1. No category

“Ensuring Infants & Children with Bronchiolitis
Receive the Best Possible Care”
Evidence-Based Practice Guideline
for the
Management of Bronchiolitis
in Infants and Children
2 October 2006
Funded by
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
‘Health for Kids in the South East’ is a Southern Health initiative funded by the
Victorian Department of Human Services through the Hospital Admission Risk
Program (HARP). This project aims to improve health outcomes for children and
young people in the Southern Health catchment area by supporting evidence-based
best practice and facilitating partnerships within and between acute and community
health services
Electronic copies of this report can be obtained from the Health for Kids in the
South East Internet site at:
http://www.mihsr.monash.org/hfk/pdf/hfkbronchguideline.pdf
For further information, please contact:
Dr Claire Harris
Project Manager, Health for Kids in the South East
Centre for Clinical Effectiveness
Monash Institute of Health Services Research
Monash Medical Centre
Clayton 3168 Australia
Phone: +61 3 9594 7576
Email: [email protected]
Acknowledgement
Southern Health supported the guideline development process, individual
departments facilitated staff participation, and many staff members contributed in
their own time.
We thank the following people for their important contribution to the development
of this guideline.
Name
Dr Trevor Kerr
Role
Unit Head, Southern
Health, Microbiology
Contribution
Expert knowledge on RSV
testing
Senior Scientists, Virus
Identification Unit
Victorian Infectious Disease
Reference Laboratory
Expert knowledge on RSV
testing
Laboratory Staff
Southern Cross Pathology,
Australia
Expert knowledge on RSV
testing
Judy Brett
Nurse Consultant, Southern
Health Infection Control
and Epidemiology Unit
Advice on infection control
measures
Emily England
John Wheeler
Metropolitan Ambulance
Service (MAS)
Consultation in regard to
MAS protocols
Funding for the development of this guideline was provided by the Victorian
Department of Human Services Hospital Admission Risk Project.
The Health for Kids Paediatric Evidence Centre was supported by a grant from the
Windermere Foundation Ltd.
Disclaimer
This guideline is designed to assist clinicians by providing a framework of expected
care based on the best available evidence at the time of publication. It should not
replace clinical judgment in patient care.
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Contents
Summary of Recommendations
1. Introduction
1.1 Statement of intent
2. Natural History and Diagnosis
2.1
2.2
2.3
2.4
Natural History
Diagnosis
Investigations
Assessment of severity
3. Pharmacological Management
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
Nebulised adrenaline
β2agonist bronchodilators
Ipratropium bromide
Antibiotics
Corticosteroids
Ribavirin
Immunoglobulin
Analgesics and antipyretics
Oral antitussives, expectorants or decongestants
4. Non-pharmacological Management
4.1 Oxygen
4.2 Feeding and Hydration
4.3 Chest Physiotherapy
4.4 Mist, Steam or Nebulised Saline
4.5 Saline drops
4.6 Suctioning
4.7 Apnoea management
4.8 Positioning
4.9 Level of care required
4.10 Observations
4.11 Hospital Infection Control
5. Patient Education and Self-Management
6. Outcomes and Audit
6.1 Process measures
6.2 Outcome measures
7. Dissemination and Implementation of the Guideline
8. Guideline Development Process
8.1
8.2
8.3
8.4
Southern Health Bronchiolitis Guideline Development
Methodology
Searches
Critical Appraisal of Identified Research
9. References
Annex 1: Management of Bronchiolitis in Hospital
Annex 2: Management of Bronchiolitis in General Practice
Annex 3: Normal Parameters for Paediatric Vital Signs
Glossary
Acronyms and Abbreviations
Contents
9
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12
12
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14
19
21
21
21
23
23
24
26
27
28
28
29
29
31
34
34
34
35
35
36
37
39
40
42
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3
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Summary of Recommendations
Natural History and Diagnosis
Page
9 An infant or child under 18 months presenting with initial signs and
12
symptoms of upper respiratory tract infection followed by cough,
tachypnoea, inspiratory crepitations and wheeze is likely to have
bronchiolitis.
D Consider other diagnoses in infants or children with recurrent bouts of
bronchiolitis-like symptoms.
13
D An infant or child with bronchiolitis-like symptoms who responds to
treatment with a bronchodilator should be treated according to asthma
management guidelines.
13
D The diagnosis of bronchiolitis is clinical. Chest x-rays should not be used to
diagnose bronchiolitis.
14
9 Chest x-rays may occasionally be warranted in infants and children where
14
D Chest x-rays should not be routinely performed in infants and children with
bronchiolitis.
15
D Consider a chest x-ray in infants and children who have severe respiratory
distress, or are at high risk of severe illness.
15
D The diagnosis of bronchiolitis is clinical. Virologic tests should not be used to
diagnose bronchiolitis.
16
D Consider virologic testing in infants and children with suspected bronchiolitis
if the diagnosis is unclear.
16
D Consider virologic testing in young febrile infants with bronchiolitis.
16
D Virologic tests should not be used to identify the viral aetiology in infants
and children with bronchiolitis unless the test result will impact on decisions
about clinical management or is required for epidemiologic surveillance.
16
D If PCR testing is available, use nasopharyngeal or nasal swabs to collect
specimens for virological testing. If PCR testing is not available, use
nasopharyngeal aspirates to collect specimens for virological testing.
17
D Blood counts should not be routinely performed in infants or children with
suspected or diagnosed bronchiolitis.
17
D Blood cultures should not be routinely performed in infants or children with
bronchiolitis.
18
D Urine cultures should not be routinely performed in infants or children with
bronchiolitis.
18
D Blood gas analysis should not be routinely performed in infants or children
with bronchiolitis.
19
D Blood gas analysis should be performed in infants or children with lifethreatening bronchiolitis.
19
D Consider blood gas analysis in infants or children with severe bronchiolitis.
19
the diagnosis is uncertain.
Introduction
4
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Page
9 Infants who are <3 months old or who were born at <36 weeks gestation,
20
and infants or children who have underlying cardiorespiratory disease are at
higher risk of more severe disease.
Pharmacological Management
A
Adrenaline should not be routinely used for treatment of bronchiolitis.
21
A
β2agonist bronchodilators should not be routinely used for treatment of
bronchiolitis.
22
D Consider a trial of a single dose of β2agonist bronchodilators in patients older
than 9 months, particularly those with recurrent wheezing.
22
D β2agonist bronchodilators should not be continued if an infant or child does
not respond to an initial trial.
22
A
Ipratropium bromide should not be routinely used for treatment of
bronchiolitis.
23
A
Antibiotics should not be routinely used for treatment of bronchiolitis.
24
D Consider antibiotics in infants and children with bronchiolitis who have
clinical signs or symptoms of a secondary bacterial infection.
24
A
Corticosteroids should not be routinely used for treatment of bronchiolitis.
25
A
Ribavirin should not be routinely used for treatment of bronchiolitis.
26
A
Immunoglobulin should not be routinely used for treatment of bronchiolitis.
27
28
D Infants and children with bronchiolitis and fever may be treated with
paracetamol or ibuprofen to bring their temperature down and reduce
irritability.
Carefully consider and exclude other potential causes of fever, irritability and
pain.
D Oral antitussives, expectorants or decongestants should not be routinely
used for treatment of bronchiolitis.
28
Non-pharmacological Management
D Give oxygen to any infant or child with life-threatening bronchiolitis or
oxygen saturations less than 90%.
29
D Consider giving oxygen to an infant or child with moderate or severe
bronchiolitis, particularly if aged less than 3 months.
29
D Consider giving oxygen while feeding to an infant or child with mild or
moderate bronchiolitis who has increased work of breathing and/or difficulty
maintaining oxygenation during feeds.
29
D In infants and children with bronchiolitis receiving oxygen therapy, provide
oxygen using the method that causes least distress to the infant or child. If
nasal prongs or face masks are used, ensure that infant or child is closely
monitored to avoid entanglement.
29
D In infants and children with bronchiolitis receiving oxygen therapy, maintain
oxygen saturation levels between 92% and 95%.
30
Introduction
5
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Page
D In infants and children with bronchiolitis receiving oxygen therapy,
administer oxygen at the lowest flow rate required to maintain oxygen
saturations between 92 and 95%.
30
D In infants and children with bronchiolitis receiving oxygen, assess oxygen
saturation, respiratory rate, heart rate and accessory muscle use hourly.
30
D In infants and children with bronchiolitis receiving oxygen therapy at a rate
>0.5l/min continuously monitor oxygen saturation.
30
D In infants and children with bronchiolitis in whom oxygen is being ceased,
assess oxygen saturation, respiratory rate, heart rate and accessory muscle
use initially hourly and then less frequently as observations are stable or
improving.
30
D In infants and children with bronchiolitis decisions management of oxygen
therapy can be made by nursing staff, in line with this guideline, and
medical staff should be informed. Nurses should consult with medical staff if
the infant or child deteriorates.
30
D Infants or children with mild or moderate bronchiolitis may continue oral
feeding unless it increases their respiratory distress.
31
D Infants or children with severe or life-threatening bronchiolitis should not be
offered oral feeds.
31
D In infants and children with bronchiolitis who have signs of circulatory
compromise, including hypotension, capillary refill time greater than 4
seconds, or skin pinch retraction time greater than 2 seconds, consult senior
paediatric or emergency medical staff to determine fluid management.
31
D Consider nasogastric or intravenous fluids for infants and children with
moderate or severe bronchiolitis.
32
D Give intravenous fluids to any infant or child with life-threatening
bronchiolitis.
32
D In infants and children with moderate bronchiolitis requiring fluid therapy,
provide fluids via nasogastric tube unless work of breathing is increased.
32
D In infants and children with life-threatening bronchiolitis, or with moderate
or severe bronchiolitis and increased work of breathing, requiring fluid
therapy, provide intravenous fluids.
32
D In infants and children with bronchiolitis receiving nasogastric fluids, give
milk (breast milk, formula, cow’s milk, etc as per usual diet).
32
D In infants and children with bronchiolitis receiving intravenous fluids, use a
continuous infusion of Glucose 5% and Sodium Chloride 0.9%.
33
D In infants and children with bronchiolitis and no signs of significant
dehydration receiving nasogastric or intravenous fluids, provide fluids at
75% of normal maintenance rate.
33
D Infants and children with bronchiolitis and signs of significant dehydration
may require fluids at a higher rate. Discuss management with a senior
clinician.
33
D Infants and children with bronchiolitis should have blood taken for glucose,
urea, electrolytes and bicarbonate if intravenous fluids are being provided.
33
Introduction
6
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Page
D Infants and children with bronchiolitis with significantly abnormal
electrolytes should be managed in consultation with a senior clinician.
33
D Infants and children with bronchiolitis with significantly abnormal
electrolytes and those receiving intravenous fluid therapy for more than 24
hours, should have their plasma biochemistry reassessed at least daily
according to results and the clinical situation.
33
A Chest physiotherapy should not be routinely used for treatment of
bronchiolitis.
34
D Mist, steam and nebulised saline should not be routinely used for treatment
of bronchiolitis.
34
D Saline nasal drops should be trialled in infants and children with bronchiolitis
who have nasal congestion, particularly before feeds.
34
D Nasal suctioning may be trialled in infants or children with bronchiolitis who
have nasal congestion.
35
D Infants and children with bronchiolitis who are at increased risk of apnoea as
a result of age less than 3 months, premature birth or previous apnoea
should be closely monitored.
35
D Infants and children with bronchiolitis-related apnoea should be managed in
consultation with senior paediatric or emergency medical staff.
35
C
36
Infants and children with bronchiolitis should be allowed to adopt the
position they find most comfortable. Infants unable to position themselves
may be placed in either a prone or supine position, with head slightly
elevated.
Infants and children with bronchiolitis who are placed in a prone position
should have continuous pulse oximetry monitoring, and the reasons for the
position should be explained to the parent.
D Infants and children with mild bronchiolitis may be managed by a general
practitioner and sent home for observation if the GP is confident the
parent/carer can adequately manage the infant/child’s illness.
37
D Infants and children with moderate bronchiolitis who do not require oxygen
or fluid therapy may be managed by a general practitioner, otherwise the
infant or child should be sent to hospital.
37
D An ambulance should be called for infants and children with severe or life
threatening bronchiolitis.
37
D If a general practitioner is not available, infants and children with moderate
bronchiolitis should be taken to a hospital emergency department.
38
D All infants or children with severe or life-threatening bronchiolitis should be
sent by ambulance to an emergency department.
38
D All infants or children with life-threatening bronchiolitis or severe
bronchiolitis requiring ongoing oxygen therapy at levels above 40%, should
be managed in conjunction with staff from the Intensive Care Unit.
38
D Infants and children with bronchiolitis can be discharged from the Intensive
Care Unit to the paediatric ward when they have no signs of life-threatening
bronchiolitis.
38
Introduction
7
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
D Infants and children with bronchiolitis can be discharged from hospital when
they have no signs of moderate bronchiolitis requiring oxygen or fluid
therapy; severe or life-threatening bronchiolitis.
38
D A letter should be sent by fax, mail or email to the GP (and any relevant
specialists) of any infant or child presenting with bronchiolitis to hospital.
39
D On discharge the family should be given information on when to seek further
medical attention, and a copy of the discharge summary.
39
D Infants and children with bronchiolitis should be reviewed by their GP 2 days
after initial GP or ED presentation or discharge from hospital, or at any time
if their clinical condition deteriorates.
39
D For infants and children with mild bronchiolitis, assess the following clinical
signs at least once every four hours, taking care not to distress the infant or
child:
• Accessory muscle use, tracheal tug or chest wall retraction
• Respiratory rate
• Oxygen saturation
• Heart rate.
40
D For infants and children with moderate bronchiolitis, assess the following
clinical signs at least once every two hours, taking care not to distress the
infant or child:
• Accessory muscle use, tracheal tug or chest wall retraction
• Respiratory rate
• Oxygen saturation
• Heart rate.
40
40
D Infants and children with life-threatening or severe bronchiolitis are likely to
require continuous monitoring and constant supervision.
Assess the following clinical signs at least once every 30 minutes and more
frequently if the infant or child’s condition is deteriorating:
• Accessory muscle use, tracheal tug or chest wall retraction
• Respiratory rate
• Oxygen saturation
• Heart rate.
41
D Infants and children with bronchiolitis at Southern Health, regardless of RSV
status, should be managed according to the Southern Health Infection
Control Guidelines following Standard, Droplet and Contact Precautions.
41
D Infants and children with bronchiolitis can be accommodated in shared
rooms where single rooms are not available.
41
D Where infants and children with bronchiolitis are accommodated in shared
rooms, infants and children and any associated equipment or toys should be
separated by at least two metres (a radius of one meter around each infant
or child).
41
9 Take special care in infants and children with bronchiolitis who have
underlying chronic illnesses which might make them more vulnerable to
infection.
Introduction
8
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
1. Introduction
This Guideline was developed by the Health for Kids in the South East
Bronchiolitis Guideline Development Group at Southern Health in 2005.
The process undertaken to develop this guideline was evidence-based.
Initially a search was undertaken to identify existing evidence-based
guidelines which could be adapted for local use. No high quality evidencebased guidelines for the management of bronchiolitis (as assessed by the
AGREE Criteria117) were identified. However an Evidence
Report/Technology Assessment “Management of Bronchiolitis in Infants
and Children”118 published by the Agency for Healthcare Research and
Quality (AHRQ) in January 2003 was identified and this report formed the
basis for much of the content in this guideline.
A multidisciplinary Bronchiolitis Guideline Development Group (GDG) was
convened that included representation from all relevant clinical areas,
nursing and medical staff, as well as consumer representatives, a General
Practitioner and specialists in evidence-based practice and guideline
development. Chapter 7 provides further details of the composition of the
GDG.
The GDG created a list of clinical questions that should be addressed in a
guideline for the management of bronchiolitis, and systematic searches
were undertaken to identify evidence to answer these questions. Where
evidence was found the GDG made recommendations based on this
evidence, integrated with clinical expertise and consumer preferences.
Where evidence was not found to answer a clinical question the GDG
made a consensus recommendation based on clinical expertise and
consumer preferences.
The levels of evidence found, and grades of recommendation made are
identified in the text of the guideline, as described in Table 1. A full
description of the development process can be found in Chapter 7.
It is intended that this guideline be updated every 2 years, to reflect
changes in the available evidence and any relevant local changes. This
guideline will therefore be due for review in October 2008.
1.1 Statement Of Intent
This guideline has been developed to ensure infants and children with
bronchiolitis receive the best possible care, based on the best available
evidence integrated with clinical expertise and parent/carer preferences.
The guideline aims to provide clinicians with recommendations for the
management of infants and children presenting with bronchiolitis and to
promote consistency of care for infants and children with bronchiolitis in
primary care and hospital settings. The guideline also aims to form the
foundation of information for parents and carers of infants and children
with bronchiolitis.
