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Education & Practice Online First, published on December 1, 2015 as 10.1136/archdischild-2015-309156
GUIDELINE REVIEW
1
Astrid Lindgren Childrens INFORMATION ABOUT CURRENT Consider referring children with increased
Hospital, Karolinska University
GUIDELINE respiratory rate >60 breaths/min, decreased
Hospital, Stockholm, Sweden
2
Respiratory Department, Bronchiolitis is a lower respiratory tract oral fluid intake or clinical dehydration.
Birmingham Childrens Hospital, infection commonly seen in children less Be mindful of differential diagnoses of
Birmingham, UK than 1 year of age.1 2 Predominantly bronchiolitis, which include virus-induced
Correspondence to
occurring in winter months, bronchiolitis wheeze and pneumonia.
Dr Jane R Clarke, Respiratory is in the majority managed in the primary
Department, Birmingham care setting, but it contributes to a signifi- For admission and management
Childrens Hospital, Steelhouse cant proportion of the admissions to Admit children with symptoms suggesting
Lane, Birmingham, B4 6NH, UK;
paediatric wards with a small number severe illness.
jane.clarke@bch.nhs.uk
requiring intensive care. The National Consider admission in those particularly at
Received 31 July 2015 Institute for Health and Care Excellence risk of severe illness (see box 2).
Revised 18 October 2015 Consider physiotherapy in children with
(NICE) guideline Bronchiolitis in
Accepted 25 October 2015
Children was published in June 2015.1 It bronchiolitis and other comorbidities who
aims to direct management of bronchio- might have difficulty clearing secretions.
litis in both primary and secondary care. Give supplemental oxygen to children
The guideline was developed by the with persistent SpO2 <92%.
National Collaborating Centre for Give continuous positive airway pressure
Womens and Childrens Health. (CPAP) to children with impending
respiratory failure.
Do not use pharmacological interventions
PREVIOUS GUIDELINE
in the treatment of bronchiolitis: adren-
This is the first NICE guideline that
aline, hypertonic saline (HS), salbutamol,
covers bronchiolitis. The Scottish
montelukast, ipratropium bromide, sys-
Intercollegiate College Network pub-
temic or inhaled corticosteroids.
lished a guideline in 2006 detailing diag-
Consider supportive fluid management as
nosis, management and prevention of
orogastric (OG) or nasogastric (NG) feed
bronchiolitis.3 The American Association
for those with inadequate oral intake.
of Paediatrics published a guideline with
Intravenous fluids are indicated for chil-
a similar scope in October 2014.2
dren who cannot tolerate OG/NG feed or
Traditionally, there is discrepancy in ter-
in those with respiratory failure.
minology between the UK and the USA,
with clinical conditions described in the
For discharge
UK as virus-induced wheeze or infantile
Consider discharge when the infant is clin-
asthma termed bronchiolitis in USA. This
ically stable, is tolerating feeds and has had
makes it difficult to compare studies and
SpO2 >92% in room air for >4 h includ-
guidelines (see table 1 and box 1).
ing during a period of sleep.
Provide information on the importance of
KEY ISSUES OF THE GUIDELINE avoiding environmental smoke exposure
RECOMMENDS because of its deleterious effects on a child
For diagnosis and referral with bronchiolitis.
Measure percutaneous oxygen saturation
(SpO2) by a health professional with UNDERLYING EVIDENCE
appropriate training for SpO2 measure- BASE/METHODOLOGY
To cite: Caffrey Osvald E, ment in infants and children. This, like all NICE recommendations, is
Clarke JR. Arch Dis Child Educ
Pract Ed Published Online
Urgently refer children with signs of severe based on systematic reviews of research
First: [ please include Day illness: apnoea, severe respiratory distress, evidence. Where no substantive clinical
Month Year] doi:10.1136/ central cyanosis, persisting SpO2 <92%, research evidence is found, the recom-
archdischild-2015-309156 inadequate fluid intake. mendation will be based on other
Caffrey Osvald E, Clarke JR. Arch Dis Child Educ Pract Ed 2015;0:13. doi:10.1136/archdischild-2015-309156 1
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
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Guideline review
Bronchiolitis definition Respiratory illness occurring in children Respiratory illness occurring in Respiratory illness occurring in children <2 years
<2 years, but commonly <1 year and children <1 year, but commonly Viral upper respiratory tract infection followed by
peaking in ages 36 months aged 36 months increased respiratory effort and wheezing. Using
Cough and tachypnoearecession, Crackles are the hallmark this diagnosis will include virus-induced wheeze
and wheezecrackles Absence of crackles and only Specific differential diagnoses not discussed
Differential diagnosis: pneumonia, wheeze is VIW
VIW and early-onset asthma Differential diagnosis: asthma,
pneumonia among others
Supplemental oxygen SpO2 <92% SpO2 <92% SpO2 <90%
Chest physiotherapy Recommended for patients with Not recommended for children not Not recommended
comorbidity admitted to intensive care
Nutrition/hydration Initially OG/NG feed unless in Consider OG/NG feeds or NG feed or intravenous fluids
(when oral intake respiratory failure intravenous fluids if unable to OG feed not discussed
inadequate) maintain oral intake or hydration
Pharmacological No role for steroids, bronchodilators, No role for antivirals, steroids, No role for steroids, bronchodilators, adrenaline
intervention adrenaline or montelukast bronchodilators, adrenaline or or montelukast
montelukast
No role for HS HS not discussed HS recommended if admitted (not in emergency
department)
Airway suctioning Recommended in children with Nasal suctioning in infants with Not recommended
apnoea, respiratory distress or respiratory distress due to nasal
difficulty feeding because of secretions blockage
Prevention strategies Not discussed Strategies to limit disease Hand washing
transmission, including hand Targeted palivizumab immunisation
washing
Targeted palivizumab
immunisation
AAP, American Association of Pediatrics; HS, hypertonic saline; NG, nasosgastric; NICE, The National Institute for Health and Care Excellence; OG,
orogastric; SIGN, Scottish Intercollegiate College Network; SpO2, percutaneous oxygen saturation; VIW, virus-induced wheeze.
evidence-based guidelines or the collective experience Empower parents and caregivers looking after children
of the Guideline Development Group (see box 1). with bronchiolitis at home to recognise signs, which
should prompt a clinical review (see box 3).
WHAT DO I NEED TO KNOW
What should I stop doing? What can I continue to do as before?
Undertaking routine blood testing or capillary gas Convey childs degree of respiratory distress and hydra-
testing. tion status when referring to secondary care.
Routinely performing chest radiographs. Recognise signs of respiratory insufficiency.
Administering nebulised HS. Provide supportive care to maintain hydration and
oxygenation.
What should I start doing?
Perform upper airway suctioning in babies with apnoea. What should I do differently?
Deciding to refer or discharge a patient should depend
on carers ability to manage bronchiolitis in the home.
Using persistent SpO2 <92% as a cut-off for commen-
cing oxygen therapy.
Box 1 Resources
2 Caffrey Osvald E, Clarke JR. Arch Dis Child Educ Pract Ed 2015;0:13. doi:10.1136/archdischild-2015-309156
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Guideline review
Caffrey Osvald E, Clarke JR. Arch Dis Child Educ Pract Ed 2015;0:13. doi:10.1136/archdischild-2015-309156 3
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These include:
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Notes