Each year, a multidisciplinary review group at St. Louis Children’s Hospital (SLCH) reviews and, as needed, revises its guidelines for inpatient treatment of bronchiolitis. Last November, the review process was influenced by the American Academy of Pediatrics’ (AAP) newly updated clinical practice guidelines for the diagnosis, management and prevention of bronchiolitis in children aged 1-23 months. Of particular interest to the review group were significant changes made by the AAP regarding treatment protocols.
“The previous AAP guidelines dated from 2006, and since that time there has been a substantial body of literature published in regard to treating bronchiolitis,” says Christine Hrach, MD, Washington University pediatric hospitalist at SLCH. “Overall, these studies supported eliminating a number of routine treatments prescribed for children with bronchiolitis and instead adopting more of a watchful waiting and supportive care approach.”
The AAP treatment recommendations for children diagnosed with bronchiolitis have three classifications: strong, moderate and weak. Among the strong recommendations are to:
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Not administer albuterol or salbutamol
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Not administer epinephrine
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Not administer systemic corticosteroids
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Not administer antibacterial medications unless there is a concomitant bacterial infection or strong suspicion of one
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Administer nasogastric or intravenous fluids for children who cannot maintain hydration orally
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Recommendations for moderate bronchiolitis include:
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Not routinely obtaining radiographic or laboratory studies when diagnosing bronchiolitis rather than relying on history and physical examination
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Refraining from administering nebulized hypertonic saline in the emergency department
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Refraining from using chest physiotherapy
“We have been proactive about keeping up with published literature, so we already had been reducing our use of albuterol and imaging and particularly discouraging the use of antibiotics,” says Anne Borgmeyer, MSN, RN, CPNP, AE-C, pediatric nurse practitioner, Asthma Intervention Model (AIM) Project. “Instead we have concentrated on, as needed, supporting hydration with nasogastric or IV fluids, supplementing oxygen to prevent hypoxia, and giving a fever reducer to make patients more comfortable. Unless patients develop a complication, it’s become a matter of letting the bronchiolitis run its course.”
The new Children’s Hospital guidelines were developed with input from SLCH hospitalists, pulmonologists and an infectious disease physician; AIM nurse practitioners; respiratory therapists; nurses and residents.
For a copy of the SLCH guideline, contact Anne Borgmeyer, [email protected] or Dr. Hrach at [email protected]. For questions call Children’s Direct at 800.678.HELP (4357).