Introduction
9
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Guidelines are a tool used to improve patient care and do not replace the
central role of clinical expertise and judgement in determining appropriate
patient care. Clinicians should apply this guideline in the context of the
individual patient. Variations from this guideline should be documented in
the patient’s medical record at the time the relevant decision is made.
The recommendations in this guideline were based on the best evidence
available at the time of writing, and should be read with an awareness of
any more recent evidence.
A number of supporting documents have been developed to facilitate the
implementation of the recommendations of this guideline into practice.
These include a one page decision support algorithm for General
Practitioners and hospital staff, an evidence-based clinical path which will
form the medical record for infants and children presenting at Southern
Health hospitals with bronchiolitis, and evidence-based information for
parents and carers of infants and children with bronchiolitis.
These documents are available on the Health for Kids website at
http://www.mihsr.monash.org/hfk/
Guideline Exclusions
This guideline does not apply to:
• children who are more than 18 months of age
• infants or children with pre-existing airway abnormalities
including cystic fibrosis
• infants or children with cyanotic cardiac anomalies
• infants or children admitted to the intensive care unit.
Clinicians should also take extra caution and consult with appropriate
specialist clinicians when caring for:
• very young infants
• infants or children born prematurely
• infants or children with significant relevant comorbidities
including chronic lung disease
• infants or children with chronic illnesses.
Take special care to exclude other diagnoses in infants and children
presenting with recurrent wheezing.
Guideline Users
This guideline is intended for use by clinicians involved in the care and
management of infants and children with bronchiolitis in general practice,
emergency departments and paediatric wards. It has been primarily
developed for use in Southern Health hospitals and by clinicians practicing
within the Southern Health catchment area in south east Melbourne,
Australia. Adaptation for local use may be necessary in other contexts.
Introduction
10
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Table 1: KEY TO EVIDENCE STATEMENTS AND GRADES OF
RECOMMENDATIONS 163
LEVELS OF EVIDENCE
1++
High quality meta-analyses, systematic reviews of randomised controlled
trials (RCTs), or RCTs with a very low risk of bias
1+
Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a
low risk of bias
1-
Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of
bias
2++
High quality systematic reviews of case control or cohort studies.
High quality case control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is causal
2+
Well conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal
2-
Case control or cohort studies with a high risk of confounding or bias and a
significant risk that the relationship is not causal
3
Non-analytic studies, e.g. case reports, case series
4
Expert opinion
GRADES OF RECOMENDATION
Note: The grade of recommendation relates to the strength of the evidence on
which the recommendation is based. It does not reflect the clinical importance of
the recommendation.
A
At least one meta-analysis, systematic review of RCTs, or RCT rated as
1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly
applicable to the target population, and demonstrating overall consistency
of results
B
A body of evidence including studies rated as 2++, directly applicable to the
target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated 1++ or 1+
C
A body of evidence including studies rated as 2+, directly applicable to the
target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated 2++
D
Evidence level 3 or 4; or
Extrapolated evidence from studies rated 2+
GOOD PRACTICE POINTS
9
Recommended best practice based on the clinical experience of the
guideline development group
Introduction
11
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
2. Natural History and Diagnosis
2.1 Natural History
Bronchiolitis is a viral infection of the respiratory tract.1 It is characterised
by:
• acute inflammation, oedema, and necrosis of epithelial cells
lining the bronchioles;
• increased mucus production;
• and bronchospasm;
all of which contribute to obstruction of the small airways.
Infants and children with bronchiolitis often present with features of both
upper and lower respiratory tract infection including rhinitis, rapid
breathing (tachypnoea), wheezing, cough, crackles, use of accessory
muscles and nasal flaring.
Bronchiolitis is the most common lower respiratory tract infection in
infants. In Australasia, Europe and North America up to 3 percent of all
children in their first year of life are hospitalised with bronchiolitis.1 Most
infants and young children experience only a mild form of bronchiolitis,
and are managed on an outpatient basis. In Australia approximately
13,500 children are admitted to hospital with bronchiolitis each year. More
than 80% of Australian children admitted with bronchiolitis are less than 1
year old.119
Bronchiolitis is commonly caused by respiratory syncytial virus (RSV) and
may also be caused by parainfluenza, adenovirus and influenza.4 Most
bronchiolitis occurs in autumn and winter, however because some types of
parainfluenza virus are present in other months, bronchiolitis can be seen
year round.
Duration of illness has been investigated in two studies.120,121 In both
studies the median duration of illness was 2 weeks, and approximately
20% of patients had symptoms lasting longer than 3 weeks.
2.2 Diagnosis
The diagnosis of bronchiolitis is clinical - no diagnostic test confirms the
disease. There is very little research evidence on which to establish
evidence-based recommendations for the diagnosis of bronchiolitis.
However, there is a consensus of opinion in the medical literature that an
infant presenting with initial signs and symptoms of upper respiratory
tract infection followed by cough, tachypnoea, inspiratory crepitations and
wheeze is likely to have bronchiolitis.
9 An infant or child under 18 months presenting with initial signs and
symptoms of upper respiratory tract infection followed by cough,
tachypnoea, inspiratory crepitations and wheeze is likely to have
bronchiolitis.
Natural History and Diagnosis
12
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Fever, hypoxia, and accessory muscle use may also be present in an
infant or child with bronchiolitis. Chest examination may be clear, but a
prolonged expiratory phase with wheeze, rhonchi and crepitations may be
found. Infants and children with bronchiolitis may also have dehydration
resulting from the combination of difficulty feeding and increased
insensible water losses due to tachypnoea.
2.2.1 Alternative diagnoses
There is very little research evidence on which to establish evidence-based
recommendations for alternate diagnoses for infants and children with
suspected bronchiolitis. The GDG agreed that in an infant or child with
bronchiolitis-like signs and symptoms conditions including asthma,
pneumonia, whooping cough, cystic fibrosis, congestive heart failure, and
an inhaled foreign body should be excluded.
The GDG agreed that bronchiolitis should also be distinguished from
transient wheezing of childhood, a condition characterised by recurrent
bouts of wheezing, in the absence of an underlying structural abnormality,
in an otherwise well infant or child. In most infants and children with
transient wheezing the symptoms do not cause significant respiratory
distress and resolve in the first three to five years of life as the airways
mature.122
D Consider other diagnoses in infants or children with recurrent bouts of
bronchiolitis-like symptoms.
2.2.1.1 Asthma
An infant or child with recurrent wheezing, particularly in the absence of
symptoms of a viral infection or at an older age may have asthma.
It is often difficult to distinguish between the infant or child who is
wheezing as a result of a viral infection of the bronchioles (bronchiolitis)
and the infant or child who is wheezing because a viral infection has
caused an acute exacerbation of asthma.
An infant or child with bronchiolitis-like symptoms who responds to
treatment with a bronchodilator such as salbutamol is likely to have
asthma.
D An infant or child with bronchiolitis-like symptoms who responds to
treatment with a bronchodilator should be treated according to asthma
management guidelines.
Natural History and Diagnosis
13
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
2.2.1.2 Pneumonia
An infant or child with bronchiolitis may also have viral pneumonia.
Differentiating between the two entities is difficult and largely unnecessary
as treatment in either case is supportive.
An infant or child with localising signs or more severe symptoms may
have bacterial pneumonia.
2.2.1.3 Pertussis (Whooping cough)
An infant or child who presents with cough as the predominant symptom
and does not have wheeze, fever or crackles may have pertussis.
Pertussis should particularly be considered in an infant or child who is
unimmunised, or partially immunised.
Not all infants or children with pertussis have the characteristic whoop,
but the presence of a whoop-type cough makes pertussis very likely.
2.2.1.4 Cystic Fibrosis
An infant or child with persistent, or repeated and prolonged, respiratory
symptoms and failure to thrive may have cystic fibrosis.
2.2.1.5 Congestive heart failure
An infant or child with congestive heart failure may present with signs
indistinguishable from bronchiolitis. A diagnosis of congestive heart failure
is more likely in the presence of a cardiac murmur, failure to thrive,
oedema or a history of slow onset of symptoms.
2.2.1.6 Inhaled foreign body
A previously well infant or child who has sudden onset of symptoms,
history of a coughing or choking episode, expiratory wheeze, loss of voice,
or differential air entry may have an inhaled foreign body.
2.3 Investigations
2.3.1 Chest radiographs
2.3.1.1 Diagnosis
No studies were identified which investigated the accuracy of chest x-rays
in diagnosing bronchiolitis.
D The diagnosis of bronchiolitis is clinical. Chest x-rays should not be used to
diagnose bronchiolitis.
9 Chest x-rays may occasionally be warranted in infants and children where
the diagnosis is uncertain.
Natural History and Diagnosis
14
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
2.3.1.2 Assessment and management
Many infants or children with bronchiolitis have abnormalities on chest xrays, 24,25,32,36-45 however there is little evidence to demonstrate that chest
x-ray findings correlate well with disease severity. Four studies were
identified which examined the relationship between x-ray abnormalities
and disease severity.
In one study32 infants with atelectasis were 2.7 times more likely (95% CI:
1.97, 3.70) to have severe disease than those without this x-ray finding.
This association persisted when it was included in a multivariable analysis.
In contrast, a second study36 demonstrated no correlation between chest xray findings and disease severity as measured by a clinical severity scoring
system.
2-
Two studies43, 123 including more than 17,000 infants and children with a
discharge diagnosis of bronchiolitis found that chest radiograph was
associated with increased antibiotic use and increased length of stay.
These data cannot be shown to be causal, and the patients receiving xrays may well comprise a group with more severe illness. The authors
suggest that the non-specific x-ray findings common to bronchiolitis may
lead clinicians to treat patients with antibiotics “just in case”. The
effectiveness of antibiotic treatment was not examined in either of these
studies.
2-
These data suggest that in most cases of bronchiolitis, chest x-rays offer
no information that is likely to improve treatment and may lead to
inappropriate use of antibiotics. Therefore the GDG agreed that they
should not be routinely performed.
D Chest x-rays should not be routinely performed in infants and children with
bronchiolitis.
D Consider a chest x-ray in infants and children who have severe respiratory
distress, or are at high risk of severe illness.
Infants and children at high risk of severe illness are outlined in section
2.4.
2.3.2 Virologic tests
2.3.2.1 Diagnosis
Bronchiolitis can be caused by a number of different viruses and
identification of the viral aetiology is not necessary for diagnosis. Many
studies have attempted to identify the aetiology of bronchiolitis. The
proportion of cases caused by RSV has been found to be between 26
percent and 95 percent, however we were unable to identify any studies
reporting viral aetiology of bronchiolitis in Australia. It has been suggested
that bronchiolitis is more likely to be due to RSV during winter.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
D The diagnosis of bronchiolitis is clinical. Virologic tests should not be used to
diagnose bronchiolitis.
D Consider virologic testing in infants and children with suspected bronchiolitis
if the diagnosis is unclear.
2.3.2.2 Assessment and management
RSV testing may be justified for assessment or management of an infant
or child with bronchiolitis in several situations:
• In a young, febrile infant to support a clinician’s diagnosis and aid
ongoing management
• Where RSV-specific therapies are being evaluated for effectiveness
• For surveillance of lower respiratory tract infections in infants
One study was identified which examined the risk of bacterial infection
(urinary tract infection, bacteraemia or meningitis) in febrile infants aged
≤60 days with bronchiolitis.126 In this study, RSV positive infants were less
likely to have a bacterial infection than RSV negative infants (7% vs 12.5%,
RR=0.6; 95%CI 0.3, 0.9). These results suggest that while a positive RSV
test makes bacterial infection less likely, such a test cannot be used to
definitively rule out bacterial infection.
2+
D Consider virologic testing in young febrile infants with bronchiolitis.
No studies were identified which examined whether RSV testing affects
clinical management of infants and children with bronchiolitis. Many
institutions test all infants being admitted to the hospital, presumably to
decrease nosocomial RSV infections by segregating RSV positive infants
and children. However, no studies were identified which examined the
effects of cohort segregation in preventing nosocomial transmission of
bronchiolitis.
In the absence of evidence the GDG agreed to the following
recommendation:
D Virologic tests should not be used to identify the viral aetiology in infants
and children with bronchiolitis unless the test result will impact on decisions
about clinical management or is required for epidemiologic surveillance.
Natural History and Diagnosis
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
2.3.2.3 Comparison of methods of specimen collection
Two studies were identified which compared different methods of
specimen collection for virological tests. The first study26 demonstrated
that viral culture, enzyme immunoassays, and immunofluorescence
assays all yielded positive results more often when performed on
nasopharyngeal aspirates (NPAs) than when performed on
nasopharyngeal swabs. Similarly the second study124 found that in 88
children hospitalised for suspected bronchiolitis, in 86% of cases nasal
swabs and NPAs produced the same result (n=76, 21 positive, 55
negative). However in 11 cases (14%) nasal swabs were negative when
NPAs were positive and in 1 case, the nasal swab was positive when the
NPA was negative.
Consultation with the Victorian Infectious Diseases Reference Laboratory,
Southern Cross Pathology Australia and the Southern Health Microbiology
Unit highlighted that the sensitivity of polymerase chain reaction (PCR)
testing of nasal swabs is high enough to make this the preferred option,
where PCR is available. However where PCR testing is not available, NPAs
are the preferred method of specimen collection as enzyme
immunoassays, and immunofluorescence assays are not very sensitive
when used on swabs, as discussed above.
D If PCR testing is available, use nasopharyngeal or nasal swabs to collect
specimens for virological testing. If PCR testing is not available, use
nasopharyngeal aspirates to collect specimens for virological testing.
At Southern Health, enzyme immunoassays, or immunofluorescence
assays and cultures are used for routine RSV testing – and so NPAs are
the preferred method of specimen collection. Results of routine RSV tests
are usually available on the same day. PCR testing can be arranged by
special request however the tests are not carried out on-site and results of
the tests are not usually available for several days.
2.3.3 Blood counts
No studies were found which examined the value of blood cell counts in
infants or children with bronchiolitis. One study was found which
examined whether blood cell counts differed between infants with RSV
lower respiratory tract infection (bronchiolitis or pneumonia) with a
concurrent bacterial infection and those without.125 The authors report
that there was no statistically significant difference in the mean white
blood cell count between patients with a positive bacterial culture and
those without (14,500 ± 7,500 cells/ml compared with 11,900 ± 5,200
cells/ml, P=0.06).
D Blood counts should not be routinely performed in infants or children with
suspected or diagnosed bronchiolitis.
Natural History and Diagnosis
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
2.3.4 Blood and urine cultures
Ten studies were found which investigated the incidence of bacterial
infections as identified by blood or urine cultures in infants or children
with a clinical diagnosis of bronchiolitis.125-134 Two studies125,129 included
only RSV positive children or infants, and seven125,126,128,129,131,133,134 only
reported data from febrile children or infants.
No positive blood cultures were found in seven of the ten studies,
including a total of 1456 children or infants. 126-130,133,134 The remaining
three studies report positive blood cultures in 0.4% (2/470),125 0.2%
(1/411)131 and 0.7% (1/140) 132 of children or infants.
These data suggest that concurrent bacteraemia is rare in infants or
children with bronchiolitis and routine blood cultures are not required.
D Blood cultures should not be routinely performed in infants or children with
bronchiolitis.
Six studies report the results of urine cultures in infants or children with
bronchiolitis.125,126,128,130,132,133
• One of these studies reported no positive urine cultures
(0/68)130,
• Three studies found that 2% of urine cultures were positive
(2/106133, 3/140132, 6/273128),
• One study found that 6.5% of urine cultures were positive
(10/156)126
• One study found that 12% of urine cultures were positive
(28/234).125
The variation between results of these studies cannot be accounted for by
differing definition of a positive urine culture (though this variedly widely)
or differing sample collection, as all of these studies used either
suprapubic aspiration or catheterised samples. Some of the positive
cultures may represent asymptomatic bacteruria.
No studies were identified which examined the impact on clinical outcome
of performing a urine culture.
Routine urine culture is unlikely to be helpful in infants or children with
bronchiolitis in whom sepsis is not suspected.
D Urine cultures should not be routinely performed in infants or children with
bronchiolitis.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
2.3.5 Blood gas analysis
No studies were identified which examined the impact of arterial blood gas
analysis on the management of infants or children with bronchiolitis.
In the absence of evidence about the role of arterial blood gas analysis,
the GDG agreed to the following recommendations:
D Blood gas analysis should not be routinely performed in infants or children
with bronchiolitis.
D Blood gas analysis should be performed in infants or children with lifethreatening bronchiolitis.
D Consider blood gas analysis in infants or children with severe bronchiolitis.
2.4 Assessment of severity
2.4.1 Clinical signs and symptoms
Seven studies were found which examined the relationship between
severity of bronchiolitis and clinical indicators.137-143 The studies used a
number of different methods to assess the underlying severity of disease.
