5/17/13

 1

Managing Bronchiolitis: Just Stand There or Do

Something? Michele Long, MD

Associate Clinical Professor Pediatric Hospitalist

Disclosures

I have nothing to disclose

Case: Emma

  Emma is a 4 month old who is brought to your AM clinic by Mom. She has a 3 day history of rhinorrhea and a 1 day history of cough. She has had no fever and is taking PO well. On exam she appears well hydrated. She has retractions that clear when she coughs and diffuse expiratory wheezing on exam. She is breathing faster than normal per Mom. You count her respiratory rate at 50. O2 saturation is 97%.

  Her Mom is very concerned…

…does Emma need a CXR?

A.  Yes to help with diagnosis B.  Yes because Mom is so concerned C.  No it is not necessary for diagnosis D.  No the risks outweigh the benefits

 5/17/13

 2

Bronchiolitis   Most common lower respiratory tract infection in infants   At least 1 in 7 normal infants will develop symptomatic

bronchiolitis before age one   Cardinal pathophysiologic features:

  Increased mucous production   Edema and necrosis of small airway epithelial cells   Acute inflammation   Air-trapping

Symptoms   Upper resp infection

  Rhinitis, Congestion   Lower resp infection

  Tachypnea   Cough   Wheezing   Crackles   Nasal flaring   Accessory muscle use

  Fever in only 30%

Emma has bronchiolitis

  Clinically consistent with mild presentation

  AAP Bronchiolitis Guidelines for CXR “Clinicians should diagnose bronchiolitis and assess

disease severity on the basis of history and physical examination. Clinicians should not routinely order laboratory and radiologic studies for diagnosis”

  Note: CXR in bronchiolitis is between 20% and 89%

* “Diagnosis and Management of Bronchiolitis” Pediatrics 2006

CXR for bronchiolitis?

  Only 2 films missed by ED had findings of concern without other warning sign (like hypoxia or severe respiratory distress)

  One lobar PNA found by radiologist, not ED (RSV+)

  31 Children in the study were hospitalized (11%)

Schuh S et al J Peds 2007

Adapted from Alverson, Hasbro Children’s

 5/17/13

 3

Emma Continued

  Emma and her mom leave clinic. Later that evening Emma is brought to the emergency department for fast breathing and poor PO intake.

  In the emergency department, she appears well hydrated, RR 55, and her oxygen saturation is 94%. Rest of exam unchanged (retractions that clear when she coughs and diffuse expiratory wheezing on exam). She drinks ½ a bottle.

  What would you do next?

What would you do?

A.  Oxygen B.  Bronchodilator trial C.  Single-dose dexamethasone D.  Suction E.  Observe

2006 AAP guidelines

  Oxygen: Warranted if Pulse ox < 90%   Bronchodilator: Consider trial; continue

only if documented clinical response   No routine steroids

  No routine antibiotics   No routine chest physiotherapy

 5/17/13

 4

The bronchodilator story

  Helpful: Schweich et al & Schuh et al improvement in O2 sat and clinical score after 2 albuterol treatments

  Equivocal/not helpful: Klassen et al noted improved clinical scores at 30 minutes – not sustained beyond 1 hour. Gadomski et al saw no benefit Inpatient by Dobson et al saw no benefit

  Meta-analysis (Flores et al) with no change in length of stay

Bronchodilators: 2006

  AAP Bronchiolitis Guideline* “Bronchodilators should not be used routinely in

the management of bronchiolitis. A carefully monitored trial …is an option…and should be continued only if there is a documented positive clinical response to the trial using an objective means of evaluation

  Rate of bronchodilator use is as high as 70%

* Diagnosis and Management of Bronchiolitis. Pediatrics 2006

Summary of Studies

Study Year Where # Bronchodilator Helps?

Schweich 92 OP/ED <50 Y, Short-term

Schuch 90 OP/ED <50 Y, Short-term

Klassen 91 OP/ED <100 Y short term

Gadomski 94 ED <100 No

Dobson 98 IP <100 No

Flores 97 IP Meta No

AAP 06 IP/OP OK to trial

Cochrane 10 IP/OP No

Reasons for avoiding

  Pharmacology: infants don’t have well-developed bronchial wall smooth muscle

  Pathophysiology: primary cause of wheezing secretion-related

  Side effects: tachycardia, tremors

  Cost

 5/17/13

 5

Take home

Cochrane- Gadomski et al 2010: “Bronchodilators produce small short-term

improvements in [outpatient] clinical scores…However, given their high cost, adverse effects and

lack of effect on oxygen saturation and other outcomes…bronchodilators cannot be recommended for routine management of first-time wheezers who

present with…bronchiolitis, in either inpatient or outpatient settings.”

