannot be generalized to these situations. The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. AOM did not influence the clinical course or laboratory findings of bronchiolitis. Patient Satisfaction and Antibiotic Prescribing for Respiratory Infections by Telemedicine, Pediatric Respiratory Illness Measurement System (PRIMES) Scores and Outcomes, Patterns of Electrolyte Testing at Childrens Hospitals for Common Inpatient Diagnoses, High-flow nasal cannula therapy for children with bronchiolitis: a systematic review and meta-analysis, Protocol: randomised trial to compare nasoduodenal tube and nasogastric tube feeding in infants with bronchiolitis on high-flow nasal cannula; Bronchiolitis and High-flow nasal cannula with Enteral Tube feeding Randomised (BHETR) trial, Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Nebulized epinephrine has been administered in the racemic form and as the purified L-enantiomer, which is commercially available in the United States for intravenous use. Your child may need to be monitored and treated in the hospital if he or she has severe bronchiolitis. In infants and children with bronchiolitis, no data exist to suggest such increases result in any clinically significant difference in physiologic function, patient symptoms, or clinical outcomes. The course of bronchiolitis is variable and dynamic, ranging from transient events, such as apnea, to progressive respiratory distress from lower airway obstruction. The diagnosis and management of acute otitis media [published correction appears in. Inappropriate secretion of antidiuretic hormone in infants with respiratory infections. Efficacy of oral dexamethasone in outpatients with acute bronchiolitis. A pilot trial in Israel that included 51 infants younger than 6 months demonstrated no significant differences in the duration of oxygen needed or time to full oral feeds between infants receiving intravenous 5% dextrose in normal saline solution or nasogastric breast milk or formula.187 Infants in the intravenous group had a shorter LOS (100 vs 120 hours) but it was not statistically significant. Monthly palivizumab prophylaxis should be restricted to infants born before 29 weeks, 0 days’ gestation, except for infants who qualify on the basis of congenital heart disease or chronic lung disease of prematurity. Signs and symptoms typically begin with rhinitis and cough, which may progress to tachypnea, wheezing, rales, use of accessory muscles, and/or nasal flaring.2. In severe respiratory distress consider IV fluids. Typically, the peak time for bronchiolitis is during the winter months.Bronchiolitis starts out with symptoms similar to those of a common cold but then progresses to coughing, wheezing and sometimes difficulty breathing. All panel members reviewed the AAP Policy on Conflict of Interest and Voluntary Disclosure and were given an opportunity to declare any potential conflicts. Respiratory rate in otherwise healthy children changes considerably over the first year of life.22–25 In hospitalized children, the 50th percentile for respiratory rate decreased from 41 at 0 to 3 months of age to 31 at 12 to 18 months of age.26 Counting respiratory rate over the course of 1 minute is more accurate than shorter observations.27 The presence of a normal respiratory rate suggests that risk of significant viral or bacterial lower respiratory tract infection or pneumonia in an infant is low (negative likelihood ratio approximately 0.5),27–29 but the presence of tachypnea does not distinguish between viral and bacterial disease.30,31, The evidence relating the presence of specific findings in the assessment of bronchiolitis to clinical outcomes is limited. The risk of RSV hospitalization is not well defined in children with pulmonary abnormalities or neuromuscular disease that impairs ability to clear secretions from the lower airway because of ineffective cough, recurrent gastroesophageal tract reflux, pulmonary malformations, tracheoesophageal fistula, upper airway conditions, or conditions requiring tracheostomy. Hypertonic (3%) saline vs 0.93% saline nebulization for acute viral bronchiolitis: a randomized controlled trial. In most cases, no investigations are required, and treatment is supportive. Any conflicts have been resolved through a process approved by the Board of Directors. OR oxygen saturation.mp. 1999;27(3):303]. Bronchiolitis is a viral lower respiratory tract infection, generally affecting children under 12 months of age It is a clinical diagnosis, based on typical history and examination Peak severity is usually at around day two to three of the illness with resolution over 7–10 days Thirdhand tobacco smoke: emerging evidence and arguments for a multidisciplinary research agenda. The new guidelines emphasize the use of supportive care, including hydration and oxygen. How to care for your child at home, and what to look out for if you think they may need hospital treatment. The role of epinephrine in the outpatient setting remains controversial. Clinicians should not administer antibacterial medications to infants and children with a diagnosis of bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one (Evidence Quality: B; Recommendation Strength: Strong Recommendation). Those studies showing benefit57–59 are methodologically weaker than other studies and include older children with recurrent wheezing. Down syndrome and respiratory syncytial virus infection. A combination of systemic corticosteroids and nebulised adrenaline. Clinicians should inquire about the exposure of the infant or child to tobacco smoke when assessing infants and children for bronchiolitis (Evidence Quality: C; Recommendation Strength: Moderate Recommendation). The search strategy is shown in the Appendix. In a study of inpatients and outpatients with bronchiolitis,9 76% of patients had RSV, 39% had human rhinovirus, 10% had influenza, 2% had coronavirus, 3% had human metapneumovirus, and 1% had parainfluenza viruses (some patients had coinfections, so the total is greater than 100%). Prophylaxis should not be administered to reduce recurrent wheezing in later years.210,211. Technical report: updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. There is emerging evidence for the role of home oxygen in reducing LOS or admission rate for infants with bronchiolitis, including 2 randomized trials.118,119 Most of the studies have been performed in areas of higher altitude, where prolonged hypoxemia is a prime determinant of LOS in the hospital.120,121 Readmission rates may be moderately higher in patients discharged with home oxygen; however, overall hospital use may be reduced,122 although not in all settings.123 Concerns have been raised that home pulse oximetry may complicate care or confuse families.124 Communication with follow-up physicians is important, because primary care physicians may have difficulty determining safe pulse oximetry levels for discontinuation of oxygen.125 Additionally, there may be an increased demand for follow-up outpatient visits associated with home oxygen use.124. , Agency for Healthcare Research and Quality common colds and other upper respiratory ailments updated guidelines management... 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