These included:
• Oxygen saturation on presentation (measured by pulse oximetry
or arterial blood gas analysis)
• Need for:
o Oxygen supplementation
o Mechanical ventilation
o Hospital admission
o Intensive care unit (ICU) admission
These differing methods of categorising severity, as well as the wide
variety of clinical indicators examined, make it difficult to synthesise the
results.
In all the studies in which they were assessed, low oxygen saturation at
presentation,139,141-3 young age at presentation,137,139,140,142-3
prematurity,139,140,143 cyanosis141-2 and increased work of breathing
(including alone and in various combinations; increased respiratory rate,
accessory muscle use, chest wall retraction, recessions, nasal flare and/or
grunting)137, 139,141-3 were associated with increased disease severity.
In the one study in which they were assessed, crepitations on auscultation
were associated with more severe disease. 142 “Toxic” appearance was also
associated with more severe disease in the one study143 in which it was
assessed as was dehydration.137 Increased heart rate was associated with
more severe disease in one137 of the four139,141-2 studies in which it was
assessed. Fever was associated with increased severity of disease in
one138 of the three139,142 studies in which it was assessed.
The clinical signs and symptoms in the table below are based on the
above described evidence and the consensus opinion of the GDG.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Table 2. Assessment of severity of disease
Mild
Severity of disease
Moderate
Severe
Any one or more of these features:
• Normal respiratory
rate
• Subtle or no accessory
muscle use
• Increased respiratory
rate
• Minor accessory
muscle use
• Markedly increased
respiratory rate
• Moderate/marked
accessory muscle use
• Nasal flare or
grunting
• Normal heart rate
• Increased heart rate
• Markedly increased
heart rate
• Able to feed
• Minor dehydration
• Some limitation of
ability to feed
• Marked dehydration
• Unable to feed
• Crackles
• Toxic appearance
• Sweaty
• Irritable
• SpO2 90-95%
• SpO2 <90%
• SpO2>95%
Life threatening
• Maximal accessory
muscle use/exhaustion
• Poor respiratory effort
• Apnoeas
• Cyanosis
N.B. Infants or children with symptoms across categories should be
treated according to their most severe features. Treatment should not be
based on a child’s oxygen saturation alone.
When assessing severity of disease, it is important to note that infants
who are <3 months old or who were born at <36 weeks gestation, and
infants who have underlying cardiorespiratory disease are at higher risk of
severe bronchiolitis.
9 Infants who are <3 months old or who were born at <36 weeks gestation,
and infants or children who have underlying cardiorespiratory disease are at
higher risk of more severe disease.
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3. Pharmacological Management
3.1 Nebulised adrenaline
A Cochrane systematic review144 was identified which investigated the
effectiveness of nebulised adrenaline in the treatment of bronchiolitis. The
review included nine randomised controlled trials (RCTs), with a total of
more than 500 infants and children, comparing adrenaline to placebo. One
of the RCTs included in the review used subcutaneous adrenaline, which is
no longer used in clinical practice; the results of this study are excluded
from this discussion. The Cochrane review included studies published up to
May 2003 and no more recent RCTs were identified in our searching.
Five of the included RCTs investigated inpatient use of adrenaline. In these
studies there was no difference between the groups in length of stay,
change in clinical score at 30 minutes, change in oxygen saturation at 30 or
60 minutes, heart rate at 30 or 60 minutes, respiratory rate at 30 or 60
minutes or pallor. Patients in the adrenaline group had a slightly greater
reduction in clinical score at 30 minutes (standardised mean difference
(SMD) -0.52; 95%CI -1.00, -0.03). The clinical scores which were used had
scales with between 9 and 17 points.
1+
Three of the included RCTs investigated outpatient or emergency
department use of adrenaline. In these studies there was no difference
between the adrenaline and control groups in admission rates, change in
clinical score at 30 minutes, change in oxygen saturation at 30 minutes or
60 minutes or heart rate at 30 minutes. Small, statistically significant
differences favouring the adrenaline group were found in change in clinical
score at 60 minutes (SMD -0.81; 95% CI -1.56, -0.07), change in oxygen
saturation at 30 minutes (weighted mean difference (WMD) 2.79; 95% CI
1.50, 4.08) and respiratory rate at 30 minutes (WMD -4.54; 95% CI -8.89,
-0.19). Heart rate was higher in the adrenaline group at 60 minutes (WMD
11.8; 95% CI 5.2, 18.4). The relatively small size and transitory nature of
these effects makes their clinical importance difficult to ascertain.
In light of the evidence that adrenaline has no impact on admission rates
or length of stay, and has little impact on clinical condition the GDG
agreed that:
A
Adrenaline should not be routinely used for treatment of bronchiolitis.
3.2 β2agonist bronchodilators
A systematic review145 was identified which investigated the effectiveness of
β2agonist bronchodilators (salbutamol or albuterol) in the treatment of
bronchiolitis. The review included 12 RCTs, with a total of more than 1000
infants and children, comparing β2agonist bronchodilators to placebo or
control. One RCT identified by the review authors and appraised as being of
excellent quality, was not referred to in the results section of the review for
reasons that are not clear. The results of this RCT have been added for this
discussion. The review included studies published up to November 2002 and
no more recent RCTs were identified in our searching.
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No differences were found in rate of admission or LOS between the
treatment and control groups in any of the seven studies reporting these
outcomes.
Nine of the included studies found no differences between the treatment
and control groups on any measured outcomes, including LOS, change in
clinical score, oxygen saturation, respiratory rate and heart rate.
Two studies reported short-term improvements in clinical score; at 30
minutes and 60 minutes after treatment in one study and 30 minutes but
not 60 minutes after treatment in the second study.
Several included studies reported possible harms associated with
bronchodilator use. One study reported significantly lower mean decreases
in respiratory rate in the control group than in the treatment group. Two
studies reported worse oxygenation in the treatment group compared to the
control group. Non-statistically significant increases in heart rate and/or
decreases in oxygenation were reported in a further five studies.
The authors conclude that the evidence does not support the routine use of
β2agonist bronchodilators for treating patients with bronchiolitis.
In light of the evidence that β2agonist bronchodilators have no impact on
admission rates or length of stay, have little impact on clinical condition
and may potentially cause harm, the GDG agreed that:
A
β2agonist bronchodilators should not be routinely used for treatment of
bronchiolitis.
As discussed in section 2.2.1.1, bronchiolitis and asthma can be difficult to
distinguish, particularly in older infants and young children. There is no
evidence to determine at what particular age it is appropriate to consider
asthma as an alternative diagnosis. Thresholds of between 8 and 12
months have been suggested. In light of this, the consensus
recommendation of the GDG was to:
D Consider a trial of a single dose of β2agonist bronchodilators in patients older
than 9 months, particularly those with recurrent wheezing.
As recommended in section 2.2.1.1, infants and children who respond to a
trial with β2agonist bronchodilators should be managed according to
asthma guidelines. Further to this the GDG agreed to recommend that:
D β2agonist bronchodilators should not be continued if an infant or child does
not respond to an initial trial.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
3.3 Ipratropium bromide
A systematic review145 was identified which investigated the effectiveness of
ipratropium bromide in the treatment of bronchiolitis. The review included
three RCTs, with a total of more than 200 infants and children, comparing
ipratropium bromide to placebo published up to November 2002. No more
recent RCTs were identified in our searching.
1+
No differences were found in LOS or clinical outcomes between the
treatment and control groups in any of the studies.
The authors conclude that there is little evidence to support a routine role
for ipratropium bromide in treating patients with bronchiolitis.
In line with the evidence that ipratropium bromide has no effect on length
of stay or clinical outcomes the GDG agreed that:
A
Ipratropium bromide should not be routinely used for treatment of
bronchiolitis.
3.4 Antibiotics
The AHRQ Health Technology Assessment118 did not locate any primary
studies of the effect of antibiotics for treatment of bronchiolitis, however
they did identify one small RCT evaluating the effectiveness of antibiotics
compared to control for lower respiratory infection in which a subset of
enrolled patients had bronchiolitis.49
The study included 61 children with an average age at enrolment of
approximately one and a half years who were RSV positive.49 The active
treatment group received oral ampicillin if under 2 years of age and oral
penicillin if over 2 years of age. Penicillin-allergic children were treated with
erythromycin. The control group did not receive antibiotic therapy on a
routine basis, although seven of 27 children ultimately did receive
antibiotics for other reasons such as persistent fever. Primary outcomes
included duration of hospitalisation and whether the child was considered
“pulmonarily healthy” on day 3, at discharge, and at 3 weeks after
treatment. The study groups did not differ significantly on any of these
outcomes.
The AHRQ report authors conclude that “No evidence suggests that
antibacterial antibiotic therapy is an effective treatment for bronchiolitis.
Bronchiolitis in infants and children is caused by viruses, primarily RSV.
Therefore, no a priori reason exists to assume that antimicrobial agents
effective against bacteria would be appropriate treatment for a viral illness.
Antibiotic treatment should be reserved for children who develop
complications related to subsequent bacterial infection.”
Non-pharmacological Management
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
In light of the evidence that antibiotics do not effect length of stay or
clinical outcomes in bronchiolitis the GDG agreed that:
A
Antibiotics should not be routinely used for treatment of bronchiolitis.
The GDG noted that a small number of infants and children with
bronchiolitis will also have a secondary bacterial infection, which would be
suitable for antibiotic treatment.
D Consider antibiotics in infants and children with bronchiolitis who have
clinical signs or symptoms of a secondary bacterial infection.
3.5 Corticosteroids
Our search for evidence on the effectiveness of corticosteroids in
bronchiolitis identified two systematic reviews146-7 and two randomised
controlled trials148-9 published since the systematic reviews were
conducted. Another RCT assessing the effectiveness of corticosteroids in
reducing development of asthma after bronchiolitis was identified,150
however the study was published only as an abstract. We attempted to
contact the authors however no reply was received.
The first systematic review146 was a Cochrane review which aimed to
determine whether the use of systemic corticosteroids improved the shortterm clinical profile of infants and young children with bronchiolitis, as
compared to infants and young children who received no corticosteroid
therapy or placebo. The review excluded studies in patients with recurrent
wheezing and studies where infants and young children were intubated and
ventilated in the intensive care setting.
The review included a total of 1,198 infants and young children aged 0 to
30 months in 13 independent randomised controlled trials, using a variety
of corticosteroids of differing doses and durations. Length of hospital stay
was the primary outcome in ten studies. Mean LOS varied between studies
from two days to 8.3 days. The meta-analysis showed a non-significant
effect of treatment on LOS, with a decrease in LOS in infants and young
children treated with corticosteroids of 0.38 days (95% CI -0.81 to 0.05).
In the three studies which included only RSV positive infants and young
children where LOS was reported, the meta-analysis gave a WMD of -0.67
(95% CI -1.11 to -0.24) indicating a shorter LOS for treated infants and
young children in this group compared to placebo.
Meta-analysis of eight trials measuring the day 3 clinical score showed no
statistically significant difference between treatment and control groups.
Similarly, no statistically significant differences in respiratory rates or
oxygen saturation were found between groups in any of the studies.
Three trials reported hospital admission rates. In two of these trials
admission rates were non-significantly, but substantially higher in the
treatment group, and in the third trial the admission rate was significantly
Non-pharmacological Management
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
higher in the placebo group. Meta-analysis found no difference between
groups.
The authors concluded that widespread use was not recommended.
Two RCTs published after the systematic review search date also
addressed the use of corticosteroids in this population.
The first RCT148 was a well conducted study in 52 infants aged younger than
12 months admitted on an inpatient ward with bronchiolitis. Infants were
randomised to receive 1mg/kg oral prednisolone for 5 days or usual care
without steroids. Infants were assessed during their hospital stay and then
again at 1, 3, 6 and 12 months post discharge. The study found no
differences in LOS, time to clinical resolution or duration of oxygen therapy
between groups. Likewise there were no differences between treatment and
control groups in rates of wheezing at 1, 3, 6 or 12 months post discharge.
A second, less well conducted RCT149 aimed to assess the benefit of adding
a single dose of 0.6mg/kg dexamethasone or placebo to adrenaline or
salbutamol in a four-arm trial in the Emergency Department. Outcomes
included heart rate, respiratory rate and clinical score at 120 minutes, 24
hours and 5 days. Unfortunately 42% of the adrenaline plus placebo group
and 43% of the salbutamol plus placebo group were lost to follow-up
making interpretation of the results of the trial difficult.
1+
1-
No patients in any of the groups were admitted and no differences were
found between the groups in retreatment rates. Fifth day Respiratory
Distress Assessment Instrument (RDAI) scores were lower in
dexamethasone groups than placebo groups, however the clinical
importance of this is unclear as there were no differences in any other
reported outcomes and the difference between groups was less than one
point on the 14 point scale.
The second systematic review147 investigated the use of oral or intravenous
corticosteroids in mechanically ventilated infants with bronchiolitis. The
review included 3 RCTs of corticosteroids in a total of 137 patients. None of
the three studies reported a significant reduction in duration of mechanical
ventilation with treatment, and the meta-analysis did not find a significant
difference between treatment and control groups. Two studies reported
duration of hospitalisation. Neither the studies individually, nor the metaanalysis found a significant difference between treatment and control
groups.
In light of the evidence that corticosteroids have no effect on clinical
outcomes in bronchiolitis, and have minimal, if any, impact on length of
stay, the GDG agreed that:
A
Corticosteroids should not be routinely used for treatment of bronchiolitis.
Non-pharmacological Management
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3.6 Ribavirin
Ribavirin is an anti-viral medication that is administered as a continuous
aerosol for a number of hours per day.
A systematic review145 was identified which investigated the effectiveness of
ribavirin in infants and young children with RSV bronchiolitis. The review
included 10 RCTs, with a total of 320 patients, and the authors note that
the quality of the included trials was generally low.
Five studies reported on outcomes such as days of hospitalisation, length of
time that a child required more intensive supportive interventions, and
duration of illness. Four of these studies found no significant differences
with ribavirin treatment compared with saline placebo. The study that did
find differences favouring ribavirin in duration of mechanical ventilation and
hospitalisation used sterile water in the placebo arm. Sterile water can
induce bronchospasm, making the ribavirin treatment seem more effective.
Six of 10 studies reported items such as clinical symptoms and clinical
scores. Three of the six studies did not find significant differences between
the groups. Differences favouring ribavirin were found for hours to
improvement in cough and crepitations but not for wheezing or improved
feeding in one study. Illness severity scores were better in the ribavirin
group compared with the water placebo group on days 1 and 4 but not on
days 2 and 3 of treatment in another study. Similarly, another study found
better clinical scores in the ribavirin group compared with the saline placebo
group on day 3 but not on days 1 and 2 of treatment.
The authors concluded that they “did not find evidence that ribavirin use led
to consistent or more than transient improvements in clinical outcomes.”
Clinical use of ribavirin is likely to also be constrained by its very high cost
and the potential risk to health care personnel, as ribavirin is known to be
teratogenic and embyrolethal.
In the absence of conclusive evidence for effectiveness of ribavirin in
bronchiolitis and in light of its high cost and serious potential health risks,
the GDG agreed that:
A
Ribavirin should not be routinely used for treatment of bronchiolitis.
Non-pharmacological Management
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3.7 Immunoglobulin
The AHRQ Health Technology Assessment118 identified two studies
examining the use of respiratory syncytial virus immunoglobulin (RSVIG)
administered intravenously for treatment of RSV bronchiolitis and we did
not identify any more recent studies.
The first trial included 101 previously healthy infants under 2 years of age
who were hospitalised with moderate to severe RSV positive bronchiolitis
and/or pneumonia and followed them for 1 year after the intervention.25
The intervention group received a single dose of 1500 mg/kg IV RSVIG and
the control group received 0.5 percent albumin placebo.
Mean days of hospitalisation and mean days of mechanical ventilation were
not statistically different between the treatment and placebo groups. There
was a trend towards a decrease in the mean number of days of ICU
admission (3.92 vs. 6.60, P = 0.06). There were no adverse events related
to RSVIG therapy. The study did not include enough patients to detect a
difference in duration of hospitalisation of less than 35 percent.
1+
The second trial included 107 high-risk infants under 2 years of age with
RSV positive bronchiolitis who had severe BPD, other serious chronic lung
disease, congenital heart disease or who had been premature at under 32
weeks gestation with a current age of less than 6 months.41 Infants were
randomised to 1500 mg/kg IV RSVIG or albumin placebo and were followed
into the next RSV season to assess possible harms, including whether there
was any increased risk of more severe RSV disease in children who
developed the disease in the second season.
No significant difference was noted between the groups in the primary
outcome of duration of hospitalisation. No significant differences were
reported for secondary outcomes such as duration of ICU admission,
duration of mechanical ventilation, need for supplemental oxygen, change
in respiratory scores, use of additional medications (bronchodilators,
ribavirin, or steroids), development of RSV bronchiolitis in the subsequent
season, or readmission during the subsequent season. Some baseline
differences between the study groups could have contributed to the
negative findings of this study. The RSVIG group had higher entry
respiratory scores and more severe disease episodes than the placebo
group. Forty-seven percent and 28 percent, respectively required ICU
admission, and 31 percent and 18 percent needed mechanical ventilation.