Controversy: hypertonic saline

Study Type N Prep (vs. NS) Results

Mandelberg 03 IP 52 3%+ epi 1 day Length Of Stay

Tal 02 IP 41 3%+ epi 0.9 day LOS

Kuzik 07 IP 96 3% 0.9 day LOS

Luo 10 IP 93 3%+ alb 1.4 day LOS

Luo 10 IP 126 3% 1.6 day LOS

Grewal 09 ED 46 3%+ epi No diff p 2 doses

Anil 10 ED 186 3%+ alb or epi No diff p 2 hr

Kuzik 10 ED 81 3%+ alb No diff p 3 doses

Al-Ansari 10 Obs 187 3% or 5% + epi Improved CSS day 2

Sarrell 02 OP 65 3%+ terb Improved CSS day 2-5

 Alverson and Ralston, Contemp Peds 2011

Wanting to Do Something

While limited data supports many bronchiolitis interventions, there are times providers still

‘intervene’ or ‘test’

  Parental insistence   Standard of care for location (ED), medico-legal   Fear of change   Peer/community pressure   Supervisor preference

PHM Choosing Wisely

Adapted from Monash & Le, UCSF Grand Rounds 2013

 5/17/13

 6

PHM Choosing Wisely

Adapted from Monash & Le, UCSF Grand Rounds 2013

PHM Choosing Wisely

Adapted from Monash & Le, UCSF Grand Rounds 2013

PHM Choosing Wisely

Adapted from Monash & Le, UCSF Grand Rounds 2013

PHM Choosing Wisely

Adapted from Monash & Le, UCSF Grand Rounds 2013

 5/17/13

 7

PHM Choosing Wisely

Adapted from Monash & Le, UCSF Grand Rounds 2013

PHM Choosing Wisely

Adapted from Monash & Le, UCSF Grand Rounds 2013

PHM Choosing Wisely

Adapted from Monash & Le, UCSF Grand Rounds 2013

PHM Choosing Wisely

Adapted from Monash & Le, UCSF Grand Rounds 2013

 5/17/13

 8

PHM Choosing Wisely

Adapted from Monash & Le, UCSF Grand Rounds 2013

!"#$%&"'()'&*+),%&'-(."/'-0+,&.#&*+.1(')#&2.%+&3#*"401.*-%)(&-,%+4-&&"'&5'"#*+."1.%.,6!"#$%&"'()*$+,'$&,-(".#$/*'"#,("(.,'$"&/,(%&(012-$/"'(,3"4$&"#$%&("&+(0"#$,&#(1$-#%.2(5%.(+$")&%-$-(%5("-#14"("&+(6.%&/1$%'$#$-($&(#1,(0,+$"#.$/(0%0*'"#$%&7(8*'#$0',(-#*+$,-(1"9,(,-#"6'$-1,+('$4$#,+(/'$&$/"'(*#$'$#2(%5(/1,-#(."+$%)."01-(5%.(0"#$,&#-(:$#1("-#14"(%.(6.%&/1$%'$#$-7(;4$--$%&(%5(#1,((*-,(%5(/1,-#(."+$%)."012(:$''(.,+*/,(/%-#-<(6*#(&%#(/%40.%4$-,(+$")&%-#$/("//*."/2("&+(/".,7

!"#$%&'"3%.#)17&3,)&5'"#*+"(.1-%"',&.#&*+.1(')#&2.%+&5'"#*+."1.%.,6=*6'$-1,+()*$+,'$&,-(+%(&%#("+9%/"#,(#1,(.%*#$&,(*-,(%5(6.%&/1%+$'"#%.-($&(0"#$,&#-(:$#1(6.%&/1$%'$#$-7(>%40.,1,&-$9,(.,9$,:-(%5(#1,('$#,."#*.,(1"9,(

$-('$4$#,+(+,4%&-#."#$%&(%5(/',".($40"/#(%5(6.%&/1%+$'"#%.(#1,."02(*0%&(#1,(/%*.-,(%5(+$-,"-,7(?++$#$%&"''2<(0.%9$+,.-(-1%*'+(/%&-$+,.(#1,(0%#,&#$"'($40"/#(%5("+9,.-,(,9,&#-(*0%&(#1,(0"#$,&#7

!"#$%&3,)&,7,%)4.*&*"'%.*",%)'".(,&.#&*+.1(')#&3#()'&8&7)-',&"9&-/)&&2.%+&-#&3#*"401.*-%)(&1"2)'&'),0.'-%"'7&%'-*%&.#9)*%."#6=*6'$-1,+()*$+,'$&,-(.,/%44,&+(#1"#(/%.#$/%-#,.%$+(4,+$/"#$%&-(&%#(6,(*-,+(.%*#$&,'2($&(#1,(4"&"),4,&#(%5(6.%&/1$%'$#$-7(@*.#1,.4%.,<("++$#$%&"'(

