Pediatrics-2006--bronsiolita guidline

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  • DOI: 10.1542/peds.2006-2223 2006;118;1774Pediatrics

    Subcommittee on Diagnosis and Management of BronchiolitisDiagnosis and Management of Bronchiolitis

    http://pediatrics.aappublications.org/content/118/4/1774.full.htmllocated on the World Wide Web at:

    The online version of this article, along with updated information and services, is

    of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2006 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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  • CLINICAL PRACTICE GUIDELINE

    Diagnosis and Management ofBronchiolitisSubcommittee on Diagnosis and Management of Bronchiolitis

    Endorsed by the American Academy of Family Physicians, the American College of Chest Physicians, and the American Thoracic Society.

    ABSTRACTBronchiolitis is a disorder most commonly caused in infants by viral lower respi-ratory tract infection. It is the most common lower respiratory infection in this agegroup. It is characterized by acute inflammation, edema, and necrosis of epithelialcells lining small airways, increased mucus production, and bronchospasm.

    The American Academy of Pediatrics convened a committee composed ofprimary care physicians and specialists in the fields of pulmonology, infectiousdisease, emergency medicine, epidemiology, and medical informatics. The com-mittee partnered with the Agency for Healthcare Research and Quality and the RTIInternational-University of North Carolina Evidence-Based Practice Center todevelop a comprehensive review of the evidence-based literature related to thediagnosis, management, and prevention of bronchiolitis. The resulting evidencereport and other sources of data were used to formulate clinical practice guidelinerecommendations.

    This guideline addresses the diagnosis of bronchiolitis as well as various ther-apeutic interventions including bronchodilators, corticosteroids, antiviral and an-tibacterial agents, hydration, chest physiotherapy, and oxygen. Recommendationsare made for prevention of respiratory syncytial virus infection with palivizumaband the control of nosocomial spread of infection. Decisions were made on thebasis of a systematic grading of the quality of evidence and strength of recommen-dation. The clinical practice guideline underwent comprehensive peer reviewbefore it was approved by the American Academy of Pediatrics.

    This clinical practice guideline is not intended as a sole source of guidance in themanagement of children with bronchiolitis. Rather, it is intended to assist clini-cians in decision-making. It is not intended to replace clinical judgment or estab-lish a protocol for the care of all children with this condition. These recommen-dations may not provide the only appropriate approach to the management ofchildren with bronchiolitis.

    INTRODUCTIONTHIS GUIDELINE EXAMINES the published evidence on diagnosis and acute manage-ment of the child with bronchiolitis in both outpatient and hospital settings,including the roles of supportive therapy, oxygen, bronchodilators, antiinflamma-tory agents, antibacterial agents, and antiviral agents and make recommendationsto influence clinician behavior on the basis of the evidence. Methods of prevention

    www.pediatrics.org/cgi/doi/10.1542/peds.2006-2223

    doi:10.1542/peds.2006-2223

    All clinical practice guidelines from theAmerican Academy of Pediatricsautomatically expire 5 years afterpublication unless reafrmed, revised, orretired at or before that time.

    The recommendations in this guidelinedo not indicate an exclusive course oftreatment or serve as a standard of care.Variations, taking into account individualcircumstances, may be appropriate.

    KeyWordbronchiolitis

    AbbreviationsCAMcomplementary and alternativemedicineLRTIlower respiratory tract infectionAHRQAgency for Healthcare Researchand QualityRSVrespiratory syncytial virusAAPAmerican Academy of PediatricsAAFPAmerican Academy of FamilyPhysiciansRCTrandomized, controlled trialCLDchronic neonatal lung diseaseSBIserious bacterial infectionUTIurinary tract infectionAOMacute otitis mediaSpO2oxyhemoglobin saturationLRTDlower respiratory tract disease

    PEDIATRICS (ISSN Numbers: Print, 0031-4005;Online, 1098-4275). Copyright 2006 by theAmerican Academy of Pediatrics

    1774 AMERICAN ACADEMY OF PEDIATRICS

    Organizational Principles to Guide andDene the Child Health Care System and/orImprove the Health of All Children

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  • are reviewed, as is the potential role of complementaryand alternative medicine (CAM).

