Bronchiolitis pittenger

1. Bronchiolitis: A
Reintroduction to
an Old Friend
Jaime Pittenger, MD, FAAP
Pediatric Hospitalist
Assistant Professor
Department of Pediatrics
University of Kentucky

2. Disclosures
 I have no disclosure to make at this time.

3. Objectives
 Briefly review basic information about
bronchiolitis
 Discuss current trends in management of
bronchiolitis
 Evaluate the evidence for evidence
based medicine

4. “Since acute viral bronchiolitis is thus a self-limited disease of relatively
good prognosis, the principle of primum non nocere should temper
frustrated anxiety to do something-anything-to relieve severe dyspnea.
Simple physical exhaustion may determine the fate of an infant laboring to
meet his metabolic requirements for oxygen. His energies should not be
frittered away by the annoyance of unnecessary or futile medications and
procedures. Rest should be treasured.”
Pediatrics, 1965
Is This New?

5. A Case
 2 month old previously healthy male infant is
brought to the Emergency Department with clinical
bronchiolitis
 Wheezing, nasal congestion, and poor feeding
reported by parent; low grade fever noted at home
 T 101°F, HR 175, RR 65, SaO2 92% on RA
 Infant in moderate respiratory distress, IC and SC
retractions, wheezing in all lung fields, CR<3 sec

7. What would you do?
 The next step in management should be:
A. Place nasal cannula and provide
supplemental oxygen
B. Provide albuterol by nebulizer
C. Provide racemic epinephrine by
nebulizer
D. Provide nasal suction

8. Risk Factors For Severe Disease
 Prematurity
 Chronic lung disease of infancy (BPD)
 Congenital heart disease
 Pulmonary hypertension
 Neuromuscular disease
 Cystic fibrosis
 Immunocompromised infant

9. Hospitalization
 Children with severe disease
 Toxic with poor
feeding, lethargy, dehydration
 Moderate to severe respiratory distress (RR
> 70, dyspnea, cyanosis)
 Apnea
 Hypoxemia
 Parent unable to care for child at home

10. Prevention
 Good hand washing
 Avoidance of cigarette smoke
 Avoiding contact with individuals with
viral illnesses
 Influenza vaccine for children > 6 months
and household contacts of those children

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

12. Shay DK, et al. JAMA. 1999;282:1440-6.
Among U.S. Children Less Than 1-Year Old, 1980-1996
Annual Bronchiolitis Hospitalizations
40,000
50,000
60,000
70,000
80,000
90,000
100,000
110,000
120,000
130,000
140,000
Hospitalizations
0
10,000
20,000
30,000

13. Is It Getting Worse?
 Maybe….
 Changes in trends:
 Routine use of pulse oximetry 1980 vs. Today
 Routine use of chest x-ray 1980 vs. Today
 Routine utilization of ED services 1980 vs.
Today
 Flat mortality rate 1979-1996
Shay DK, et al. J Infect Dis 2001;183:16–22

14. Bronchiolitis Management Preferences and the
Influence of Pulse Oximetry and Respiratory Rate
on the Decision to Admit
Mallory MD, et al. Pediatrics 2003;111:e45–e51.
 Members of AAP Section of Emergency Medicine
 76% Board Certified in Pediatric EM
 Mean post-training experience = 10 years
 Randomized into 4 groups and sent different
questionnaires

16. Bronchiolitis Management Preferences and the
Influence of Pulse Oximetry and Respiratory Rate on
the Decision to Admit
Mallory MD, et al. Pediatrics 2003;111:e45–e51.
Measured Outcome Oxygen sat = 94% Oxygen sat = 92%
RR=50
(n=119)
RR=65
(n=125)
RR=50
(n=124)
RR=65
(n=117)
Decision to admit 43% 58% 83% 85%
(Χ2 = 5.021;P = .025) (Χ2 = 0.126;P = 0.723)
Treat with
bronchodilator
92% 95% 97% 98%
2nd neb if no benefit 60% 56% 62% 62%
Supplemental
Oxygen
34% 39% 75% 81%
Nasal Suction 80% 82% 85% 80%
Chest x-ray 55% 58% 64% 67%

17. Here’s the Punch Line…

18. The Baby Goes with the NOSE!
Nose suction is
the most
common, yet
unstudied, inte
rvention for
bronchiolitis

19. Bronchiolitis ALWAYS affects
the nose
FIX MY
nose!!!!

20. 23

21. The diagnosis should be made
clinically
Bronchodilators are not recommended
Corticosteroids are not recommended
Ribavirin is not recommended
Antibiotics are not recommended
Chest physiotherapy is not
recommended, oral rehydration is
preferred
AAP practice guideline: Diagnosis and
management of bronchiolitis. Pediatrics
2006;118(4):1774-93.