1+
In the absence of evidence for effectiveness of immunoglobulin for the
treatment of bronchiolitis, the GDG agreed that:
A
Immunoglobulin should not be routinely used for treatment of bronchiolitis.
Non-pharmacological Management
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3.8 Analgesics and antipyretics
No studies were identified which examined the effectiveness of analgesics
or antipyretics in infants or children with bronchiolitis.
One RCT152 was found which compared paracetamol with ibuprofen in
27,065 febrile infants and children aged less than two years, including more
than 1,600 with lower respiratory tract infections. In the participants with
bronchiolitis or asthma, there was no difference in hospitalisation rate
between paracetamol and ibuprofen groups.
1+
Analysis of the entire 27,065 cohort found that there were no infants or
children hospitalised for acute renal failure, anaphylaxis or Reye’s
syndrome. Three children (all in the ibuprofen group) were hospitalised with
evidence of gastrointestinal bleeding. The bleeds were not severe and
resolved with conservative management.
The GDG noted that some clinicians are concerned that analgesics and
antipyretics may potentially mask clinically important symptoms, or that
reducing fever may not be appropriate as it may be a physiologically
important response to infection. Equally, other clinicians believe that
reducing fever can lead to increased appetite, decreased irritability and,
therefore, potentially better outcomes.
The GDG noted that analgesics and antipyretics are not treatments for
bronchiolitis as such, but may be useful adjuncts to treatment, by
decreasing fever and irritability. In the absence of evidence the GDG
agreed that paracetamol or ibuprofen may be useful in infants or children
with bronchiolitis, but that clinicians must carefully consider and exclude
other potential causes of fever, irritability and pain before giving these
medications.
D Infants and children with bronchiolitis and fever may be treated with
paracetamol or ibuprofen to bring their temperature down and reduce
irritability.
Carefully consider and exclude other potential causes of fever, irritability and
pain.
3.9 Oral antitussives, expectorants or decongestants
No studies were identified which examined the safety or effectiveness of
oral antitussives, expectorants or decongestants in infants or children with
bronchiolitis.
In the absence of evidence the GDG agreed that:
D Oral antitussives, expectorants or decongestants should not be routinely
used for treatment of bronchiolitis.
Non-pharmacological Management
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
4 Non-pharmacological Management
4.1 Oxygen
There is little research investigating the effectiveness of oxygen in infants
and children with bronchiolitis, however the rationale for its use is clear.
4.1.1 When to commence oxygen
There is no evidence to determine what oxygen saturation should be used
as a threshold to begin giving oxygen. Thresholds between 90 and 95%
have been suggested. Neither is there any evidence to determine whether
oxygen should be provided to infants or children who have increased work
of breathing but acceptable oxygen saturations.
In the absence of evidence the GDG made the following
recommendations:
D Give oxygen to any infant or child with life-threatening bronchiolitis or
oxygen saturations less than 90%.
D Consider giving oxygen to an infant or child with moderate or severe
bronchiolitis, particularly if aged less than 3 months.
The GDG noted that some infants and children with mild or moderate
bronchiolitis will have increased work of breathing and/or difficulty
maintaining oxygenation during feeds.
In the absence of evidence the GDG made the following recommendation:
D Consider giving oxygen while feeding to an infant or child with mild or
moderate bronchiolitis who has increased work of breathing and/or difficulty
maintaining oxygenation during feeds.
4.1.2 Method of delivery of oxygen
There is no evidence to determine what method should be used to deliver
oxygen to infants and children with bronchiolitis. Methods including nasal
prongs, face masks, head boxes and oxygen tents have been used. Each
of these methods has strengths and limitations. Head boxes and oxygen
tents substantially restrict movement and limit contact between the infant
or child and clinicians or family members, potentially causing unnecessary
distress to the infant or child. Nasal prongs and face masks remove this
difficulty but may be removed by the infant/child, and may also become
entangled if the infant/child is not closely monitored.
In the absence of evidence the GDG made the following recommendation:
D In infants and children with bronchiolitis receiving oxygen therapy, provide
oxygen using the method that causes least distress to the infant or child. If
nasal prongs or face masks are used, ensure that infant or child is closely
monitored to avoid entanglement.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
4.1.3 Saturation level to be maintained on oxygen
There is no evidence to determine what optimal oxygen saturation or
other clinical indicators should be maintained by oxygen therapy. Oxygen
saturations ranging from 90% to 95% have been suggested.
In the absence of evidence the GDG made the following consensus
recommendation:
D In infants and children with bronchiolitis receiving oxygen therapy, maintain
oxygen saturation levels between 92% and 95%.
There is no evidence to determine when infants or children with
bronchiolitis should be weaned off oxygen therapy.
In the absence of evidence the GDG made the following recommendation:
D In infants and children with bronchiolitis receiving oxygen therapy,
administer oxygen at the lowest flow rate required to maintain oxygen
saturations between 92 and 95%.
4.1.4 Observations while on oxygen therapy
There is no evidence to determine what clinical observations should be
undertaken when an infant or child with bronchiolitis is receiving or being
weaned off oxygen.
In the absence of evidence the GDG made the following consensus
recommendations:
D In infants and children with bronchiolitis receiving oxygen, assess oxygen
saturation, respiratory rate, heart rate and accessory muscle use hourly.
D In infants and children with bronchiolitis receiving oxygen therapy at a rate
>0.5l/min continuously monitor oxygen saturation.
D In infants and children with bronchiolitis in whom oxygen is being ceased,
assess oxygen saturation, respiratory rate, heart rate and accessory muscle
use initially hourly and then less frequently as observations are stable or
improving.
4.1.5 Orders for commencing, weaning and ceasing oxygen
There is no evidence to determine who should be responsible for deciding
when to commence, wean and cease oxygen.
In the absence of evidence the GDG made the following consensus
recommendation:
D In infants and children with bronchiolitis decisions management of oxygen
therapy can be made by nursing staff, in line with this guideline, and
medical staff should be informed. Nurses should consult with medical staff if
the infant or child deteriorates.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
4.2 Feeding and Hydration
Infants and children with bronchiolitis are prone to become dehydrated as
a result of the combined effects of poor oral intake and increased water
losses due to increased respiratory rate and work of breathing.
There is little evidence available to guide decisions about feeding and
hydration in infants and children with bronchiolitis.
4.2.1 Oral feeding
There is no evidence to determine whether infants or children with
bronchiolitis should continue oral feeding while acutely unwell. Oral
feeding is important in infants and children with bronchiolitis as it helps to
avoid dehydration, however it may also increase respiratory distress,
particularly in infants and children with severe or life-threatening
bronchiolitis.
In the absence of evidence the GDG made the following consensus
recommendations:
D Infants or children with mild or moderate bronchiolitis may continue oral
feeding unless it increases their respiratory distress.
D Infants or children with severe or life-threatening bronchiolitis should not be
offered oral feeds.
4.2.2 When to commence hydration
There is no evidence to establish the most appropriate way of assessing
severity of dehydration in infants and children with bronchiolitis. Signs of
dehydration may be confounded by respiratory distress in these infants
and children. There is also no evidence to suggest how infants and
children with bronchiolitis who are severely dehydrated should be
managed.
In the absence of evidence the GDG made the following consensus
recommendation:
D In infants and children with bronchiolitis who have signs of circulatory
compromise, including hypotension, capillary refill time greater than 4
seconds, or skin pinch retraction time greater than 2 seconds, consult senior
paediatric or emergency medical staff to determine fluid management.
There is no evidence to determine when infants and children with
bronchiolitis should receive nasogastric or intravenous hydration. Infants
and children with mild bronchiolitis who are feeding well are unlikely to
require intravenous or nasogastric fluids. With increasing respiratory
distress, and inability to feed, infants and children with bronchiolitis may
need intravenous or nasogastric fluids.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
In the absence of evidence the GDG made the following consensus
recommendations:
D Consider nasogastric or intravenous fluids for infants and children with
moderate or severe bronchiolitis.
D Give intravenous fluids to any infant or child with life-threatening
bronchiolitis.
Note: Refer to next section for discussion of why infants and children with
life-threatening bronchiolitis should not receive nasogastric fluids.
4.2.3 Methods of hydration
There is no evidence to determine whether nasogastric or intravenous
fluids are more appropriate for infants and children with bronchiolitis.
Historically most authors have suggested intravenous fluids, however
more recently authors have suggested using the nasogastric route. There
is a concern that the nasogastric tube may increase obstruction of the
airway, increasing respiratory distress, particularly in small infants, and
also that it may increase the risk of aspiration. However these risks have
not been assessed in controlled studies.
In the absence of evidence the GDG made the following consensus
recommendations:
D In infants and children with moderate bronchiolitis requiring fluid therapy,
provide fluids via nasogastric tube unless work of breathing is increased.
D In infants and children with life-threatening bronchiolitis, or with moderate
or severe bronchiolitis and increased work of breathing, requiring fluid
therapy, provide intravenous fluids.
There is no evidence to determine which fluid should be used for fluid
therapy in infants and children with bronchiolitis.
In the absence of evidence the GDG made the following consensus
recommendation:
D In infants and children with bronchiolitis receiving nasogastric fluids, give
milk (breast milk, formula, cow’s milk, etc as per usual diet).
For infants and children with bronchiolitis receiving intravenous fluids,
there is considerable debate in the medical literature about the most
appropriate fluid choice. Anti-diuretic hormone secretion is increased in
lower respiratory tract infection, and it has been suggested that giving
increased (or even normal maintenance) fluids might lead to
hyponatraemia. Various approaches have been suggested, including
reducing the volume or osmolarity of fluids provided, however none of
these have been tested in controlled trials.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
In the absence of evidence the GDG decided to recommend practice in
line with existing consensus guidelines and local practice.
D In infants and children with bronchiolitis receiving intravenous fluids, use a
continuous infusion of Glucose 5% and Sodium Chloride 0.9%.
A range of rates of fluid therapy have been suggested ranging from 50%
to 100% of normal maintenance rates.
In the absence of evidence the GDG decided to recommend practice in
line with existing consensus guidelines and local practice.
D In infants and children with bronchiolitis and no signs of significant
dehydration receiving nasogastric or intravenous fluids, provide fluids at
75% of normal maintenance rate.
D Infants and children with bronchiolitis and signs of significant dehydration
may require fluids at a higher rate. Discuss management with a senior
clinician.
There is no evidence to determine what plasma biochemistry monitoring is
required for infants and children with bronchiolitis who are having fluid
therapy.
In the absence of evidence the GDG made the following consensus
recommendation:
D Infants and children with bronchiolitis should have blood taken for glucose,
urea, electrolytes and bicarbonate if intravenous fluids are being provided.
Most infants and children with bronchiolitis will have mildly abnormal
plasma biochemistry (often hyponatraemia resulting from increased antidiuretic hormone secretion as discussed above) which will not require any
further intervention. There is no evidence to determine how often plasma
biochemistry should be reassessed, or what action should be taken if
abnormal levels are identified.
In the absence of evidence the GDG made the following consensus
recommendations:
D Infants and children with bronchiolitis with significantly abnormal
electrolytes should be managed in consultation with a senior clinician.
D Infants and children with bronchiolitis with significantly abnormal
electrolytes and those receiving intravenous fluid therapy for more than 24
hours, should have their plasma biochemistry reassessed at least daily
according to results and the clinical situation.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
4.3 Chest Physiotherapy
One Cochrane systematic review153 was identified which included studies
published before June 2004, and no further RCTs were identified in our
searching.
The review included 3 RCTs, with a total of 156 participants with acute
bronchiolitis aged between 0 and 24 months. Participants were randomised
to chest physiotherapy (percussion or vibration techniques were used in all
studies) or standard care. The authors note that the quality of the RCTs was
generally good, but they were not placebo controlled, and included small
numbers of participants.
Meta-analysis was not possible due to differences in outcome measures,
however no significant differences were found between treatment and
control groups for any outcome measures, including change in severity of
illness, duration of oxygen supplementation or length of hospital stay. The
authors concluded that “vibration and percussion techniques have not been
shown to reduce length of hospital stay in acute bronchiolitis or to improve
a severity clinical score”.
1+
In light of the absence of evidence for effectiveness of chest
physiotherapy on clinical outcomes the GDG made the following consensus
recommendation:
A Chest physiotherapy should not be routinely used for treatment of
bronchiolitis.
4.4 Mist, Steam or Nebulised Saline
No studies were identified which investigated the effectiveness of mist,
steam or nebulised saline in the treatment of infants and children with
bronchiolitis.
In the absence of evidence for effectiveness the GDG agreed that:
D Mist, steam and nebulised saline should not be routinely used for treatment
of bronchiolitis.
4.5 Saline drops
It has been suggested that saline nasal drops might ease congestion in
infants and children with bronchiolitis – however there is no evidence to
determine whether they are effective.
In the absence of evidence the GDG agreed that:
D Saline nasal drops should be trialled in infants and children with bronchiolitis
who have nasal congestion, particularly before feeds.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
4.6 Suctioning
It has been suggested that nasal suctioning might help ease congestion in
infants and children with bronchiolitis – however there is no evidence to
determine whether it is effective.
In the absence of evidence the GDG made the following consensus
recommendation:
D Nasal suctioning may be trialled in infants or children with bronchiolitis who
have nasal congestion.
4.7 Apnoea management
There is very little evidence to guide the management of infants and
children with apnoea secondary to bronchiolitis.
Four case-control studies were identified which reported incidence of
apnoea associated with respiratory syncytial virus infection (a combination
of infants with either bronchiolitis or pneumonia were included in all
studies) varying between 16 and 21 percent.154-157 Young age (less than 3
months) was the only factor consistently related with apnoea in infants and
children with RSV in the four studies identified. Three studies reported that
prematurity also increased the risk of apnoea.155-157 One study found that
infants and children with bronchiolitis and recurrent apnoea were at greater
risk for mechanical ventilation.154
2-
In light of the minimal evidence available the GDG made the following
consensus recommendation:
D Infants and children with bronchiolitis who are at increased risk of apnoea as
a result of age less than 3 months, premature birth or previous apnoea
should be closely monitored.
A small number of case series were identified which investigated the role
of methylxanthines (caffeine, aminophylline, theophylline) in the
treatment of infants and children with bronchiolitis related apnoea.158-161
These studies do not provide evidence to guide treatment, but suggest
that randomised controlled trials are warranted to further evaluate the
effectiveness of these agents.
In the absence of evidence the GDG made the following consensus
recommendation:
D Infants and children with bronchiolitis-related apnoea should be managed in
consultation with senior paediatric or emergency medical staff.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
4.8 Positioning
A Cochrane systematic review162 was identified that investigated the impact
of positioning (prone, supine, lateral and head elevated) on measures of
respiratory distress in infants and children.
The review included one RCT of prone versus supine positioning in 17
infants with bronchiolitis. This RCT did not find a significant difference
between prone and supine positions. It is likely that this study did not have
a large enough sample size to detect a clinically important difference
between groups.
In the meta-analysis of all included trials, prone positioning was
significantly more beneficial than supine positioning in terms of oxygen
saturation, partial pressure of arterial oxygen, oxygenation index, thoracoabdominal synchrony, and episodes of desaturation. There were no
statistically significant differences between any other positions. The review
included three very small studies (n=12, 17 and 17) which investigated the
impact of elevation. None of these studies found a significant difference
between elevated and flat positioning (supine, prone or lateral). The three
studies reported different outcomes and their results could not be
combined.
It is important to note that the meta-analysis included studies in:
o 322 preterm neonates (228 of which were mechanically ventilated),
o 49 newborn infants (3 mechanically ventilated) and
o 65 infants and children aged 1 month – 16 years (20 mechanically
ventilated).
The results of the meta-analysis are therefore unlikely to be generalisable
to infants and children with bronchiolitis.
It is also important to note that prone positioning increases the risk of
Sudden Infant Death Syndrome, and for this reason, infants and children
with bronchiolitis who are placed in a prone position should have
continuous pulse oximetry monitoring.
In the absence of clear evidence the GDG agreed that:
C
Infants and children with bronchiolitis should be allowed to adopt the
position they find most comfortable. Infants unable to position themselves
may be placed in either a prone or supine position, with head slightly
elevated.
Infants and children with bronchiolitis who are placed in a prone position
should have continuous pulse oximetry monitoring, and the reasons for the
position should be explained to the parent.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
4.9 Level of care required
Note: for details on levels of severity referred to in these sections see
Table 2 on Page 17
There is no evidence to determine when infants and children with
bronchiolitis should be referred to particular levels of medical care. In the
absence of evidence the GDG agreed to the following recommendations:
4.9.1 General Practitioner
Most infants and children with signs of mild and some with moderate
bronchiolitis can be adequately managed by a general practitioner.
D Infants and children with mild bronchiolitis may be managed by a general
practitioner and sent home for observation if the GP is confident the
parent/carer can adequately manage the infant/child’s illness.
