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Bronchiolitis: Less is More

Shawn Ralston, MDChildren’s Hospital at DartmouthGeisel School of Medicine at Dartmouth

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NO Conflict of Interest to declare.

It’s bronchiolitis, of course I am going to talk about off-label use of medication.

What else is there?

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AAP practice guideline: Diagnosis and management of bronchiolitis. Pediatrics 2006;118(4):1774-93.

1. The diagnosis is clinical2. Bronchodilators are not recommended3. Corticosteroids are not recommended4. Ribavirin is not recommended5. Antibiotics are not recommended6. Chest physiotherapy is not recommended, oral rehydration pref.7. Oxygen saturation threshhold is 90% and continuous monitoring no necessary8. Prophylaxis is recommended for particular subsets of patients9. Hand hygiene with alcohol hand gel is preferred10. Secondhand smoke exposure is bad and should be addressed

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Has anything changed in the last 7 years? -Yes and no….

Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010; (12):CD001266.

Hartling L, Bialy LM, Vandermeer B. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2011;(6):CD003123.

Fernandes RM, Bialy LM, Vandermeer B. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2010;(10):CD004878.

Perotta C, Ortiz Z, Roque M. Chest physiotherapy for acute bronchiolitis in pediatric patients between 0 and 24 months old. Cochrane Database of Syst Rev. 2007;(1):CD004873.

Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP. Nebulized hypertonic saline for acute bronchiolitis in infants. Cochrane Database of Syst Rev. 2013;(7):CD006458.

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Beta-Agonists

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Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010; (12):CD001266

Hospitalization Rates

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Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010; (12):CD001266

Duration of Hospitalization

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Clinical Scores

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Epinephrine

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Hartling L, Bialy LM, Vandermeer B. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2011;(6):CD003123

Hospitalization Rates

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Hartling L, Bialy LM, Vandermeer B. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2011;(6):CD003123

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Hartling L, Bialy LM, Vandermeer B. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2011;(6):CD003123

Clinical Score

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HOT OFF THE PRESS!

Skjerven et al. Racemic adrenaline and inhalation strategies in acute bronchiolitis. NEJM 2013.

-study of 404 infants randomized to epi or saline, scheduled vs. on demand

CONCLUSIONS: In the treatment of acute bronchiolitis in infants, inhaled racemic adrenaline is not more effective than inhaled saline. However, the strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule. (huh? It doesn’t work, but it works better if you use it less)

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Corticosteroids

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Fernandes RM, Bialy LM, Vandermeer B. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2010;(10):CD004878

Length of Stay

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Fernandes RM, Bialy LM, Vandermeer B. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2010;(10):CD004878.Hospitalization Rates

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Clinical Scores

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HOT OFF THE PRESS

Al Ansari et al. Oral dexamethasone for bronchiolitis: a randomized trial. Pediatrics 2013

-200 infants(mean age 3.5 mos) with eczema or prior wheezing received high doses of Dex, 1mg/kg on day one and then 0.6mg/kg for 4 days thereafter, decreased time to discharge from short stay unit, decreased risk of admission

Directly contradictory to Corneli, NEJM 2007, who examined a 1 mg/kg dose of Dex in the ED in multiple US centers in 600 infants and saw no decreased risk of admission, including a subset of nearly 400 infants with the hx of eczema or family hx of asthma

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Hypertonic Saline

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Zhang L, et al. Nebulized hypertonic saline for acute bronchiolitis in infants. Cochrane Database of Syst Rev. 2013;(7):CD006458.

Length of Stay

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Zhang L, et al. Hospitalization Rate

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Zhang L, et al. Respiratory Scores

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Last I checked…not much works!

“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 DF, et al. Effect of practice variation on resource utilization in infants hospitalized for viral lower respiratory illness. Pediatrics. 2001;108:851-855.

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Chest Radiography

Schuh S, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007 Apr;150(4):429-33.

Prospective cohort study, 265 pts, Infants with typical bronchiolitis do not need imaging because it is almost always consistent with bronchiolitis, especially in children with saturation higher than 92% and mild to moderate distress.

Yong JH, et al. A cost effectiveness analysis of omitting radiography in diagnosis of acute bronchiolitis. Pediatr Pulmonol. 2009 Feb;44(2):122-7.

For infants with typical bronchiolitis, omitting radiography is cost saving without compromising diagnostic accuracy of alternate diagnoses and of associated pneumonia.

Knapp JF et al. Benchmarks for the emergency department care of children with asthma, bronchiolitis, and croup. Pediatr Emerg Care. 2010 May;26(5):364-9

Benchmarks for ordering x-rays were 17% for both asthma and bronchiolitis

Papoff P et al. Incidence and predisposing factors for severe disease in previously healthy term infants experiencing their first episode of bronchiolitis. Acta Paediatr. 2011 Jul;100(7):e17-23.

Consolidation of CXR did not characterize disease severity in the multiple regression analysis

Van Cleve WC, et al. Unnecessary care for bronchiolitis decreases with increasing inpatient prevalence of bronchiolitis. Pediatrics. 2011 Nov;128(5):e1106-12.