22. Oxygen saturation threshold is 90%
and continuous monitoring not
necessary
Prophylaxis is recommended for
particular subsets of patients
Hand hygiene with alcohol hand gel is
preferred
Secondhand smoke exposure is bad
and should be addressed
Ask about use of alternative medicine

23. New meta-analyses since last
guideline
 Beta-agonists: Gadomski AM, Brower M. Bronchodilators
for bronchiolitis. Cochrane Database Syst Rev. 2010;
(12):CD001266.
 Epinephrine: Hartling L, Bialy LM, Vandermeer B.
Epinephrine for bronchiolitis. Cochrane Database Syst
Rev. 2011;(6):CD003123.

24. Gadomski AM, Brower M. Bronchodilators for bronchiolitis.
Cochrane Database Syst Rev. 2010; (12):CD001266.
Authors’ conclusions:
 Bronchodilators do not improve oxygen
saturation, do not reduce hospital admission
after outpatient treatment, do not shorten the
duration of hospitalization and do not reduce
the time to resolution of illness at home.
 The small improvements in clinical scores for
outpatients must be weighed against the
costs and adverse effects of bronchodilators.

25. Hartling L, Bialy LM, Vandermeer B.
Epinephrine for bronchiolitis. Cochrane
Database Syst Rev. 2011;(6):CD003123.
Author’s Conclusions:
 This review demonstrates the superiority of epinephrine
compared to placebo for short-term outcomes for
outpatients, particularly in the first 24 hours of care.
 Exploratory evidence from a single study suggests
benefits of epinephrine and steroid combined for later
time points. More research is required to confirm the
benefits of combined epinephrine and steroids among
outpatients.
 There is no evidence of effectiveness for repeated dose
or prolonged use of epinephrine or epinephrine and
dexamethasone combined among inpatients.

26. 29
1. Randomized, double-blind, placebo controlled trial
2. 5 day course of prednisolone or placebo
3. 700 enrolled , ages 10 months- 60months
4. Primary outcome: LOS
5. Secondary outcomes: Score on Preschool Respiratory
Assessment Measure ; Albuterol use; 7 day symptom score

27. Author’s Conclusions:
 Current evidence does not support a clinically
relevant effect of systemic or inhaled
glucocorticoids on admissions or length of
hospitalization.
 Combined dexamethasone and epinephrine
may reduce outpatient admissions, but results
are exploratory and safety data limited.
Fernandes RM, Bialy LM, Vandermeer B.
Glucocorticoids for acute viral bronchiolitis in
infants and young children. Cochrane
Database Syst Rev. 2010;(10):CD004878.

28. So why bother?

29. Berwick, D. M. et al. JAMA doi:10.1001/jama.2012.362
Waste in US Healthcare

30. Choosing Wisely
 Don’t order chest radiographs in children with
uncomplicated asthma or bronchiolitis.
 Don’t routinely use bronchodilators in children with
bronchiolitis.
 Don’t use systemic corticosteroids in children under 2
years of age with an uncomplicated lower respiratory
tract infection.
 Don’t treat gastroesophageal reflux in infants
routinely with acid suppression therapy.
 Don’t use continuous pulse oximetry routinely in
children with acute respiratory illness unless they are
on supplemental oxygen.

31.  Airway clearance: suction first, last, and as
needed
 Nutritional Support: Often overlooked
 Oxygen: recommendations for its use and
clear guidelines for its discontinuation.
 Eliminate the utilization of unnecessary
resources with the implementation of an
objective scoring tool to validate the
effectiveness and the need for continuation
of an intervention.
Basic Elements of Evidence –
based care for Bronchiolitis.
34