D Infants and children with moderate bronchiolitis who do not require oxygen
or fluid therapy may be managed by a general practitioner, otherwise the
infant or child should be sent to hospital.
4.9.2 Ambulance
There is no evidence to determine when infants and children with
bronchiolitis should be taken to hospital by ambulance. The main reason
to call an ambulance to take an infant or child to hospital, rather than to
take the child by car is concern that the degree of airway obstruction may
suddenly increase and the child’s condition may rapidly deteriorate.
In the absence of evidence, and in consultation with the Victorian
Metropolitan Ambulance Service, the GDG agreed to the following
consensus recommendations:
D An ambulance should be called for infants and children with severe or life
threatening bronchiolitis.
The person calling an ambulance should be prepared to answer a series of
questions designed to enable the Metropolitan Ambulance Service to
establish the level of urgency and send appropriate vehicles and staff.
Questions may include:
•
•
•
•
•
•
What is the exact location of the emergency?
What is your call back phone number?
What is the problem? (What exactly happened?)
How old is the child?
Is the child conscious?
Is the child breathing?
Further questions may be necessary.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
4.9.3 Emergency Department
D If a general practitioner is not available, infants and children with moderate
bronchiolitis should be taken to a hospital emergency department.
D All infants or children with severe or life-threatening bronchiolitis should be
sent by ambulance to an emergency department.
Most infants and children with bronchiolitis will have mild or moderate
bronchiolitis and will be observed in the emergency department and then
sent home. A small number of infants or children with bronchiolitis may
require a short hospital admission.
4.9.4 Intensive Care Unit
Infants or children with life-threatening bronchiolitis, should be managed
in conjunction with staff from the Intensive Care Unit. The Intensive Care
Unit should also be consulted in the management of infants and children
with severe bronchiolitis who require ongoing oxygen therapy at levels
above 40%.
D All infants or children with life-threatening bronchiolitis or severe
bronchiolitis requiring ongoing oxygen therapy at levels above 40%, should
be managed in conjunction with staff from the Intensive Care Unit.
4.9.5 Discharge Criteria
There is no evidence on which to make a recommendation as to the
appropriate discharge criteria for infants or children who present to
hospital with bronchiolitis.
In the absence of evidence the GDG made the following consensus
recommendations:
D Infants and children with bronchiolitis can be discharged from the Intensive
Care Unit to the paediatric ward when they have no signs of life-threatening
bronchiolitis.
D Infants and children with bronchiolitis can be discharged from hospital when
they have no signs of moderate bronchiolitis requiring oxygen or fluid
therapy; severe or life-threatening bronchiolitis.
4.9.6 Follow-up
There is no evidence on which to make a recommendation as to the
appropriate follow-up or referral procedures for infants or children with
bronchiolitis.
The GDG agreed that it was essential that the child’s GP be notified
promptly of the child’s presentation to hospital. They also noted the
importance of patient confidentiality and emphasised that every care
should be taken to ensure that communication with the GP is as secure as
possible.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
On discharge from hospital the family should be given information on
when to seek further medical attention and alerted to the importance of
communication between the hospital and GP.
D A letter should be sent by fax, mail or email to the GP (and any relevant
specialists) of any infant or child presenting with bronchiolitis to hospital.
D On discharge the family should be given information on when to seek further
medical attention, and a copy of the discharge summary.
The GDG agreed that infants and children with bronchiolitis should usually
be seen by a doctor (preferably their GP) to review their progress, 2 days
after discharge from hospital or 2 days after their initial presentation, if
not admitted to hospital.
Infants and children who are at higher risk of severe bronchiolitis, such as
those who are <3 months old, were born at <36 weeks gestation, or who
have underlying cardiorespiratory disease, may require more rapid review.
D Infants and children with bronchiolitis should be reviewed by their GP 2 days
after initial GP or ED presentation or discharge from hospital, or at any time
if their clinical condition deteriorates.
4.10 Observations
There is little evidence on which to base recommendations for ongoing
observations for assessment of severity of disease in infants and children
with bronchiolitis.
4.10.1 Clinical signs
The GDG agreed that the most important observations for infants and
children with bronchiolitis are:
• Accessory muscle use, nasal flare, grunting, tracheal tug or chest
wall retraction
• Respiratory rate
• Oxygen saturation
• Heart rate
(see table 2 on page 17)
4.10.2 Frequency of observations
There is no evidence on which to make a recommendation about the
frequency of observations in infants and children with bronchiolitis. In the
absence of evidence the GDG agreed to the following recommendations:
4.10.3 Mild to moderate bronchiolitis
In infants and children with mild-moderate bronchiolitis, nursing
observations using the clinical signs outlined in section 3.4.1 should be
undertaken regularly while the infant or child is in hospital.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
D For infants and children with mild bronchiolitis, assess the following clinical
signs at least once every four hours, taking care not to distress the infant or
child:
• Accessory muscle use, tracheal tug or chest wall retraction
• Respiratory rate
• Oxygen saturation
• Heart rate.
D For infants and children with moderate bronchiolitis, assess the following
clinical signs at least once every two hours, taking care not to distress the
infant or child:
• Accessory muscle use, tracheal tug or chest wall retraction
• Respiratory rate
• Oxygen saturation
• Heart rate.
4.10.4 Severe or life-threatening bronchiolitis
In infants and children with severe or life-threatening bronchiolitis close
medical assessment is necessary and nursing observations should be
more frequent.
D Infants and children with life-threatening or severe bronchiolitis are likely to
require continuous monitoring and constant supervision.
Assess the following clinical signs at least once every 30 minutes and more
frequently if the infant or child’s condition is deteriorating:
• Accessory muscle use, tracheal tug or chest wall retraction
• Respiratory rate
• Oxygen saturation
• Heart rate.
4.11 Hospital Infection Control
Most of the little evidence which is available about infection control in
infants and children with bronchiolitis refers to RSV positive infants and
children only.
In RSV positive infants and children the Southern Health Infection Control
and Epidemiology Manual recommends that Standard Precautions, along
with Droplet and Contact Precautions be employed. The most recent
edition of this publication is available on the Southern Health Intranet.
As a result of the fact that RSV testing is not recommended for most
infants and children with bronchiolitis, usually it will not be clear whether
infants and children with bronchiolitis at Southern Health hospitals are
infected with RSV or another organism. Regardless of the organism
causing bronchiolitis, it is sensible to take precautions to ensure it is not
spread.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
In the absence of evidence, in light of the existing Southern Health
Infection Control Guidelines and in discussion with the Southern Health
Infection Control & Epidemiology Unit, the GDG agreed that:
D Infants and children with bronchiolitis at Southern Health, regardless of RSV
status, should be managed according to the Southern Health Infection
Control Guidelines following Standard, Droplet and Contact Precautions.
The Southern Health Infection Control Guidelines for RSV infection
suggest that where possible RSV positive infants and children should be
accommodated in single rooms, and that where this is not possible infants
and children can be managed in shared rooms with other infants and
children infected with the same micro-organism.
As discussed above, the infecting micro-organism will not be identified for
most infants and children with bronchiolitis. The GDG and Southern Health
Infection Control & Epidemiology Unit noted that most infants and children
with bronchiolitis will be accommodated in cots which restrict the
movement of the infant or child and thus, to some extent, the
transmission of the infecting organism. Keeping infants and children with
bronchiolitis separated by at least two metres (a radius of one meter
around each infant or child) will further reduce the possibility of
transmission of micro-organisms by contact or droplets.
In the absence of evidence, in line with the existing Southern Health
Infection Control Guidelines and in discussion with the Southern Health
Infection Control & Epidemiology Unit, the GDG agreed that:
D Infants and children with bronchiolitis can be accommodated in shared
rooms where single rooms are not available.
D Where infants and children with bronchiolitis are accommodated in shared
rooms, infants and children and any associated equipment or toys should be
separated by at least two metres (a radius of one meter around each infant
or child).
9 Take special care in infants and children with bronchiolitis who have
underlying chronic illnesses which might make them more vulnerable to
infection.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
5. Patient Education and Self-Management
Patient Education and Self-Management
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Patient Education and Self-Management
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
6. Outcome and Audit
There are many different frameworks for developing outcome and audit
measures. For the purpose of evaluating the implementation of this
guideline we defined two types of measures; process and outcome.
Process measures assess the success of the implementation process and
the degree of implementation achieved. Outcome measures assess
whether the implementation has improved clinical practice and patient
outcomes.
6.1 Process measures
6.1.1 Implementation process
• Proportion of target groups that received the interventions
outlined in the implementation and dissemination plan. This
information will be collected by attendance sheets and other
similar documentation.
6.1.2 Degree of implementation
• Proportion of eligible patients on clinical paths and proportion of
clinical paths completed correctly. This information will be
collected by audit of patient records
6.2 Outcome measures
6.2.1 Clinical practice
A survey was sent to members of the GDG and clinicians involved in
paediatric services at Southern Health which asked them to reviewed the
recommendations for clinical management of infants and children with
bronchiolitis from this guideline and to identify which of the
recommendations would require a change from existing clinical practice.
Outcome measures were then chosen to enable assessment of whether
clinical practice had changed to reflect the recommendations of the
guideline in appropriate clinical areas.
These measures are not an exhaustive list but represent those areas of
clinical practice change agreed by the GDG to be most relevant and
important.
•
Proportion of infants and children with bronchiolitis
o receiving oxygen therapy in whom oxygen saturations are
maintained between 92 and 95%
o who receive virological testing
o receiving the recommended fluids
o receiving fluids by oral, nasogastric, intravenous routes.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
6.2.2 Patient outcomes
To develop a set of outcome measures we reviewed the original aims of
the guideline development. These aims included reducing emergency
department presentations, reducing hospital admissions, reducing length
of stay in hospital and reducing the representation rate
In light of this, the GDG agreed that the following measures should be
assessed for infants and children with bronchiolitis, prior to and post
implementation of the guideline through a clinical path:
• Number of presentations to ED, number of admissions and number of
representations to ED within seven days
• Proportion of presentations to ED admitted and proportion of
presentations to ED representing within seven days
• Length of stay
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
7. Dissemination and Implementation of the
Guideline
Inform
Educate
Motivate
Raise awareness of the
guideline and clinical path
through multiple strategies
that will inform a wide range of
staff
Provide information at a
variety of forums to outline
how and why the guideline and
clinical path were developed.
Provide hands-on training for
staff to be up skilled in their
knowledge of the management
of bronchiolitis and to provide
education to patients and their
families
• Meeting with the Children’s
Program Management about
guideline and clinical path
• Discussion at SMS meeting of
guideline and clinical path
• Discussion with those
responsible for physician
training about guideline and
clinical path
• HMO education re guideline
and clinical path
• Meeting with NUMs, nurse
educators, nurse facilitators &
site DON about guideline,
clinical path &
implementation strategy
• Nurse facilitators to provide
education on unit with
support from implementation
group
• Meet with paediatric Allied
Health about guideline and
clinical path
Work with staff to provide
ongoing support and a
feedback mechanism
throughout the implementation
of the guideline and clinical
path
Who
Program
Management
Medical
• Put notices in SMS pigeon
holes about the availability of
guideline and implementation
of clinical path
Nursing
Allied Health
Ward Clerks
General
Practitioners
Community
Health
General
• One-on-one meetings with
key clinicians and opinion
leaders to encourage them
to motivate others
• Involve Nurse Educators and
Clinical Nurse Specialists in
ongoing education
• One-on-one meetings with
NUMs to encourage them to
motivate their staff
• Work with Allied Health
representatives to motivate
staff and involve them in
implementation
• Meet with Ward Clerks to
• Work with the Ward Clerks
explain clinical path and how
to keep them informed and
it is used
motivated throughout the
implementation
• An implementation plan to address the specific needs of General Practitioners is being developed
by the GP Liaison Officer as a separate strategy to the acute implementation plan
• Strategies to inform pharmacists and other relevant community health services are currently
being developed
• Place guideline on Southern
• Include as part of
• Regular meetings with
Health internet and intranet
orientation for new staff
different groups to discuss
• Email all relevant staff about
• ED education sessions re
benefits/challenges of
the availability of the
guideline and clinical path
guideline and clinical path
guideline
• Provide “hands on” training
• Regular updates about
• Distribute copies of guideline
for medical, nursing and
progress in implementation
to key staff and place in
Allied Health staff
and resulting improvements
EDs, wards, staff rooms
• Use GDG members to
• Use posters in departments
motivate staff to use
to inform and remind staff of
documents
guidelines etc
• Put notice in Purple Peril
about availability of
guideline
• Put notice on payslips about
availability of the guideline
Dissemination and Implementation of the Guideline
46
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8. Guideline Development Process
8.1 Southern Health Bronchiolitis Guideline
Development
The development of these Guidelines was undertaken by the Health for
Kids in the South East Bronchiolitis Guideline Development Group at
Southern Health. Melinda Wilson (Clinical Scholar — Health for Kids in the
South East) and Fiona Wilkinson (Senior Project Officer — Health for Kids
in the South East) co-ordinated the process and Tari Turner (Senior
Project Officer — Health for Kids in the South East) was responsible for
identifying and appraising the evidence, and drafting the guidelines.
Members of the Guideline Development Group represented all clinical
areas at Southern Health relevant to the care of infants and children with
bronchiolitis, as well as consumer representation.
Members of the group were:
Name
Role
Merrin Bamert
Shirley Burke
Rowena Clayton
Simon Costello
Graeme Downe
Peter Francis
Peter Fritz
Claire Harris
Natalie Hood
Ilana Laser
Angela Luangrath
David Meldrum
Anna Murphy
Daniel O’Neill
Mali Ranasinghe
Junelle Rhodes
Gina Ruwoldt
Alia Sadiq
Amanda Smith
Jody Smith
Priya Thangarajah
Clinical Nurse Educator, Emergency Department, Monash Medical
Centre
Paediatric Clinical Nurse Educator
Nurse, Emergency Department, Casey Hospital
Paediatrician, Monash Medical Centre
GP Liaison Officer
Emergency Physician, Emergency Department, Monash Medical
Centre
Senior Medical Officer, Emergency Department, Dandenong
Hospital
Project Manager, Health for Kids in the South East
Emergency Physician, Emergency Department, Monash Medical
Centre
Paediatric Resident, Monash Medical Centre
Paediatric Resident, Monash Medical Centre
Paediatrician, Emergency Department, Casey Hospital
Paediatric Respiratory Fellow, Monash Medical Centre
Clinical Nurse Specialist, Emergency Department, Casey Hospital
Paediatric Nurse, Dandenong Hospital
Consumer
Nurse Unit Manager, 42North, Monash Medical Centre
Consumer
Paediatric Fellow, Monash Medical Centre
Clinical Guidelines and Pathway Co-ordinator, Royal Children’s
Hospital Melbourne
Paediatric Nurse, 41North, Monash Medical Centre
Declaration of Interest forms were completed by all members of the
Guideline Development Group, no conflicts of interest were identified.
Guideline Development Process
47
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.1.2 Acknowledgements
We thank the following people for their important contribution to the
development of this guideline.
Name
Role
Contribution
Dr Trevor Kerr
Unit Head, Southern
Health, Microbiology
Victorian Infectious Disease
Reference Laboratory
Southern Cross Pathology,
Australia
Nurse Consultant, Southern
Health Infection Control
and Epidemiology Unit
Metropolitan Ambulance
Service (MAS)
Expert knowledge on RSV
testing
Expert knowledge on RSV
testing
Expert knowledge on RSV
testing
Advice on infection control
measures
Senior Scientists, Virus
Identification Unit
Laboratory Staff
Judy Brett
Emily England
John Wheeler
Consultation in regard to
MAS protocols
8.2 Methodology
This guideline was developed by a multidisciplinary guideline development
group (GDG) which included representatives of all clinical areas involved
in caring for infants and children with bronchiolitis and their parents. The
membership of the group is outlined above in section 7.1.
The development process followed is outlined in figure #.
A broad search was undertaken to identify existing evidence-based
guidelines for the management of bronchiolitis. The search included:
• published literature (Medline, CINAHL, Embase),
• websites referring to clinical guidelines (including
www.guidelines.gov, www.rch.org.au, www.nhmrc.gov.au,
http://www.leitlinien.de)
• the internet.
Several existing clinical practice guidelines for the management of
bronchiolitis were identified. In most cases it was clear that these
guidelines were consensus-based (not evidence-based) documents. Some
guidelines appeared to be potentially evidence-based, in these cases the
GDG attempted to contact the authors, or publishing institutions in order
to determine the methodology used in the guideline development. No
guidelines were identified which had been developed by a
methodologically rigorous, evidence-based process. An Evidence
Report/Technology Assessment “Management of Bronchiolitis in Infants
and Children” published by the Agency for Healthcare Research and
Quality (AHRQ) in January 2003 was identified and this report was a
useful reference in the development of this guideline.
In the absence of existing evidence-based guidelines for the management
of infants and children with bronchiolitis, the GDG decided to develop a
new guideline, following an evidence-based process.