    The goal of this guideline is to provide an evidence-based approach to the diagnosis, management, and pre-vention of bronchiolitis in children from 1 month to 2years of age. The guideline is intended for pediatricians,family physicians, emergency medicine specialists, hos-pitalists, nurse practitioners, and physician assistantswho care for these children. The guideline does notapply to children with immunodeficiencies includingHIV, organ or bone marrow transplants, or congenitalimmunodeficiencies. Children with underlying respira-tory illnesses such as chronic neonatal lung disease(CLD; also known as bronchopulmonary dysplasia) andthose with significant congenital heart disease are ex-cluded from the sections on management unless other-wise noted but are included in the discussion of preven-tion. This guideline will not address long-term sequelaeof bronchiolitis, such as recurrent wheezing, which is afield with distinct literature of its own.

    Bronchiolitis is a disorder most commonly caused ininfants by viral lower respiratory tract infection (LRTI).It is the most common lower respiratory infection in thisage group. It is characterized by acute inflammation,edema and necrosis of epithelial cells lining small air-ways, increased mucus production, and bronchospasm.Signs and symptoms are typically rhinitis, tachypnea,wheezing, cough, crackles, use of accessory muscles,and/or nasal flaring.1 Many viruses cause the same con-stellation of symptoms and signs. The most commonetiology is the respiratory syncytial virus (RSV), with thehighest incidence of RSV infection occurring betweenDecember and March.2 Ninety percent of children areinfected with RSV in the first 2 years of life,3 and up to40% of them will have lower respiratory infection.4,5

    Infection with RSV does not grant permanent or long-term immunity. Reinfections are common and may beexperienced throughout life.6 Other viruses identified ascausing bronchiolitis are human metapneumovirus, in-fluenza, adenovirus, and parainfluenza. RSV infectionleads to more than 90 000 hospitalizations annually.Mortality resulting from RSV has decreased from 4500deaths annually in 1985 in the United States2,6 to anestimated 510 RSV-associated deaths in 19976 and 390in 1999.7 The cost of hospitalization for bronchiolitis inchildren less than 1 year old is estimated to be more than$700 million per year.8

    Several studies have shown a wide variation in howbronchiolitis is diagnosed and treated. Studies in theUnited States,9 Canada,10 and the Netherlands11 showedvariations that correlated more with hospital or individ-ual preferences than with patient severity. In addition,length of hospitalization in some countries averagestwice that of others.12 This variable pattern suggests alack of consensus among clinicians as to best practices.

    In addition to morbidity and mortality during the

    acute illness, infants hospitalized with bronchiolitis aremore likely to have respiratory problems as older chil-dren, especially recurrent wheezing, compared withthose who did not have severe disease.1315 Severe dis-ease is characterized by persistently increased respiratoryeffort, apnea, or the need for intravenous hydration,supplemental oxygen, or mechanical ventilation. It isunclear whether severe viral illness early in life predis-poses children to develop recurrent wheezing or if in-fants who experience severe bronchiolitis have an un-derlying predisposition to recurrent wheezing.

    METHODSTo develop the clinical practice guideline on the diagno-sis and management of bronchiolitis, the AmericanAcademy of Pediatrics (AAP) convened the Subcommit-tee on Diagnosis and Management of Bronchiolitis withthe support of the American Academy of Family Physi-cians (AAFP), the American Thoracic Society, the Amer-ican College of Chest Physicians, and the European Re-spiratory Society. The subcommittee was chaired by aprimary care pediatrician with expertise in clinical pul-monology and included experts in the fields of generalpediatrics, pulmonology, infectious disease, emergencymedicine, epidemiology, and medical informatics. Allpanel members reviewed the AAP Policy on Conflict ofInterest and Voluntary Disclosure and were given anopportunity to declare any potential conflicts.

    The AAP and AAFP partnered with the AHRQ and theRTI International-University of North Carolina Evi-dence-Based Practice Center (EPC) to develop an evi-dence report, which served as a major source of infor-mation for these practice guideline recommendations.1

    Specific clinical questions addressed in the AHRQ evi-dence report were the (1) effectiveness of diagnostictools for diagnosing bronchiolitis in infants and children,(2) efficacy of pharmaceutical therapies for treatment ofbronchiolitis, (3) role of prophylaxis in prevention ofbronchiolitis, and (4) cost-effectiveness of prophyla