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SIGN guideline on bronchiolitis in infants

J Harry Baumer Arch. Dis. Child. Ed. Pract. 2007;92;149-151 doi:10.1136/adc.2007.126524

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SIGN GUIDELINE ON BRONCHIOLITIS IN INFANTS

Edited by Foxit Reader Copyright(C) by Foxit Software Company,2005-2008 GUIDELINE REVIEW For Evaluation Only.

J Harry Baumer

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Arch Dis Child Educ Pract Ed 2007; 92:ep149ep151. doi: 10.1136/adc.2007.126524

predictable event in the paediatricians year is the advent of the bronchiolitis season somewhere around November or December, with large numbers of hospital admissions of infants, especially those under 6 months of age. This continues to occur despite recent developments including the availability of palivizumab for prophylaxis in high-risk infants. The Scottish Intercollegiate Guidelines Network (SIGN) published an evidence-based guideline on the condition in November 2006.1 The guidelines purpose is to reduce some of the reported variations in management, avoiding unnecessary tests and interventions. It covers prevention; recognition and differential diagnosis; indications for hospital admission and the in-patient management of infants with bronchiolitis; limiting disease transmission, and prognosis. Its scope includes infants up to 12 months of age and excludes management in intensive care. This review highlights those aspects particularly relevant to paediatricians. The other recommendations in the guideline can readily be accessed from the SIGN website (http:// www.sign.ac.uk). The grading system gives a grade A to directly relevant evidence from randomised controlled trials (RCTs) with a low risk of bias; grade B to evidence from cohort or case control studies with a very low risk of bias or confounding and a strong likelihood that the relationship is causal, or extrapolated evidence from RCTs; grade C to less reliable evidence from cohort or case control studies; and grade D to evidence from case reports, case series or expert opinion. Good practice points (3) represent the opinion of the guideline development group.

KEY POINTS
Prophylaxis c Routine use of palivizumab is not recommended (3). c Palivizumab may be considered for use, on a case-by-case basis, in infants less than 12 months old with (3): extreme prematurity acyanotic congenital heart disease congenital or acquired significant orphan lung diseases* immune deficiency. c A local lead specialist should work with the appropriate clinical teams to identify those infants who may benefit from palivizumab (3). Hospital referral c Most infants with acute bronchiolitis will have mild disease and can be managed at home with primary care support. Parents/caregivers should be given information on how to recognise any deterioration in their infants condition and asked to bring them back for reassessment should this occur (3). c Any of the following indications should prompt hospital referral/acute paediatric assessment in an infant with acute bronchiolitis or suspected acute bronchiolitis (3): poor feeding (,50% of usual fluid intake in preceding 24 h) lethargy history of apnoea respiratory rate .70/min presence of nasal flaring and/or grunting severe chest wall recession cyanosis oxygen saturation (94%
*

__________________________ Correspondence to: Dr J H Baumer, Consultant Paediatrician, Derriford Hospital, Plymouth, Devon PL6 8DH, UK; harry.baumer@phnt. swest.nhs.uk __________________________

Rare lung diseases

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Edited by Foxit Reader GUIDELINE REVIEW Copyright(C) by Foxit Software Company,2005-2008 For Evaluation Only.
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uncertainty regarding diagnosis. Clinicians assessing the need to refer (or review in primary care) should also take account of whether the illness is at an early (and perhaps worsening) stage, or at a later (improving) stage (3). The threshold for hospital referral should be lowered in patients with significant comorbidities, those less than 3 months of age or infants born at less than 35 weeks gestation. Geographical factors/transport difficulties and social factors should also be taken into consideration (3).

Hospital management

chest physiotherapy using vibration and percussion (Grade A). Nasal suction should be used to clear secretions in infants hospitalised with acute bronchiolitis who exhibit respiratory distress due to nasal blockage (Grade D). Nasogastric feeding should be considered in infants with acute bronchiolitis who cannot maintain oral intake or hydration (Grade D). Infants with oxygen saturation levels (92% or who have severe respiratory distress or cyanosis should receive supplemental oxygen by nasal cannulae or facemask (Grade D).