In consultation with their colleagues, the GDG developed a list of
questions that a bronchiolitis management guideline should address.
Guideline Development Process
48
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Where these questions were addressed by the AHRQ Evidence Report,
searches were taken to identify any more recent evidence, and the
content of the report revised to be appropriate for the local context.
Where a question was not addressed by the AHRQ Evidence Report,
searches of published research evidence were then undertaken to identify
evidence to answer the questions.
Evidence identified to answer the clinical questions was appraised using a
standard appraisal format (see section 7.4).
Where evidence existed to answer clinical questions, evidence-based
recommendations were made, with the level of the recommendation
reflecting the quality and generalisability of the evidence available to
answer the question.
Where there was no, or very low quality, evidence to answer a clinical
question, recommendations were made on the basis of the consensus of
the GDG.
Each chapter of the guideline was drafted by a member of the GDG with
expertise in the identification and appraisal of research evidence, in
consultation with the coordinators of the GDG process, and then revised
and adapted in the light of feedback from GDG meetings.
The development of the guideline also included consultation with the
Melbourne Metropolitan Ambulance Service.
The final document was circulated to key clinical leaders outside the GDG
and members of the Southern Health Executive for endorsement.
Guideline Development Process
49
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Figure 1. Guideline Development Process
1. Define and scope the guideline
Are there suitable existing
evidence-based guidelines?
yes
Is adaptation for local
situation required?
no
yes
no
2. Convene a multidisciplinary
guideline panel
3. Develop the clinical question(s)
4. Identify and appraise scientific
evidence to answer questions
Is there Level I-IV evidence in
respect of each recommendation?
yes
5a. Develop evidence-based
recommendations or update
existing recommendations
no
Is there consensus?
no
yes
5b. Develop consensusbased recommendations
that indicate lack of
clear evidence but
acknowledge consensus
5c. Make brief non-consensus
statement (state options and
acknowledge uncertainty)
6. Write 3 guideline versions
7. Consultation & pilot testing
8. Disseminate and implement
9. Evaluate and revise
Guideline Development Process
50
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.3 Searches
All searches to identify research evidence to answer clinical questions
followed a standard process.
Medline from 1966-present (Ovid) and CINAHL (Ovid) were searched on
each occasion and The Cochrane Library was searched for all questions
regarding management.
Searches were restricted by language of publication (English) and to those
publications reporting on studies in humans. A summary of the searches
undertaken is provided below. Details of each search strategy are
available on request.
Duration of illness
Search Term
1
2
3
Bronchiolitis terms
Duration terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Chest x-rays
Search Term
1
2
3
4
Bronchiolitis terms
X-ray terms
Combine 1 & 2
Limit to 2002-2005
Abstracts reviewed
Papers reviewed
Papers used
Nasopharyngeal aspirates
Search Term
1
2
3
4
Bronchiolitis terms
NPA terms
Combine 1 & 2
Limit to 2002-2005
Abstracts reviewed
Papers reviewed
Papers used
Guideline Development Process
Medline
1966present
1652
452877
182
188
2
2
CINAHL
1982 current
182
22304
32
Medline
1966present
1652
625630
116
25
27
1
0
CINAHL
1982 current
182
24028
11
6
Medline
1966present
1652
3206
95
28
28
1
1
CINAHL
1982 current
182
33
3
2
26/09/05
The Cochrane
Library
Not applicable
27/09/05
The Cochrane
Library
Not applicable
28/09/05
The Cochrane
Library
Not applicable
51
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Blood and/or urine culture
Search Term
1
2
3
Bronchiolitis terms
Blood or urine culture terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Blood gas analysis
Search Term
1
2
3
Bronchiolitis terms
Blood gas analysis terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Assessment of severity
Search Term
1
2
3
Bronchiolitis terms
Blood gas analysis terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Isolation
Search Term
1
2
3
Bronchiolitis terms
Isolation terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Adrenaline
Search Term
1
2
3
Bronchiolitis terms
Adrenaline terms
Combine 1 & 2
Restricted to 2002-2005
Abstracts reviewed
Papers reviewed
Papers used
Guideline Development Process
Medline
1966present
1652
179835
55
24
13
12
CINAHL
1982 current
182
6217
4
Medline
1966present
1653
27871
32
23
0
0
CINAHL
1982 current
182
2765
6
Medline
1966present
1653
692545
300
300
16
7
CINAHL
1982 current
182
47373
43
Medline
1966present
1652
670744
124
CINAHL
1982 current
182
8432
4
28/09/05
The Cochrane
Library
Not applicable
28/09/05
The Cochrane
Library
Not applicable
30/09/05
The Cochrane
Library
Not applicable
27/09/05
The Cochrane
Library
230
6932
16
0
Medline
1966present
1669
53996
59
33
33
12
1
CINAHL
1982 current
193
1101
19
15/11/05
The Cochrane
Library
233
4486
30
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Bronchodilators
Search Term
1
2
3
Bronchiolitis terms
Bronchodilator terms
Combine 1 & 2, restrict to 20022005
Abstracts reviewed
Papers reviewed
Papers used
Ipratropium bromide
Search Term
1
2
3
Bronchiolitis terms
Ipratropium bromide terms
Combine 1 & 2, restrict to 20022005
Abstracts reviewed
Papers reviewed
Papers used
Antibiotics
Search Term
1
2
3
Bronchiolitis terms
Antibiotic terms
Combine 1 & 2, restrict to 20022005
Abstracts reviewed
Papers reviewed
Papers used
Corticosteroids
Search Term
1
2
3
Bronchiolitis terms
Steroid terms
Combine 1 & 2, restrict to 20022005
Abstracts reviewed
Papers reviewed
Papers used
Ribavirin
Search Term
1
2
3
Bronchiolitis terms
Ribavirin terms
Combine 1 & 2, restrict to 20022005
Abstracts reviewed
Papers reviewed
Papers used
Guideline Development Process
Medline
1966present
1669
168601
76
CINAHL
1982 current
193
3214
34
16/11/05
The Cochrane
Library
233
12853
34
40
10
2
Medline
1966present
1669
1675
9
CINAHL
1982 current
193
154
2
17/11/05
The Cochrane
Library
233
1052
11
5
2
1
Medline
1966present
1669
404413
31
CINAHL
1982 current
193
9413
7
17/11/05
The Cochrane
Library
233
11421
12
10
2
1
Medline
1966present
1670
300523
43
CINAHL
1982 current
193
8343
16
18/11/05
The Cochrane
Library
233
23694
33
25
8
4
Medline
1966present
1670
4412
22
CINAHL
1982 current
193
343
5
21/11/05
The Cochrane
Library
233
935
7
10
4
1
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Immunoglobulin
Search Term
1
2
3
Bronchiolitis terms
Immunoglobulin terms
Combine 1 & 2, restrict to 20022005
Abstracts reviewed
Papers reviewed
Papers used
Analgesics and Antipyretics
Search Term
1
2
3
Bronchiolitis terms
Analgesic and Antipyretic terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Cough mixture and decongestants
Search Term
1
2
3
Bronchiolitis terms
Cough mixture / decongestant
terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Oxygen
Search Term
1
2
3
Bronchiolitis terms
Oxygen terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Hydration
Search Term
1
2
3
Bronchiolitis terms
Hydration terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Guideline Development Process
Medline
1966present
1670
227661
3
CINAHL
1982 current
193
1776
2
21/11/05
The Cochrane
Library
233
4659
0
3
1
1
Medline
1966present
1670
217950
6
1
1
0
CINAHL
1982 current
193
1286
0
Medline
1966present
1670
44374
CINAHL
1982 current
193
1249
3
3
1
0
0
Medline
1966present
1720
269130
208
35
10
0
CINAHL
1982 current
197
9882
37
Medline
1966present
1720
448425
108
22
9
0
CINAHL
1982 current
197
18661
24
21/11/05
The Cochrane
Library
233
17760
8
24/11/05
The Cochrane
Library
233
3207
1
20/01/06
The Cochrane
Library
234
14377
78
23/01/06
The Cochrane
Library
234
46484
43
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Chest Physiotherapy
Search Term
1
2
3
Bronchiolitis terms
Chest Physiotherapy terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Saline drops
Search Term
1
2
3
Bronchiolitis terms
Drop terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Suctioning
Search Term
1
2
3
Bronchiolitis terms
Suctioning terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Apnoea
Search Term
1
2
3
Bronchiolitis terms
Apnoea terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Position
Search Term
1
2
3
Bronchiolitis terms
Position terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Guideline Development Process
Medline
1966present
1720
133474
24
1
1
1
CINAHL
1982 current
197
25546
14
Medline
1966present
1720
68589
7
1
0
0
CINAHL
1982 current
197
3785
2
Medline
1966present
1720
14463
12
0
0
0
CINAHL
1982 current
197
1318
5
Medline
1966present
1725
21833
46
47
11
0
CINAHL
1982 current
197
2231
6
Medline
1966present
1731
401156
13
1
1
1
CINAHL
1982 current
197
21721
4
24/01/06
The Cochrane
Library
234
5992
3
24/01/06
The Cochrane
Library
234
11607
25
24/01/06
The Cochrane
Library
234
1229
6
24/01/06
The Cochrane
Library
234
1789
4
31/01/06
The Cochrane
Library
236
12231
10
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Oximetry
Search Term
1
2
3
Bronchiolitis terms
Oximetry terms
Combine 1 & 2
Abstracts reviewed
Papers reviewed
Papers used
Guideline Development Process
Medline
1966present
1735
8872
32
4
2
2
CINAHL
1982 current
201
1414
9
15/02/06
The Cochrane
Library
238
928
19
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.4 Critical Appraisal of Identified Research
8.4.1 Nebulised adrenaline
Study Selection Criteria
Patient
Infants or children with bronchiolitis
Intervention
Nebulised adrenaline
Hartling et al
Sys Rev
8 studies
(365
patients)
Placebo
Outcomes
Study Type
Any
Language English
Characteristics of included studies:
Study
Study Type N(total) Patients
144
Comparison
Publication Date
Infants and young children
up to 24 months of age
with bronchiolitis
Any
Any
Number of included studies:
1 SR
Intervention
Comparison
Outcomes
Adrenaline
Placebo
Clinical score, oxygen
saturation, admission to
hospital, LOS, RR, HR,
pulmonary function tests
Hartling et al
144
Yes
Yes
Yes
Some
Statistically
Yes
Strengths and
limitations of
included studies
discussed
Summary of main
results presented
Homogeneity
between studies
assessed
Validity of included
trials appraised
Explicit and
comprehensive
search strategy
Study
Specified
inclusion/
exclusion criteria
Focused research
question
Quality of included studies:
Little
Comments
• Includes adrenaline vs salbutamol (not discussed here)
• Appraisal of papers was blind to authors and institutes
• Minimal discussion of appraisal of papers and
homogeneity
Results of included studies:
• 5 studies investigated inpatient use of adrenaline. In these studies there was no difference between the groups in change in clinical score at 30mins,
change in oxygen saturation at 30mins or 60 mins, HR at 30 or 60 mins, RR at 30 or 60 mins, LOS, or pallor. Infants in the adrenaline group had a
slightly greater reduction in clinical score at 30 mins SMD -0.52(95%CI -1.00, -0.03)
• 3 studies investigated outpatient use of adrenaline. In these studies there was no difference between the groups in admission rates, change in clinical
score at 30mins, change in oxygen saturation at 30mins or 60 mins or HR at 30mins. Statistically significant differences were found in change in clinical
score at 60 minutes (SMD -0.81; 95% CI -1.56,-0.07), change in oxygen saturation at 30 minutes (WMD 2.79; 95% CI 1.50,4.08), respiratory rate at
30 minutes (WMD -4.54; 95% CI -8.89,-0.19),
Guideline Development Process
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.4.2 β2agonist bronchodilators
Study Selection Criteria
Patient
Infants or children with bronchiolitis
Comparison
Placebo or control
Intervention
β2agonist bronchodilators
Outcomes
Any
Study Type
Any
Language English
Characteristics of included studies:
Study
Study Type N(total) Patients
King et al145
Sys Rev
1036 (12
studies)
Publication Date
Infants and children with
bronchiolitis
Any
Number of included studies:
1 Sys Rev
Intervention
Comparison
Outcomes
Beta2agonist
bronchodilators
Placebo or no treatment
Hospitalisation, LOS,
clinical score, HR, RR<
oxygen saturation
King et al
145
Yes
Yes
Yes
Yes
Unclear
Yes
Strengths and
limitations of
included studies
discussed
Summary of main
results presented
Homogeneity
between studies
assessed
Validity of included
trials appraised
Explicit and
comprehensive
search strategy
Study
Specified
inclusion/
exclusion criteria
Focused research
question
Quality of included studies:
Minimal
Results of included studies:
Comments
• Study by Patel 2002 (their reference 21) is missing from Table 4,
but present in Table 3. Results of this study not included (though
consistent) in β2agonist bronchodilators discussion.
• 12 studies compared β2agonist bronchodilator to placebo.
• No differences were found between groups in any of the 7 studies reporting admission or LOS outcomes.
• 9 studies found no differences between groups on any measured outcomes.
• 2 studies reported short term improvements in clinical score; at 30mins and 60mins in one study and at 30mins only in the 2nd study.
• 1 study reported lower mean decrease in RR in placebo group.
• 1 study reported worse oxygenation in treatment group.
• Non-significant increased tachycardia and/or decreased oxygenation was reported in 5 studies
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.4.3 Ipratropium bromide
Study Selection Criteria
Patient
Infants or children with bronchiolitis
Comparison
Placebo or control
Intervention
Ipratropium bromide
Outcomes
Any
Study Type
Any
Language English
Characteristics of included studies:
Study
Study Type N(total) Patients
King et al145
Sys Rev
240 (3
studies)
Publication Date
Infants and children with
bronchiolitis
Any
Number of included studies:
1 Sys Rev
Intervention
Comparison
Outcomes
Ipratropium bromide
Placebo or no treatment
Hospitalisation, LOS,
clinical score, HR, RR<
oxygen saturation
King et al
145
Yes
Yes
Yes
Yes
Results of included studies:
Unclear
Yes
Strengths and
limitations of
included studies
discussed
Summary of main
results presented
Homogeneity
between studies
assessed
Validity of included
trials appraised
Explicit and
comprehensive
search strategy
Study
Specified
inclusion/
exclusion criteria
Focused research
question
Quality of included studies:
Minimal
Comments
• Studies described in Table 4 as they also have arms testing
β2agonist bronchodilators
• 3 studies compared ipratropium bromide to placebo.
• No differences were found between ipratropium bromide and placebo groups in LOS or clinical outcomes.
• One trial showed that ipratropium bromide + salbutamol was better than either agent alone, but the combination was not significantly more effective
than placebo.
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.4.4 Antibiotics Appraisal Table from AHRQ HTA118
Study Characteristics
Author: Friis et al, 198449
Setting: Denmark, Inpatient
Stated Objective of Study
To assess the effect of routine
administration of antibiotics in the
treatment of viral pneumonia and
bronchiolitis
Follow-up: Acute, short
term, 3 wks
Study design RCT - No
placebo
Length of enrolment:
Dec 1979 to Nov 1982
Masking: Open label
Intervention
Intervention
Group A (n = 34)
Antibiotics:
• If < 2 yrs, Ampicillin PO
100mg/kg/day TID x 6 days
• If > 2 yrs, V Penicillin 300000 IU TID
x 6 days
• If > 2 yrs with penicillin allergy,
erythromycin 30 - 50mg/kg/day TID
x 6 days
• Treatment changed if strains were
resistant (No details reported)
Group B (n = 27) Control
No therapy, 7 patients given antibiotics
when they developed cyanosis, or
bacterial complications, or fever lasting
more than 4 days without viral
infection diagnosed by IFA antibody
test.
Other treatment NR
Guideline Development Process
Inclusion/Exclusion Criteria
Demographic Characteristics and
Cormorbidities
Inclusion criteria
• Children with pneumonia admitted to
pediatric wards
• Ill for less than one wk
• No antibiotics before
• hospital admission
Number: 136 eligible of which 61 had RSV (evidence
table limited to RSV Subgroup)
Exclusion criteria
• Chronic pulmonary or cardiac disease
• Mental retardation
• Oncologic diseases
• Severe breathing difficulties or
cyanosis Oxygen treatment or
artificial ventilation
• Suspected septicemia
Median age at enrollment in mos :
Antibiotics: 18 Control: 17.5
Mean gestational age NR
Sex:
Antibiotics: 65% male (47/72)
Control: 67% male (44/66)
Comorbidities: None
Outcome
Primary outcome
• Mean duration of hospitalization in days ± SE
(antibiotics vs. control for RSV subgroup) 5.2 ± 0.3 vs.
