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Improving the Management of Children With BronchiolitisUpdate of Bronchiolitis Guideline: The Updated American Academy of Pediatrics Clinical Practice Guideline FREE TO VIEW

Siew C. Su, MBBS; Anne B. Chang, MBBS, PhD
Author and Funding Information

From the Queensland Children’s Respiratory Centre (Dr Su and Prof Chang), Queensland Children’s Medical Research Institute, Royal Children’s Hospital Brisbane, Queensland University of Technology; and Child Health Division (Prof Chang), Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.

CORRESPONDENCE TO: Anne B. Chang, MBBS, PhD, Queensland Children’s Respiratory Centre, Royal Children’s Hospital Brisbane, Herston Rd, Herston, QLD, 4029, Australia; e-mail: annechang@ausdoctors.net


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(6):1428-1430. doi:10.1378/chest.14-2024
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Published online

Bronchiolitis is the most common cause of hospitalization of very young children.1 Although the mortality associated with bronchiolitis is low in affluent countries, the related cost and morbidity are high,2 especially in some minority groups, such as indigenous children.3 Despite the burden of illness, there is a relative paucity of evidence-based guidelines on the management of bronchiolitis in and out of hospitals. Prior to the updated bronchiolitis guideline from the American Academy of Pediatrics (AAP),1 the latest most comprehensive collation of evidence for the management of bronchiolitis was that from the Scottish Intercollegiate Guidelines Network (SIGN) guideline from the United Kingdom,2 where the latest search date was 2005. Thus, the updated AAP bronchiolitis guideline,1 which has incorporated relevant data from the past 10 years, should be a welcomed document by clinicians worldwide.

The updated guideline contains many new and clinically important changes1; of the 14 recommendations, only four (1, 7, 8, and 11) have minimal or no changes from the 2006 guideline.4 The rest of the recommendations are new or amended, reflecting the evidence obtained from newer studies. Statements referring to the use of ribavirin and complementary and alternative medicines, present in the previous guideline,4 have been omitted in the updated guideline.1 All but four recommendations (6, 9, 12b, and 14) have B-rated evidence (studies with minor limitations; consistent findings from multiple observational studies) or higher.1 The most important cost-saving change is arguably the recommendation (10a) against the use of palivizumab prophylaxis for all healthy children born prematurely (≥ 29 weeks gestation).1,5 Not surprisingly, this was followed by “big pharma” remonstration.6

Other important changes in the updated guideline1 include when to consider the use of hypertonic saline (recommendation 4), the definitive statement not to use short-acting β2-agonists (recommendation 2) or epinephrine (recommendation 3), and the alternate use of nasogastric fluids to IV fluids (recommendation 9). The technical report is currently in preparation1 and will contain further information not reflected in the recommendations, such as data on nasal suctioning and the use of high-flow nasal and home therapy oxygen.

Like the 2006 AAP bronchiolitis guideline,4 important dissimilarities between the updated 2014 guideline1 and SIGN guideline2 are the following: when supplementary oxygen should be considered (AAP, oxygen saturation as measured by pulse oximetry [Spo2] < 90%1,4; SIGN, Spo2 ≤ 92%2), the use of continuous Spo2 monitoring (AAP, not routinely recommended1,4; SIGN, recommended for 8-12 h after cessation of oxygen2), and virology testing (AAP recommends that laboratory testing should not be obtained1,4; SIGN recommends rapid virologic testing for cohorting children2).

Why should clinicians take note of or use clinical practice guidelines? The previous AAP bronchiolitis guideline4 has been credited with a significant reduction in the use of diagnostic and therapeutic resources7 in the United States, although variation in bronchiolitis management persists even after almost 8 years of implementation.8 High-quality and well-implemented guidelines can reduce variance in clinical care, reduce cost,7 and, most importantly, improve clinical outcomes.9 However, the quality of guidelines are highly variable,9 including those endorsed by academic societies,10 and perhaps unsurprisingly, guidelines are not universally popular. Furthermore, poorly developed guidelines, such as those overseen by panel members with close relationships with big pharma, propagate discontent about guidelines,10 create management dilemmas for physicians, and are possibly harmful to patients.9,10 Good clinical guidelines are transparent, derived from a rigorous process, and reviewed externally, and they disseminate “the most scientifically sound healthcare practice”9 undertaken by a multidisciplinary panel whose members are free of financial conflicts.9,11 The updated AAP guideline1 has a multidisciplinary panel (including a methodologist, a parent/consumer, a family physician, a neonatologist, general pediatricians, pediatric pulmonologists, pediatric hospitalists, emergency physicians, intensivists, and infectious disease physicians) that has no financial ties to pharmaceutical companies and that underwent an extensive peer review process (including review by the American Academy of Family Physicians, American College of Chest Physicians, American Thoracic Society, and American College of Emergency Physicians). The panel of the updated AAP guideline1 thus responds to the eight items of guideline panel review outlined by Lenzer and colleagues.9

The updated AAP guideline1 lists ideas for future research, highlighting the incompleteness of the guideline related to insufficient existing data. Other important clinical questions include issues reflecting the differences in the AAP1,4 and SIGN guidelines2 described previously; the diagnosis and management of possible coexisting pneumonia in settings with a high incidence of pneumonia-related deaths; postdischarge monitoring, particularly for at-risk children; and postbronchiolitis syndrome and its management.12

Guidelines should never represent “cookbook medicine” and are not a substitute for individualized high-quality clinical care because patients, families, and settings are heterogenous, necessitating individualized nuances and deviations in selected circumstances. However, when implemented well, the contribution of untainted high-quality guidelines to improved clinical outcomes is undisputed.9,11 The field of guideline development and implementation has undergone substantial changes11 since defined in the 1990s as “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.”13 The high standard of the 2014 AAP guideline is important in our current era and advances the field of guidelines and the management of bronchiolitis as described previously. It is thus highly likely that the updated guideline1 along with its accompanying technical report and that on the guidance for the use of palivizumab5 will be welcomed by clinicians worldwide. The guideline’s value in improving clinical outcomes and the use of resources now depends on its implementation.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Prof Chang has undertaken studies related to the management of bronchiolitis and is a panel member for several guidelines unrelated to bronchiolitis. Dr Su has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Ralston S, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis and management of bronchiolitis. Pediatrics. In press.
 