Investigations
c

Pulse oximetry should be performed in every child who attends hospital with acute bronchiolitis (Grade C). Infants with oxygen saturation (92% require inpatient care. Decision-making around hospitalisation of infants with oxygen saturations between 92% and 94% should be supported by detailed clinical assessment, consideration of the phase of the illness and take into account social and geographical factors. Infants with oxygen saturations .94% in room air may be considered for discharge. Blood gas analysis (capillary or arterial) is not usually indicated in acute bronchiolitis. It may have a role in the assessment of infants with severe respiratory distress or who are tiring and may be entering respiratory failure. Knowledge of arterialised carbon dioxide values may guide referral to high dependency or intensive care (3). Chest x ray should not be performed in infants with typical acute bronchiolitis (Grade C). Chest x ray should be considered in those infants where there is diagnostic uncertainty or an atypical disease course (3). Unless adequate isolation facilities are available, rapid testing for respiratory syncytial virus (RSV) is recommended in infants who require admission to hospital with acute bronchiolitis, in order to guide cohort arrangements (Grade D). Routine bacteriological testing (of blood and urine) is not indicated in infants with typical acute bronchiolitis. Bacteriological testing of urine should be considered in febrile infants less than 60 days old. (Grade C) Full blood count is not indicated in assessment and management of infants with typical acute bronchiolitis (Grade D). Measurement of urea and electrolytes is not indicated in the routine assessment and management of infants with typical acute bronchiolitis but should be considered in those with severe disease (Grade D).

High dependency or intensive care

c

Indications for high dependency/intensive care unit consideration include (3): failure to maintain oxygen saturations of greater than 92% with increasing oxygen therapy deteriorating respiratory status with signs of increasing respiratory distress and/or exhaustion recurrent apnoea. Early discussion with a paediatric intensive care unit and introduction of respiratory support should be considered in all patients with severe respiratory distress or apnoeas (3).

Discharge planning
c

Infants who have required supplemental oxygen therapy should have oxygen saturation monitoring for a period of 8 12 h after therapy is discontinued (including a period of sleep) to ensure clinical stability before being considered for discharge (3). Infants with oxygen saturations .94% in room air may be considered for discharge (3). Hospitalised infants should not be discharged until they can maintain an adequate daily oral intake (.75% of usual intake) (3). Parents and carers should be informed that, from the onset of acute bronchiolitis, around half of infants without comorbidity are asymptomatic by two weeks but that a small proportion will still have symptoms after four weeks (Grade B).

Infection control
c

Treatment
c

The following are not recommended for the treatment of acute bronchiolitis in infants: nebulised ribavirin (grade B) antibiotic therapy (3) inhaled beta 2 agonist bronchodilators (grade B) nebulised ipratropium (3) nebulised epinephrine (Grade A) inhaled corticosteroids (Grade A) oral systemic corticosteroids (Grade A)

Healthcare professionals should be educated about the epidemiology and control of RSV where appropriate (Grade D). Staff should decontaminate their hands (with soap and water or alcohol gel) before and after caring for patients with viral respiratory symptoms (Grade D). Gloves and plastic aprons (or gowns) should be used for any direct contact with the patient or their immediate environment (Grade D). Infected patients should be placed in single rooms. If adequate isolation facilities are unavailable, the allocation of patients into cohorts should be based on laboratory confirmation of infection in all in-patients less than 2 years of age with respiratory symptoms (Grade D). Both service providers and staff should be aware of the risk that those with upper respiratory tract infections pose for high-risk infants (Grade D). Local policies should restrict hospital visiting by those with symptoms of respiratory infections (Grade D).

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GUIDELINE REVIEW

There should be ongoing surveillance by control of infection staff to monitor compliance with infection control procedures (Grade D).