During winter months, with each 1% absolute increase in inpatient bronchiolitis prevalence, patients were less likely to receive radiographs (incidence rate ratio: 0.988)

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Viral TestingMansbach, et al. Prospective multicenter study of the viral etiology of bronchiolitis in the emergency department. Acad Emerg Med. 2008 Feb;15(2):111-8.

Children with only rhinovirus present were more likely to be African American, have a history of wheezing, and receive steroids in the ED.

Bozel, et al. Frequent detection of viral coinfection in children hospitalized with acute respiratory tract infection using a real-time polymerase chain reaction. Pediatr Infect DisJ. 2008 Jul;27(7):589-94.

Viral co-infection is frequent (16.1%), especially with RSV and human bocavirus

Flaherman, et al. Respiratory syncytial virus testing during bronchiolitis episodes of care in an integrated health care delivery system: a retrospective cohort study. ClinTher. 2010 Dec;32(13):2220-9.

Among hospitalized infants who were tested and had a diagnostic code suggesting treatment with antibiotics, use of antibiotics was significantly lower among those with a positive RSV test (63.4%) than those with a negative RSV test (75.5%)

Papoff, et al. Incidence and predisposing factors for severe disease in previously healthy term infants experiencing their first episode of bronchiolitis. Acta Paediatr. 2011 Jul;100(7):e17-23.

RSV infection independently associated with severe disease (not consistent with other lit)

Mansbach, et al. Prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis. Arch Pediatr Adolesc Med. 2012 Aug;166(8):700-6.

Multiple pathogen infections were present in 29.8% of the children and children with RSV had longer LOS than those without.

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Ancillary testing/CBC’s

Tarini , et al. Institutional variation in ordering complete blood counts for children hospitalized with bronchiolitis. J Hosp Med. 2007 Mar;2(2):69-73.

Unexplained variation across hospitals, increased cost

Purcell, et al. Lack of usefulness of an abnormal white blood cell count for predicting a concurrent serious bacterial infection in infants and young children hospitalized with respiratory syncytial virus lower respiratory tract infection.Pediatr Infect Dis J. 2007 Apr;26(4):311-5.

The probability of an abnormal WBC count <5000 and 15,000-30,000 being associated with a concurrent serious bacterial infection was very low and no different from that of a normal WBC count in febrile patients admitted with RSV LRTI.

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Why should I care?

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Berwick, D. M. et al. JAMA doi:10.1001/jama.2012.362

Waste in US Healthcare

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Author Intervention/Location Outcomes

Adcock 1998Local Guideline,Kosair Children’s Hospital,Louisville, Kentucky

RSV testing Bronchodilator utilization Isolation precautions Readmission rates Antibiotic utilization LOS

Perlstein 1999

Local Guideline (with order set and respiratory score),Children’s Hospital Medical Center Cincinnati, Ohio

Admission rates LOS Beta-agonist utilization RSV testing Chest radiographs Cost

Perlstein 2000Local Guideline (same as above),Children’s Hospital Medical Center Cincinnatti, Ohio

Admission rates LOS Beta-agonist utilization RSV testing Chest radiographs Cost

Harrison 2001Local Guideline,Syracuse, NY

Albuterol utilization Documentation of response to

albuterol Discharged on albuterol Utilization of oxygen Utilization of cardiorespiratory

monitoring

Quality Improvement Literature

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Study Intervention/Location Outcomes

Kotagal 2002

Local Guidelines,Eleven children’s hospitals in the Child Health Accountability Initiative

Bronchodilator usage Steroid use LOS

Todd 2002Local 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 2005Multi-center Pathway,Four hospitals in Australia

Readmission rates IV fluid utilization Steroid utilization

King 2007CPOE decision support,Children’s Hospital of Eastern Ontario

Albuterol utilization Antibiotic utilization

Quality Improvement Literature

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Kotagal UR, et al. Impact of a bronchiolitis guideline: a multisite demonstration project. Chest. 2002;121:1789-97.

Figure 1. Frequency and intensity of bronchodilator treatments.

80% of patients get an average of 10 doses per patient

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Kotagal UR, et al. Impact of a bronchiolitis guideline: a multisite demonstration project. Chest. 2002;121:1789-97.

Figure 1. Frequency and intensity of bronchodilator treatments.

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Ralston S, et al. Reducing unnecessary utilization in acute bronchiolitis care: Results from the value in inpatient pediatrics network. Journal of Hospital Medicine. 2013; 8:25-30.

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

2007 2008 2009 2010

Bronchodilator doses/patient

2007 2008 2009 2010

7.6 6.5 6.3 4.2 p<0.001

5.2-9.9 4.6-8.4 4.7-7.9 3.3-5.1 CI

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Wright FH, Beem MO. Management of Acute Bronchiolitis in Infancy. Pediatrics 1965;35;334.

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¿Questions?

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Evaluations