Scottish Intercollegiate Guidelines Network. Bronchiolitis in children, 2006. SIGN website. http://www.sign.ac.uk/pdf/sign91.pdf. Accessed August 15, 2014.
 
Chang AB, Brown N, Toombs M, et al. Lung disease in indigenous children [published online ahead of print May 16, 2014]. Paediatr Respir Rev. doi:10.1016/j.prrv.2014.04.016.
 
American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118(4):1774-1793. [CrossRef] [PubMed]
 
Committee on Infectious Diseases and Bronchiolitis Guidelines Committee. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics. 2014;134(2):415-420. [CrossRef] [PubMed]
 
Tanner L. Virus drugmaker fights pediatricians’ new advice. Associated Press website. http://bigstory.ap.org/article/virus-drugmaker-fights-pediatricians-new-advice. Accessed August 26, 2014.
 
Parikh K, Hall M, Teach SJ. Bronchiolitis management before and after the AAP guidelines. Pediatrics. 2014;133(1):e1-e7. [CrossRef] [PubMed]
 
Florin TA, Byczkowski T, Ruddy RM, Zorc JJ, Test M, Shah SS. Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics Bronchiolitis Guidelines [published online ahead of print July 8, 2014]. J Pediatr. doi:10.1016/j.jpeds.2014.05.057.
 
Lenzer J, Hoffman JR, Furberg CD, Ioannidis JP; Guideline Panel Review Working Group. Ensuring the integrity of clinical practice guidelines: a tool for protecting patients. BMJ. 2013;347:f5535. [CrossRef] [PubMed]
 
Lenzer J. Why we can’t trust clinical guidelines. BMJ. 2013;346:f3830. [CrossRef] [PubMed]
 
Woolf S, Schünemann HJ, Eccles MP, Grimshaw JM, Shekelle P. Developing clinical practice guidelines: types of evidence and outcomes; values and economics, synthesis, grading, and presentation and deriving recommendations. Implement Sci. 2012;7:61. [CrossRef] [PubMed]
 
McCallum GB, Morris PS, Chang AB. Antibiotics for persistent cough or wheeze following acute bronchiolitis in children. Cochrane Database Syst Rev. 2012;12:CD009834. [PubMed]
 
Field MJ, Lohr KN., eds. Clinical Practice Guidelines: Directions for a New Program. Institute of Medicine. Washington, DC: National Academy Press; 1990.
 

Figures

Tables

References

Ralston S, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis and management of bronchiolitis. Pediatrics. In press.
 
Scottish Intercollegiate Guidelines Network. Bronchiolitis in children, 2006. SIGN website. http://www.sign.ac.uk/pdf/sign91.pdf. Accessed August 15, 2014.
 
Chang AB, Brown N, Toombs M, et al. Lung disease in indigenous children [published online ahead of print May 16, 2014]. Paediatr Respir Rev. doi:10.1016/j.prrv.2014.04.016.
 
American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118(4):1774-1793. [CrossRef] [PubMed]
 
Committee on Infectious Diseases and Bronchiolitis Guidelines Committee. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics. 2014;134(2):415-420. [CrossRef] [PubMed]
 
Tanner L. Virus drugmaker fights pediatricians’ new advice. Associated Press website. http://bigstory.ap.org/article/virus-drugmaker-fights-pediatricians-new-advice. Accessed August 26, 2014.
 
Parikh K, Hall M, Teach SJ. Bronchiolitis management before and after the AAP guidelines. Pediatrics. 2014;133(1):e1-e7. [CrossRef] [PubMed]
 
Florin TA, Byczkowski T, Ruddy RM, Zorc JJ, Test M, Shah SS. Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics Bronchiolitis Guidelines [published online ahead of print July 8, 2014]. J Pediatr. doi:10.1016/j.jpeds.2014.05.057.
 
Lenzer J, Hoffman JR, Furberg CD, Ioannidis JP; Guideline Panel Review Working Group. Ensuring the integrity of clinical practice guidelines: a tool for protecting patients. BMJ. 2013;347:f5535. [CrossRef] [PubMed]
 
Lenzer J. Why we can’t trust clinical guidelines. BMJ. 2013;346:f3830. [CrossRef] [PubMed]
 
Woolf S, Schünemann HJ, Eccles MP, Grimshaw JM, Shekelle P. Developing clinical practice guidelines: types of evidence and outcomes; values and economics, synthesis, grading, and presentation and deriving recommendations. Implement Sci. 2012;7:61. [CrossRef] [PubMed]
 
McCallum GB, Morris PS, Chang AB. Antibiotics for persistent cough or wheeze following acute bronchiolitis in children. Cochrane Database Syst Rev. 2012;12:CD009834. [PubMed]
 
Field MJ, Lohr KN., eds. Clinical Practice Guidelines: Directions for a New Program. Institute of Medicine. Washington, DC: National Academy Press; 1990.
 
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