,300'),,."#&%+)'-076

(

:$#1("/$+(-*00.,--$%&(#1,."027

((

%.(:,''(+%/*4,&#,+7

3

1

2

5

4

(%&(#1$-('$-#(%.(#1,$.($&+$9$+*"'(-$#*"#$%&(-1%*'+(/%&-*'#(#1,$.(012-$/$"&7(

!"#$%&'(")(*"+,$&-.(/%0$#$1%(2(:)(.-%'.*&;",0.%-1&<)(.*.#)

=.>)&?+.#/,&:+7,.*.-#,&&-#(&:-%.)#%,&@+"31(&A3),%."#

http://www.choosingwisely.org

QI Approach

  Consensus   Measure current   Define a shared goal (achievable)   Intervention   Re-measure   Modify intervention

0 10 20 30 40 50 60 70 80

Bron

chod

ilato

rs

CXR

Ster

oids

Ches

t PT

Mean use (2009) Target

VIP Inpatient Data

 5/17/13

 9

Summary   Current best evidence does not support ordering

CXR’s or routine use of bronchodilators in uncomplicated bronchiolitis

  Hypertonic Saline shows promise but further evidence is needed

  Good hand washing and avoiding cigarette smoke are among the best evidence-supported advice we can provide patients

  Changing practice patterns takes time and may be more effective with QI approaches and if we commit to ‘Choosing Wisely’

Acknowledgements

  Tim Kelly MD

  Karen Sun MD

  Brad Monash MD

  Brian Alverson MD

  Emily Whitgob MD

Key References and Resources   Choosing Wisely- Pediatric Hospital Medicine guidelines. Feb

2011 www.choosingwisely.org.

  American Academy of Pediatrics. Diagnosis and Management of Bronchiolitis, Subcommittee on Diagnosis and Management of Bronchiolitis. Pediatrics. 2006 Oct;118(4):1774-93.

  Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database of Systematic Reviews 2010.

  Alverson B, Ralston S. Bronchiolitis: focus on hypertonic saline. Contemporary Pediatrics. Feb 2011.

  Wright M, Mullett CJ, Piedimonte G. Pharmacologic Management of Acute Bronchiolitis. Ther Clin Risk Manag. 2008 Oct;4(5):895-903.

References and Resources   Schuh S, Canny G, Reisman JJ, et al. Nebulized albuterol in

acute bronchiolitis. J Pediatr. 1990;117:633–7.   Schweich PJ, Hurt TL, Walkley EI, et al. The use of nebulized

albuterol in wheezing infants. Pediatr Emerg Care. 1992;8:184–8.

  Klassen TP, Rowe PC, Sutcliffe T, et al. Randomized trial of salbutamol in acute bronchiolitis. J Pediatr. 1991;118:807–11.

  Gadomski AM, Lichenstein R, Horton L, et al. Efficacy of albuterol in the management of bronchiolitis. Pediatrics. 1994;93:907–12.

  Dobson JV, Stephens-Groff SM, Mcmahon SR, et al. The use of albuterol in hospitalized infants with bronchiolitis. Pediatrics. 1998;101:361–8.

 5/17/13

 10

References and Resources   Flores G, Horwitz RI. Efficacy of beta2-agonists in

bronchiolitis: a reappraisal and meta-analysis. Pediatrics. 1997;100:233–9.

  Schuh S, Coates AL, Binnie R, Allin T, Goia C, Corey M, et al. Efficacy of oral dexamethasone in outpatients with acute bronchiolitis. J Pediatr 2002;140:27-32.

  Corneli HM, Zorc JJ, Mahajan P, Shaw KN, Holubkov R, Reeves SD, et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med 2007;357:331-9.

  Yong JHE et al. A cost effectiveness analysis of omitting radiography in diagnosis of acute bronchiolitis. Pediatric Pulmonology 44:122-127, 2009

References and Resources   Schuh S et al. Evaluation of the Utility of Radiography in

Acute Bronchiolitis. J of Pediatrics. 2007;150:429–433.   Von Woensel JB, van Aalderen WM, Kimpen JL. Viral lower

respiratory tract infection in infants and young children. BMJ 2003 Jul 5;327(7405):36–40.

  PEM Bronchiolitis Blog pemcincinnati.com   AAP Section on Hospital Medicine Listserv

Extra NOTES