5.4 ± 0.4
• ‘Pulmonarily healthy’ on day 3 (antibiotics vs. control
for RSV subgroup) 11 (32.4%) vs. 9 (33.3%)
• ‘Pulmonarily healthy’ at discharge (antibiotics vs.
control for RSV subgroup) 25 (73.5%) vs. 24 (88.9%)
• ‘Pulmonarily healthy’ after 3 wks (antibiotics vs. control
for RSV subgroup) 27 (79.4%) vs. 20 (74.1%)
Secondary outcomes
• Respiratory rate per mins measured at days 1, 2, 3 and
discharge
• Radiological findings on admission and after 3 wks
Quality
Significant differences
between study groups
• No, P value NR
• No, P value NR
• No, P value NR
Quality: Fair
Significant differences at
baseline: NR
Other comments
• Neither patients nor
investigators were blinded
• No, P value NR
• No, P value NR
• No, P value NR
Adverse events: Fever, respiratory distress, coughing,
otalgia, skin eruptions, GI symptoms, medical attention,
antibiotics after day 10 for all patients, details NR for
bronchiolitis group
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.4.5 Corticosteroids
Study Selection Criteria
Patient
Infants or children with bronchiolitis
Comparison
Placebo or control
Intervention
Corticosteroids
Outcomes
Any
Study Type
Any
Language English
Characteristics of included studies:
Study
Study Type N(total) Patients
Publication Date
Any
Number of included studies:
2 Sys Revs, 2RCTs
Intervention
Comparison
Outcomes
Patel et al146
Sys Rev
1198 (13
studies)
Infants and children with
acute viral bronchiolitis –
recurrent wheezers and
ICU admissions excluded
Oral, intravenous or
intramuscular
corticosteroids
Placebo or control
Hospitalisation, LOS,
clinical score, HR, RR<
oxygen saturation
Davison et al147
Sys Rev
137 (3
studies)
Mechanically ventilated
infants and children with
bronchiolitis
Oral, intravenous or
intramuscular
corticosteroids
Placebo or control
Duration of mechanical
ventilation, LOS
Patel et al
146
Yes
Strengths and
limitations of
included studies
discussed
Summary of main
results presented
Homogeneity
between studies
assessed
Validity of included
trials appraised
Explicit and
comprehensive
search strategy
Study
Specified
inclusion/
exclusion criteria
Focused research
question
Quality of included studies:
Comments
Yes
Yes
Yes
Yes
Yes
Some
• Study results were significantly heterogeneous
Davison et al
Yes
Yes
Results of included studies:
Yes
Yes
Yes
Yes
Some
• Study treatments were of varying duration and dose
147
Patel et al146 found
• a non-significant a decrease in LOS in patients treated with corticosteroids of 0.38 days (95% CI -0.81 to 0.05).
• In the 3 studies of 100% RSV positive infants and young children where LOS was reported, the meta-analysis gave a WMD of -0.67 (95% CI -1.11 to 0.24) LOS for treated infants and young children in this group compared to placebo.
• No statistically significant differences in clinical scores, respiratory rates or oxygen saturation were found between treatment groups in an of the studies.
• 3 trials reported hospital admission rates. In 2 of these trials admission rates were non-significantly, but substantially higher in the treatment group,
and in the third trial the admission rate was significantly higher in the placebo group. Meta-analysis found no difference between groups.
Davison et al146 found no significant differences in duration of mechanical ventilation or LOS between groups.
Guideline Development Process
61
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.4.5 Corticosteroids continued – Randomised Controlled Trials
Characteristics of included studies:
Study
Study Type
N(total)
Zhang et al
148
Kuyucu et al149
Patients
Intervention
Comparison
Outcomes
RCT
52
Infants ≤12months
admitted with bronchiolitis
1mg/kg prednisolone for
5 days
No steroids
Prevalence of wheezing
at 1, 3, 6 & 12 months,
LOS, duration of O2,
RCT
69
Infants 2-21 months in ED
with acute bronchiolitis
with RDAI≥4
Adrenaline and
dexamethasone, or
salbutamol and
dexamethasone
Adrenaline and placebo,
or salbutamol and
placebo
RR, HR, RDAI at
admission, 30, 60, 90
and 120mins
Not
described
Not
described
Some
See
note
Some
12
months
2
months
Proportion lost to
follow up
Yes
Duration of
follow-up
Blinding –
patients/
investigators/
assessors
Yes
Inclusion of all
subjects in
analysis
Yes
Yes
Objective &
independent
assessment of
outcomes
Kuyucu et al149
Yes
Groups similar at
baseline
Zhang et al
148
Concealment of
allocation
Study
Adequate method
of randomisation
Specified
inclusion/
exclusion criteria
Quality of included studies:
2 (8%)
in
steroid
group
Mostly
Yes
42-3%
in
placebo
12% &
4% in
treated
Yes
Comments
• Investigators but not patients or families
were blind
• Parents recorded days of wheeze, but also
tested at clinic
No
• Baseline characteristics only given for
patients who completed the trial.
Large proportion of data missing.
• Parents and investigators blind, ED nurse
prepared solutions
Results of included studies:
• Zhang et al148 found no differences in LOS or duration of O2 therapy between groups. Likewise there was no difference in rates of wheezing at 1, 3, 6 or
12 months post discharge.
• Substantial proportion of placebo groups lost to follow-up in Kuyucu et al149 study makes interpretation of results difficult. No patients in any groups were
admitted which suggests initial severity was low. No differences were found in retreatment rates. 5th days RDAI scores were lower in dexamethasone
groups than placebo groups, however there were no differences in other outcomes so this may be an artefact, or related to high loss to follow-up
Guideline Development Process
62
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.4.6 Ribavirin
Study Selection Criteria
Patient
Infants or children with bronchiolitis
Comparison
Placebo or control
Intervention
Ribavirin
Outcomes
Any
Study Type
Any
Language English
Characteristics of included studies:
Study
Study Type N(total) Patients
King et al145
Sys Rev
320 (10
studies)
Publication Date
Infants and children with
bronchiolitis
Any
Number of included studies:
1 Sys Rev
Intervention
Comparison
Outcomes
Ribavirin
Placebo or no treatment
Hospitalisation, LOS,
duration of ventilation
clinical score, HR, RR<
oxygen requirement
145
King et al
Yes
Yes
Results of included studies:
Yes
Yes
Unclear
Yes
Strengths and
limitations of
included studies
discussed
Summary of main
results presented
Homogeneity
between studies
assessed
Validity of included
trials appraised
Explicit and
comprehensive
search strategy
Study
Specified
inclusion/
exclusion criteria
Focused research
question
Quality of included studies:
Minimal
Comments
•
•
Guideline Development Process
63
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.4.7 Immunoglobulin Appraisal Table from AHRQ HTA118
Study Characteristics
Stated Objective
of Study
Author: Rodriguez et al., 199725
To determine the
safety and efficacy
of RSVIG in the
treatment of
previously healthy
children hospitalized
with RSV infection
Setting: United States,
Inpatient at baseline, telephone
follow-up
Follow-up:
• Acute , Short term -Monthly
telephone calls
• Long-term at 1 yr after
intervention
Study design: RCT-P
Length of enrolment: 4 RSV
seasons (yrs not stated)
Masking: Double-blind
Inclusion/Exclusion Criteria
Inclusion criteria
Number: 101 eligible, 98
completed study
specimens positive for RSV
• Acute lower respiratory symptoms of less than 4 days duration
• Respiratory score of = 2.5
Exclusion criteria
• Known or suspected cardiopulmonary disease
• Premature birth with GA <32 wks
• Immunodeficiency disease (including HIV infection)
• Known serum IgA deficiency
• Renal failure
• Previous reaction to blood products
• Receipt of blood or blood products in the preceding 60 days
• Established diagnosis of reactive airway disease
• Apnea without evidence of LRI on presentation
• Inability to establish an intravenous line after 4 attempts
• Admitted for Ribavirin therapy
Sex:
RSVIG: 48% male (22/46)
Placebo 50% male (26/52)
• Previously healthy ≤2 yrs of age
• Hospitalized with bronchiolitis and/or pneumonia with nasal wash
Intervention
Intervention
Group A (n = 46)
RSVIG 30ml/kg (1500 mg/kg)
IV infusion x 1 dose
Group B (n = 52)
Placebo IV Albumin 0.5%, same
volume as intervention
Other treatment
Ribavirin therapy, IV fluids,
nebulization treatments, steroids
or antibiotics, supplemental
oxygen, mechanical ventilation
Guideline Development Process
Demographic Characteristics
and Cormorbidities
Mean age at enrollment (yr.±
SD)
RSVIG: 0.20 ± 0.03 Placebo: 0.19
± 0.03
Mean gestational age (wk.± SD)
RSVIG: 38.0 ± 0.4 Placebo: 38.2 ±
0.4
Comorbidities:
Patients on ventilators: RSVIG:
12/46 (26%) Placebo: 19/52 (37%)
Outcome
Primary outcome
• Mean duration of hospitalization in days ± SE (RSVIG vs. Placebo)
4.58 ± 0.4 vs. 5.52 ± 0.69
• Mean duration of stay in ICU in days ± SE (RSVIG vs. placebo) 3.92
± 0.58 (n = 25) vs. 6.60 ± 1.31 (n = 33)
Quality
Significant differences
between study groups
• No (P = 0.24)
• No (P = 0.06)
Secondary outcomes
•
•
•
•
•
•
•
•
Duration of mechanical ventilation
Duration of oxygen therapy
Use of ribavirin
Supplemental oxygen
RSV neutralizing antibody
Proportion of cultures for RSV
Hospitalization of LRI in subsequent season
Hospitalization of RSV LRI in subsequent season
Subgroup analysis
• Severity of illness
• No (P = 0.45)
• No
• No
• No
• No
• No
• NR
• NR
• P values not
Quality
Good
Significant differences at
baseline
• RSVIG grp more likely to
have = 85% study entry O2
saturation level (46% vs.
29%, P = 0.07)
• Placebo grp more likely to
need ICU care and
mechanical ventilation
(Pvalue NR)
Other comments
• If pt received 25% of
infusion, was eligible for
adverse outcomes reporting
64
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
•
-Among subgroup with more severe disease (respiratory scores =
3.0), lower duration of hospitalization in RSVIG grp than placebo
ICU stay at entry
-Lower duration of hospitalization in RSVIG grp than placebo
provided, n too small
and if 75% of infusion then
also for all other outcomes
• P values not
provided, n too small
Adverse events
• Benign nocturnal myoclonus not related to RSVIG (1 RSVIG pt)
• Cardiopulmonary findings (6 RSVIG pts, 8 placebo pts)
Study Characteristics
Author:
Rodriguez et al., 199741
Year: 1997
Setting:
United States, Multi-center,
Inpatient
Stated Objective
of Study
To evaluate the
efficacy of
intravenous RSVIG
to treat severe RSV
in high risk infants
Follow-up:
• Acute
• Short term -Monthly
telephone calls
• Long-term at 1 yr after
intervention
Intervention
Guideline Development Process
Number
107 enrolled, 102 received
adequate dose, 96 at 8 wk followup, 98 at 1 yr follow-up
High-risk criteria definitions:
− severe BPD
− other serious chronic lung disease
− congenital heart disease
− preterm infants <6 months old and <32 wks gestation
Sex
RSVIG: 45% male (23/51)
Placebo: 57% male (29/51)
Exclusion criteria
Masking: Double-blind
Primary outcome
Demographic Characteristics
and Cormorbidities
Inclusion criteria
• High risk infants and children 2 yrs and younger
• Hospitalized for RSV, bronchiolitis and/or pneumonia
• Positive for RSV antigens
• Poorly controlled congestive heart failure before RSV illness
• Renal failure
• Ventilator dependency before RSV illness
• Life expectancy< 6 months from study onset
• Treatment with ribavirin before enrollment
• Previous adverse reaction to blood products
• Known IgA or other immunodeficiency
• Enrollment in concurrent RSVIG study
• Cystic fibrosis
• Asthma
• Reactive airway disease w/o BPD
• Apnea w/o LRI
• Admission for ribavirin therapy
Outcome
Study design: RCT-P
Intervention
Group A (n = 51)
Inclusion/Exclusion Criteria
Mean age at enrollment (yr.± SE)
RSVIG: 0.55 ± 0.07
Placebo: 0.58 ± 0.06
Mean gestational age (wk.± SE)
RSVIG: 31.0 ± 0.8
Placebo: 30.7 ± 0.7
Comorbidities
• Groups balanced at entry for
•
Significant differences
between study groups
BPD, congenital heart disease
and prematurity.
History of LRI significantly more
frequent in placebo group (37%
for placebo vs. 18% for RSVIG)
Quality
Quality
Excellent
65
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
RSVIG 30 mL/kg (1.5 mg/kg) IV x 1
dose over 12 hrs
Group B (n = 53)
Placebo 0.15 mg/kg albumin
(identically appearing solution and
schedule)
Other treatment
Supplemental oxygen, mechanical
ventilation, ribavirin therapy
• Mean duration of hospitalization in days ± SE (RSVIG vs.
placebo) 8.41± 0.97 vs. 8.89 ± 0.99
• Mean duration of ICU stay in days ± SE (RSVIG vs. placebo) 9.77± 1.66 (n = 31) vs. 10.27 ± 1.81 (n = 18)
• Development of RSV in hospitalized patients during subsequent
respiratory season 3/48 (6%) vs. 3/50 (6%)
• Readmission during subsequent respiratory season(RSVIG vs.
placebo) -5/48 (10%) vs. 6/50 (12%)
Secondary outcomes
•
•
•
•
•
•
Duration of mechanical ventilation
Requirement for supplemental oxygen during hospitalization
Change in respiratory scores 24, 48, 72 and 96 hrs after infusion
Bronchodilator use
Ribavirin use
Steroid use
Subgroup analysis
• Underlying diagnosis
• Gestational age, year, center
• Respiratory score
• ICU stay at entry
• No (P = 0.73)
• No (P = 0.90)
• No (Pvalue NR)
• No (Pvalue NR)
• No
• No
• No
• No
• No
• No
Significant differences at
baseline
RSVIG group had more severe
disease than placebo group:
-ICU admission: 47% vs. 28%
(P = 0.03)
-Mechanical ventilation: 31% vs.
18% (P = 0.01)
-Mean respiratory scores of 4 -5:
45% vs. 29% (P = 0.38)
Other comments
• No
• No
• No
• No
Adverse events
• RSVIG
-22 events in 16 patients
-16/22 possibly drug-related
• Placebo
-11 events in 10 patients
-8/11 events possibly drug-related
Guideline Development Process
66
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.4.8 Analgesics or antipyretics
Study Selection Criteria
Patient
Intervention
Infants or children with bronchiolitis
Comparison
Placebo
Analgesics or antipyretics
Outcomes
Any
Study Type
Any
Language English
Characteristics of included studies:
Study
Study Type N(total) Patients
Lesko and
Mitchell152
RCT
27,065
Publication Date
Acutely febrile children <2
years old seen as
outpatients, >1500 with
LRI
Any
Number of included studies:
1 RCT
Intervention
Comparison
Outcomes
Paracetamol 12mg/kg
Ibuprofen 5mg/kg or
10 mg/kg
Hospitalisation, adverse
events
Lesko and
Mitchell152
Yes
Yes
Yes
Yes
Yes
4
weeks
0.3%
Yes
Inclusion of all
subjects in
analysis
Objective &
independent
assessment of
outcomes
Proportion lost to
follow up
Duration of
follow-up
Blinding –
patients/
investigators/
assessors
Groups similar at
baseline
Concealment of
allocation
Adequate method
of randomisation
Study
Specified
inclusion/
exclusion criteria
Quality of included studies:
Yes
Comments
• Methodological details provided in a
separate, referenced paper which was
accessed in full text.
Results of included studies:
• In the participants with bronchiolitis or asthma, there was no difference in hospitalisation rate between paracetamol and ibuprofen groups.
• Analysis of the entire 27,065 cohort found that there were no infants or children hospitalised for acute renal failure, anaphylaxis or Reye’s syndrome.
• Three children (all in the ibuprofen group) were hospitalised with evidence of gastrointestinal bleeding. The bleeds were not severe and resolved with
conservative management.
Guideline Development Process
67
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.4.9 Chest Physiotherapy
Study Selection Criteria
Patient
Infants or children with bronchiolitis
Comparison
Any
Intervention
Chest physiotherapy
Outcomes
Any
Study Type
Any
Language English
Characteristics of included studies:
Study
Study Type N(total) Patients
Perotta et al153
Systematic
Review
156 (3
RCTs)
Publication Date
Infants younger
than 24months of
age with acute
bronchiolitis in all
settings
Any
Number of included studies:
1 SR
Intervention
Comparison
Outcomes
Any type of chest physiotherapy:
postural drainage, chest
percussion, vibration, chest
shaking, directed coughing or
forced exhalation
Standard care
(excluding chest
physiotherapy) or
other drainage or
breathing techniques.