COMMENTARY
The guideline provides a ready source of information about the current evidence for or against the different aspects of management of bronchiolitis in infants under 12 months of age. It includes a quick reference guide and written advice for parents. One of its aims is to reduce the use of unnecessary investigations and treatments. There are recommendations against a number of treatments, including four with a Grade A. In general a recommendation against treatment can be made if there is evidence that any benefits are outweighed by harm, if there is evidence of ineffectiveness, or if the cost is considered unacceptable. In the case of oral steroids the Cochrane reviewers2 conclude that limited current evidence is unable to show any benefit and widespread use is not recommended until the benefits and harms can be clarified further. In the two RCTs that considered outcomes separately in infants less than 1 year of age there was no difference in length of hospital stay. A very recent and much larger 20 centre RCT from the USA3 that enrolled 600 infants under 12 months of age found no significant difference in rate of hospitalisation or respiratory score at 4 h or subsequent outcome from 1 mg/kg of dexamethasone administered orally in the hospital emergency room, compared to placebo. The Cochrane review on nebulised adrenaline in bronchiolitis4 did not look separately at outcomes in infants under 12 months of age, and the one RCT cited by the guideline authors5 did not find any significant benefits. Similarly, the evidence from RCTs for nebulised steroid treatment and chest physiotherapy suggests lack of benefit. The use of palivizumab is dealt with in some detail. This humanised monoclonal antibody does not prevent RSV infection but reduces the risk of hospital admission in infected preterm infants, with an estimate that between 16 and 21 such infants would need to be treated to prevent one admission with RSV bronchiolitis. There is no evidence of benefit in hospitalised infants with bronchiolitis, nor of prevention of RSV infection. The financial costs of treatment outweigh savings from reduced hospital admission. Studies to date have not targeted the highest-risk preterm infants. The current

recommendation of the UK Joint Committee on Vaccination and Immunisation6 is for palivizumab use in: c Children under 2 years of age with chronic lung disease (oxygen dependency for at least 28 days from birth), on home oxygen or who have had prolonged use of oxygen. c Infants less than 6 months of age who have left to right shunt haemodynamically significant congenital heart dis- ep151 ease and/or pulmonary hypertension. c Children under 2 years of age with severe congenital immunodeficiency. This would mean an estimated 2000 infants a year in the UK needing prophylaxis. A recent bronchiolitis guideline from the American Academy of Pediatrics,7 while covering children up until their second birthday, is largely consistent with the SIGN guideline in most of its recommendations. However, it does recommend oxygen supplementation if the oxygen saturation falls persistently below 90% in previously healthy infants, based on expert opinion and reasoning from first principles. The SIGN guideline advice recommending somewhat higher acceptable oxygen saturation levels is based on the views of the guideline development group. This difference will have a significant impact on the decisions to admit and discharge infants with bronchiolitis. This guideline provides a good basis for local bronchiolitis management policies and for local agreements identifying infants who may benefit from palivizumab.
Competing interests: None declared.

REFERENCES
1 Scottish Intercollegiate Guidelines Network. Bronchiolitis in children, NHS Quality Improvement Scotland. 2 Patel H, Platt R, Lozano JM, et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev 2004;3:CD004878. 3 Corneli H, Zorc J, Majahan P, et al. for the Bronchiolitis Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). A multicenter, randomized, controlled trial of desamethasone for bronchiolitis. N Engl J Med 2007;357 (in press). 4 Hartling L, Wiebe N, Russell K, et al. Epinephrine for bronchiolitis. Cochrane Database Syst Rev 2004;1:CD003123. 5 Wainwright C, Altamirano L, Cheney M, et al. A multicenter, randomized, double-blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med 2003;349:2735. 6 Joint Committee on Vaccination and Immunisation. Minutes of the meeting held on Wednesday 22 June 2005. UK: Department of Health, 2005. Available at http://www.advisorybodies.doh.gov.uk/jcvi/mins220605.htm (accessed 18 July 2007). 7 American Academy of Pediatrics. Diagnosis and management of bronchiolitis. Pediatrics, 2006;118:177493.Available at http:// aappolicy.aappublications.org/cgi/reprint/pediatrics;118/4/1774.pdf (accessed 18 July 2007).

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