32. Author Intervention/Location Outcomes
Adcock 1998
Local Guideline,
Kosair Children’s Hospital,
Louisville, Kentucky
RSV testing
Bronchodilator utilization
Isolation precautions
Readmission rates
Antibiotic utilization
LOS
Perlstein 1999
Local Guideline,
Children’s Hospital Medical Center
Cincinnati, Ohio
Admission rates
LOS
Beta-agonist utilization
RSV testing
Chest radiographs
Cost
Perlstein 2000
Local Guideline (same as above),
Children’s Hospital Medical Center
Cincinnatti, Ohio
Admission rates
LOS
Beta-agonist utilization
RSV testing
Chest radiographs
Cost
Harrison 2001
Local Guideline,
Syracuse, NY
Albuterol utilization
Documentation of response to
albuterol
Discharged on albuterol
Utilization of oxygen
Utilization of cardiorespiratory
monitoring

33. Study Intervention/Location Outcomes
Kotagal 2002
Local Guidelines,
Eleven children’s hospitals in the Child
Health Accountability Initiative
Bronchodilator usage
Steroid use
LOS
Todd 2002
Local Guideline and Respiratory
Distress Score, The Children’s
Hospital,
Denver, Colorado
Bronchodilator utilization
Antibiotic utilization
Chest physiotherapy
RSV testing
Ribavirin utilization
Nosocomial infection rate
Muething 2004
ED care algorithm, admission order
set, respiratory score;
Children’s Hospital Medical Center
Cincinnatti, Ohio
Bronchodilator Utilization
RSV testing
Chest radiographs
LOS
Cheney 2005
Multi-center Pathway,
Four hospitals in Australia
Readmission rates
IV fluid utilization
Steroid utilization
King 2007
CPOE decision support,
Children’s Hospital of Eastern Ontario
Albuterol utilization
Antibiotic utilization

34. Respiratory Assessment Score
0 - Normal 1 – Mild 2 - Moderate 3 - Severe
Resp Rate < 40 40 – 50 50 – 60 > 60
Color
O2 Sat on RA
Cap Refill
Normal
>97%
< 2 sec.
Normal
94-96% on RA
< 2 sec.
Normal
90-93% on RA
< 2 sec.
Dusky, Mottled
< 90%
= > 3 sec.
Retractions /
WOB
None Subcostal Intercostal &
Subcostal when
Quiet
Supraclavicular
Sternal
Paradoxical
respiration
Air Entry
Wheezing
Breath Sounds
Clear / Good
Good Entry
End Exp. Wheeze
+/- Rales
Fair Air Entry
Insp and Exp
Wheeze +/- Rales
Poor / Grunting
Insp and Exp
Wheeze +/- Rales
LOC Normal / Alert Mild Irritability Restless When
Disturbed -
Agitated
Lethargic, Hard
to Arouse
Dayton Children’s Medical Center, by permission.

35. Nebulizer Trial
SCORE RESPIRATORY TREATMENT OTHER THERAPY
0-2 NORMAL Assess Q6 PRN Normal Saline Nose Drops; Bulb
Syringe Suction for Home
3-6 MILD Aerosol Trial with Racemic Epinephrine or Albuterol; If
response is positive continue aerosol Q6; If not
responsive assess Q6 PRN
Oxygen per Protocol (SpO2>91%);
Suction PRN with Bulb Syringe,
Neotech Little Sucker™ or Catheter
7-10 MODERATE Aerosol Trial with Racemic Epi or Albuterol; If response
is positive continue aerosol Q4. If not responsive, trial
alternate medication. Assess Q4 PRN
Consider Chest X-ray; consider
capillary blood gas; Normal Saline
Nose Drops; Suction PRN with Bulb
Syringe, Neotech Little Sucker™ or
Catheter; IV fluids if patient exhibits
dehydration or failure to feed; Oxygen
per Protocol
11-15 SEVERE Aerosol Trial with Racemic Epi or Albuterol, If response
is positive continue aerosol Q2-4, If not responsive trial
alternate medication. Assess Q2 PRN
Chest X-Ray; IV fluids; Blood Gas;
Excessive PCO2, acidosis or
hypoxia should be transferred to ICU;
Oxygen per Protocol

36. ED Algorithm
Admit as 23-hr Observation Admit as Inpatient
Admit to PICU
DC Home
Nebulizer Trial
Admit to PICU
Assess Clinical Symptoms,
including Respiratory Score
Pt < 24 months presents with upper
respiratory infection symptoms & wheezing
Meets DC
Criteria?
Does Pt
Require IV
Fluids
Or O2?
Symptoms Improve?
Symptoms
Resolve with
Nasal Suctioning?
Witnessed
Apnea?
Yes
Yes
Yes
Yes
Yes
Yes
No
Meets ICU
Criteria?
No
No
No
No
No
No
Modified from Bronchiolitis CPG, Children’s Medical
Center, Dayton, OH