Change in severity, oxygen
saturation, duration of
oxygen supplementation,
length of hospital stay, use
of bronchodilators/steroids
153
Perotta et al
Yes
Yes
Results of included studies:
Yes
Yes
Yes
Yes
Strengths and
limitations of
included studies
discussed
Summary of main
results presented
Homogeneity
between studies
assessed
Validity of included
trials appraised
Explicit and
comprehensive
search strategy
Study
Specified
inclusion/
exclusion criteria
Focused research
question
Quality of included studies:
Comments
Yes
• No significant differences were found between treatment and control groups for any outcome measures.
• Trials were not placebo controlled.
• The authors concluded that “vibration and percussion techniques have not shown to reduce length of hospital stay in acute bronchiolitis or to improve a
severity clinical score”
Guideline Development Process
68
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.4.10 Position
Study Selection Criteria
Patient
Infants or children with bronchiolitis
Comparison
Any
Intervention
Position
Outcomes
Any
Study Type
Any
Language English
Characteristics of included studies:
Study
Study Type N(total)
Wells et al162
Sys Rev
Publication Date
Total of 21 studies
(n=436), 1 focused
on bronchiolitis
(n=17)
Any
Number of included studies:
1 SR
Patients
Intervention
Comparison
Outcomes
Infants and children
hospitalised with
acute respiratory
distress
Position
Any
SaO2, PaO2, PCO2, oxygenation index,
desaturation episodes, RR, tidal volume,
minute volume, work of breathing, dynamic
lung compliance, total pulmonary
resistance, inspiratory and expiratory
resistance, thoracoabdominal synchrony,
HR, oesophageal pressure
Wells et al162
Yes
Yes
Yes
Yes
Yes
Yes
Strengths and
limitations of
included studies
discussed
Summary of main
results presented
Homogeneity
between studies
assessed
Validity of included
trials appraised
Explicit and
comprehensive
search strategy
Specified
inclusion/
exclusion criteria
Study
Focused research
question
Quality of included studies:
Yes
Comments
•
322 patients were preterm neonates, 228 of which were
mechanically ventilated
•
49 were newborn infants (3 mechanically ventilated) and 65
were aged 1 month – 16 years (20 mechanically ventilated
Results of included studies:
• The one RCT including infants and children with bronchiolitis did not find a significant difference between prone and supine positions. The RCT is likely to
have been underpowered
• In the meta-analysis prone positioning was significantly more beneficial than supine positioning in terms of oxygen saturation, partial pressure of arterial
oxygen, oxygenation index, thoraco-abdominal synchrony, and episodes of desaturation. There were no statistically significant differences between any
other positions.
Guideline Development Process
69
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.4.11 Apnoea
Study Selection Criteria
Patient
Infants or children with bronchiolitis
Comparison
No apnoea
Intervention
Apnoea
Outcomes
Any
Study Type
Any
Language English
Characteristics of included studies:
Study
Study Type N(total) Patients
Publication Date
Any
Number of included studies:
4 case-control
185
Patients <12 months
admitted with RSV
Gestational age at birth, PCA, sex, birth weight, clinical signs,
Sa02, x-ray findings, disease course, apnoea of prematurity
Apnoea by history or
direct observation
Anas et al155
Case-control
32
Patients <18 months
admitted with RSV
Gestational age at birth, PCA, sex, clinical status, length of
illness
Apnoea by history or
direct observation
Bruhn et al156
Case-control
112
Patients <6 months
with RSV
Gestational age at birth, PCA, sex, clinical signs, cyanosis
Apnoea by history or
direct observation
Church et al157
Case-control
261
Patients <12 months
admitted with RSV
Gestational age at birth, PCA, sex, birth weight, apnoea of
prematurity, Sa02
Apnoea by history or
direct observation
Objective &
independent
assessment of
exposure
Yes
Yes
Yes
Unclear
Yes
Unclear
No
Yes
• 38 infants with apnoea and 147 without apnoea
Yes
Yes
Yes
Unclear
Yes
Unclear
No
Yes
• Only 5 infants with apnoea and 27 without
Bruhn et al
No
Yes
No
Unclear
Yes
Unclear
No
No
• 56 infants with apnoea and 56 without apnoea
matched by birth date from larger cohort
Church et al157
Yes
Yes
Yes
Unclear
Yes
Unclear
No
Yes
• 48 infants with apnoea and 213 without apnoea
Study
Kneyber et al154
155
Anas et al
156
Guideline Development Process
Sufficient
duration
Comparable
groups with
respect to
confounders
Controls
randomly
selected from the
source
population
Explicit definition
of cases
Specified
inclusion/
exclusion criteria
Quality of included studies:
Inclusion of all
subjects in
analysis
Outcomes
Case-control
Outcomes
assessed blindly
with respect to
disease status
Exposure
Kneyber et al154
Comments
70
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
8.4.11 Apnoea continued
Results of included studies:
• Kneyber et al154 found that in multivariate analysis, age at admission was the only significant variable contributing to risk of apnoea. Infants with apnoea
were significantly younger than those without (mean 2.3±2.5 vs 3.3±2.8 months, p<0.05).
• Anas et al155 found that infants with apnoea had a younger gestational age at birth (33±2 vs 39±2wks, p<0.01), and younger post-conceptional age at
admission (37±2 vs 53±8wks, p<0.01) than infants without apnoea
• Bruhn et al156 found that apnoeic infants were younger and more apnoeic infants were born at <38 weeks GA than non-apnoeic infants (57% vs 20%,
p<0.001). Higher incidence of otitis media and fever in the non-apnoeic group. Higher incidence of cyanosis in the apnoeic group.
• Church et al157 found that apnoeic infants were younger (2 vs 3months, p<0.005) and more likely to have been born at ≤37weeks (58% vs 26%,
p<0.005), they were also more likely to have a history of apnoea of prematurity (90% vs 45%, p<0.05)
Guideline Development Process
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Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
9. References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
1.
13.
14.
15.
16.
Glezen WP, Taber LH, Frank AL, Kasel JA.
Risk of primary infection and reinfection
with respiratory syncytial virus. Am J Dis
Child.1986;140:543-546.
Eriksson M, Bennet R, Rotzen-Ostlund M,
von Sydow M, Wirgart BZ. Populationbased rates of severe respiratory syncytial
virus infection in children with and without
risk factors, and outcome in a tertiary care
setting. Acta Paediatr. 2002;91:593-598.
Wang EE, Law BJ, Stephens D. Pediatric
Investigators Collaborative Network on
Infections in Canada (PICNIC) prospective
study of risk factors and outcomes in
patients hospitalized with respiratory
syncytial viral lower respiratory tract
infection. J Pediatr. 1995;126:212-9.
Hall CB. Respiratory syncytial virus and
parainfluenza virus. N Engl J Med.
2001;344:1917-1928.
Shay DK, Holman RC, Newman RD, Liu LL,
Stout JW, Anderson LJ. Bronchiolitis associated hospitalizations among US
children, 1980-1996. JAMA.
1999;282:1440- 1446.
American Academy of Pediatrics.
Respiratory Syncytial Virus. In: Pickering
LK, ed. 2000 Red Book: Report of the
Committee on Infectious Diseases. 25th
ed. Elk Grove Village, Il: American
Academy of Pediatrics; 2000:484.
Perlstein PH, Kotagal UR, Bolling C, et al.
Evaluation of an evidence-based guideline
for bronchiolitis. Pediatrics.
1999;104:1334-1341.
Committee on Infectious Diseases.
Reassessment of the indications for
ribavirin therapy in respiratory syncytial
virus infections. Pediatrics. 1996;97:37140.
Flores G, Horwitz RI. Efficacy of beta2agonists in bronchiolitis: a reappraisal and
meta-analysis. Pediatrics. 1997;100:233239.
Kellner JD, Ohlsson A, Gadomski AM, Wang
EE. Bronchodilators for bronchiolitis.
Cochrane Database Syst Rev.
2000;CD001266.
Garrison MM, Christakis DA, Harvey E,
Cummings P, Davis RL. Systemic
corticosteroids in infant bronchiolitis: A
metaanalysis. Pediatrics. 2000;105:E44.
American Academy of Pediatrics Committee
on Infectious Diseases and Committee of
Fetus and Newborn. Prevention of
respiratory
syncytial virus infections: indications for
the use of palivizumab and update on the
use of RSV-IGIV. Pediatrics.
1998;102:1211-1216.
Joffe S, Ray GT, Escobar GJ, Black SB, Lieu
TA. Cost-effectiveness of respiratory
syncytial virus prophylaxis among preterm
infants. Pediatrics. 1999;104:419-427.
Lofland JH, O'Connor JP, Chatterton ML, et
al. Palivizumab for respiratory syncytial
virus prophylaxis in high-risk infants: a
costeffectiveness analysis. Clin Ther.
2000;22:1357-1369.
Carande-Kulis VG, Maciosek MV, Briss PA,
et al. Methods for systematic reviews of
economic evaluations for the Guide to
Community Preventive Services. Task
Force on Community Preventive Services.
Am J Prev Med. 2000;18:75-91.
Centers for Disease Control. The
Community Guide: Guide to Community
Preventive Services. 1996. Web Page.
Available at:
http://www.thecommunityguide.org/PDFS/
References
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
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141. Mai TV, Selby AM, Simpson JM, Isaacs D.
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76
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Annex 1 Management of Bronchiolitis in Hospital
DIAGNOSIS
Consider alternate diagnoses in a child who presents with:
•
Recurrent wheezing
•
Cough as the predominant
•
Persistent, or repeated a
•
Failure to thrive
•
Cardiac murmur, oedema
•
Sudden onset of symptom
wheeze, loss of voice, or differential air entry
Trial Of Bronchodilator Therapy
A child with bronchiolitis-like symptoms who responds to treatment with a bronchodilator is likely to have asthma.
s in patients older than 9 months, particularly with recurrent wheezing.
rologic tests should NOT be used to diagnose bronchiolitis.
h:
al signs and symptoms of an upper respiratory tract infection
h
ypnoea
ratory crepitations
eze
ASSESSMENT OF SEVERITY OF DISEASE
Moderate
mal
Severe
Increased
•
respiratory rate
r
increased respiratory rate
Minor
•
Markedly
•
Moderate/marked
•
accessory muscle use
accessory muscle use
•
•
•
re
• M
•
Nasal flare
and/or grunting
mal
•
to
•
heart rate#
feeding
Increased
•
Difficulty
•
•
increased heart rate#
Minor
•
dehydration
Markedly
Unable to feed
Marked
dehydration
Crepitations
•
gen
•
saturation 90-95%
Oxygen
Toxic appearance
Sweaty
Irritable
•
•
•
•
saturation <90%
Oxygen
N.B. If patient has signs or symptoms across categories, always treat according to their most severe features.
Treatment should not be based on a child’s oxygen saturation alone.
<36 weeks gestation, and those who have underlying cardiorespiratory disease as they have an increased risk of more severe disease and apnoea. Consider virolo
INITIAL TREATMENT
•
Consult senior
•
Give oxygen if
•
medical staff
•
Int
saturation <90%
oxy
Consider
•
Consider oxygen
oxygen if child is
<3 months old, has increased work of
if child is
<3 months old, has increased work of breathing,
breathing, decreased oxygenation during feeds or saturation 90decreased oxygenation during feeds or saturation 90-92%
92%
Give oxygen at the lowest flow rate required to maintain saturations between 92-95%.
If requiring oxygen at >0.5L/min, provide continuous pulse oximetry.
•
If requiring
oxygen therapy above 40%, consult ICU.
•
Encourage
•
Consider
•
small frequent feeds
nasogastric (NG) usual fluids or intravenous (IV) fluids if increased
int
•
If not
work of breathing
tolerating oral feeds, consider nasogastric (NG) usual fluids or
•
If circulatory
•
intravenous (IV) fluids if increased work of breathing
compromise or severe dehydration discuss fluids with senior medical
cir
staff
wit
If providing IV fluids give glucose 5% & sodium chloride 0.9% at 75% of maintenance rates and take blood for assessment of glucose, urea, ele
•
Consider blood
•
gas analysis
blo
•
If nasal
•
If nasal
•
congestion, trial saline nasal drops & consider suctioning
congestion, trial saline nasal drops & consider suctioning
urg
•
urage
harge
eason
)
Discharge
•
if NOT requiring oxygen or NG or IV fluids
Reassess within 1
•
hour
wit
If reason
•
Annexes
•
77
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
not to discharge,
reassess within 1 hour
ONGOING TREATMENT
IF DETERIORATING:
•
•
•
de oxygen and/or fluid therapy as per above criteria
harge when not requiring oxygen or fluid therapy
de patient information, including reasons to return to hospital
or post letter to GP and other relevant specialists
Consult senior paediatric
Reconsider diagnosis
Consider chest x-ray, blo
Annex 2 Management of Bronchiolitis in General Practice
DIAGNOSIS
h:
Consider alternate diagnoses in a child who presents with:
al signs and symptoms of an upper respiratory tract infection
•
Recurrent wheezing
h
•
Cough as the predominant
ypnoea
•
Persistent, or repeated a
iratory crepitations
•
Failure to thrive
eze
•
Cardiac murmur, oedema
rologic tests should NOT be used to diagnose bronchiolitis.
•
Sudden onset of symptom
wheeze, loss of voice, or differential air entry
Trial Of Bronchodilator Therapy
A child with bronchiolitis-like symptoms who responds to treatment with a bronchodilator is likely to have asthma.
Consider a trial of a single dose of β2 agonist bronchodilators in patients older than 9 months, particularly with recurrent wheezing.
ASSESSMENT OF SEVERITY OF DISEASE*
Moderate
mal
Severe
Increased
•
Markedly
•
respiratory rate
increased respiratory rate
•
•
re
r
Minor
•
Moderate/marked
•
accessory muscle use
accessory muscle use
• M
•
Nasal flare
•
and/or grunting
mal
Increased
•
heart rate
to
Markedly
•
increased heart rate
Difficulty
•
feeding
Unable to feed
•
Marked
•
Minor
•
dehydration
dehydration
Crepitations
•
gen
•
saturation 90-95%*
Oxygen
•
Toxic appearance
•
Sweaty
•
Irritable
•
saturation <90%*
Oxygen
<36 weeks gestation, and those who have underlying cardiorespiratory disease as they have an increased risk of more severe disease and apnoea. Consider virolo
INITIAL TREATMENT
Send to
•
SEND TO HOSPITAL BY AMBULANCE
hospital if requiring oxygen
Consider
•
sending to hospital if not tolerating oral feeds
•
urage
Consider
oxygen if child is
<3 months old, has increased work of
breathing, decreased oxygenation during feeds or saturation 9092%
•
Provide oxygen
oxy
Encourage
•
small frequent feeds
asal
If nasal
•
congestion, trial saline nasal drops
Annexes
•
78
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
de
Provide
•
•
patient information, including reasons to return
nge
Arrange
•
review in next 2 days
d
Stay with the
•
Send written
•
patient until the ambulance arrives
•
wit
assessment and referral details
wr
Send home
•
if stable
*N.B. If patient has signs or symptoms across categories, always treat according to their most severe features.
ndicator of severity however it is recognised that this form of assessment will not be available to most GPs. Treatment should not be based on a child’s
Annexes
79
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Annex 3
Normal Parameters for Paediatric Vital Signs
Neonate
Heart Rate (awake)
Toddler
(2 yrs)
Preschool
School-age
(7 yrs)
Adolescent
(15yrs)
100-180
Infant
(6
months)
100-160
80-150
70-110
65-110
60-90
80-160
80-160
70-120
60-90
60-90
50-90
30-80
30-60
24-40
22-34
18-30
12-20
60-90
87-105
95-105
95-110
97-112
112-128
20-60
50-66
50-66
50-78
57-80
66-80
36.5-37.5
36.5-37.5
36.0-37.2
36.0-37.2
36.0-37.2
36.0-37.2
(beats/min)
Heart Rate (asleep)
(beats/min)
Respiratory Rate
(breaths/min)
Systolic BP
(5-95%) (mmHg)
Diastolic BP
(5-95%) (mmHg)
Temperature
(oC)
Annexes
80
Southern Health Clinical Practice Guideline for the Management of Bronchiolitis in Infants and Children
Glossary
Child
Infant
Person aged between 12 months and 19 years
Person aged 12 months or less
Acronyms and Abbreviations
95%CI
ABG
ALRI
BPD
CBC
CLD
EIA
GDG
HR
ICU
IFA
IQR
LOS
NPA
PCR
RDAI
RR
RSV
RSVIG
Glossary
95% confidence interval
Arterial blood gas
Acute lower respiratory infection
Bronchopulmonary dysplasia
Complete blood count
Chronic lung disease
Enzyme immuno-assays
Guideline development group
Heart rate
Intensive care unit
Immunofluorescence assay
Interquartile range
Length of stay
Nasopharyngeal aspirate
Polymerase chain reaction
Respiratory Distress Assessment Instrument
Respiratory rate
Respiratory syncytial virus
Respiratory syncytial virus immunoglobulin
81