37. Nebulizer Trial is Recommended For a Post Suction Score of 3 or Higher
(Racemic Epinephrine if no history of wheezing; Albuterol if history of wheezing)
BRONCHIOLITIS SCORING SHEET
Pre
Suction
Score
Post
Suction
Score (Pre
Nebulizer)
Post
Nebulizer
Score
Pre
Suction
Score
Post
Suction
Score
(Pre
Nebulizer
)
Post
Nebulizer
Score
Respiratory Rate
0),<40 2)50-60
1)40-50 3)>60
Color, Room Air Saturation, Capillary Refill
0),>97,<2seconds 2),90-93,<2seconds
1),94-96,<2seconds 3)Dusky/mottled,<90,>3seconds
Retractions
0)None 2)Intercostal and subcostal when quiet
1)Subcostal 3)Supraclavicular,sternal,paradoxical respiration
Air Entry, Breath Sounds
(insp=inspiratory, exp=expiratory)
0)Good,clear 2)Fair,insp and exp wheeze +/- rales
1)Good,exp wheeze 3)Poor,insp and exp wheeze +/- rales
LOC
0)Normal/alert 2)Restless when disturbed/agitated
1)Mild irritability 3)Lethargic/hard to arouse
Total
Nebulizer trial recommended Yes____ No____
Medication Used: Albuterol or Racemic Epinephrine
Date/Time___________ Initials_______ Date/Time__________ Initials_______
Positive Response Yes___ No___ Positive Response Yes___ No___
(A positive response is defined as a decrease in the post nebulizer score by 2 or more.)
Continued Management/Education/Comments:
___________________________________________________________________________________________
___________________________________________________________________________________________

38.  New AAP guideline currently being
developed and will be published in mid to
late 2014
 Will not change the basic
recommendations in the 2006 guideline but
will be a little clearer about not routine
using albuterol and what to trial – evidence
favors epi over albuterol
 Will not recommend hypertonic saline
Evidence on the horizon
41

39. ~2900 Studies later….

40. The Bottom Line
“Ascertainment of optimal care is difficult
because our therapies are supportive, not
curative, and most children do well
irrespective of differences in therapy.
Consequently, there is a propensity to
persist in care practices that may offer
little or marginal benefit.”
Willson, et al. Pediatr
2001;108(4):851
16

41. A Case
 2 month old previously healthy male infant is
brought to the Emergency Department with clinical
bronchiolitis
 Wheezing, nasal congestion, and poor feeding
reported by parent; low grade fever noted at home
 T 101°F, HR 175, RR 65, SaO2 92% on RA
 Infant in moderate respiratory distress, IC and SC
retractions, wheezing in all lung fields, CR<3 sec

42. What would you do?
 The next step in management should be:
A. Place nasal cannula and provide
supplemental oxygen
B. Provide albuterol by nebulizer
C. Provide racemic epinephrine by
nebulizer
D. Provide nasal suction
E. Obtain a chest x-ray

43. MUST READ!
 Diagnosis and Management of
Bronchiolitis
Subcommittee on Diagnosis and
Management of Bronchiolitis
Pediatrics 2006;118;1774-1793

44. Further Reading
 McBride. RSV and Asthma: Is There a Link? 1998;34.
 Lowell et al. Pediatrics. 1987;79:939.
 Menon et al. J Pediatr. 1995;126:1004.
 Infants have airway tone and responsiveness to ß-agonists similar to older
children & adults
Goldstein A, et al. Am J Resp Crit Care Med 2001;164:447-54
 Responsiveness to bronchodilators in bronchiolitis is not age dependent
Modl M et al. J Pediatr 2005;147:617-21
 Short acting beta-agonists have no clear benefit in children less than 2 years
old
Chavasse R, et al. Cochrane Rev 2009
 1-2% of nebulized dose reaches lungs of infants
Amirav I, et al. J Nucl Med 2002;43(4):487-91
 α / β-agonist epinephrine has no clear benefit in inpatients with bronchiolitis
Harding L, et al. The Cochrane Database of Systematic Reviews 2004;1.
 RSV may reduce β-agonist responsiveness of human airway smooth muscle
Moore P, et al. Am J Resp Cell Molec Biol 2006;35:559-64.

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