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A clinical companion to the NICE guide on bronchiolitis

The authors discuss the realities of clinical practice and the evidence behind common interventions for bronchiolitis.

The authors discuss the realities of clinical practice and the evidence behind common interventions for bronchiolitis

Picture: Alamy

The National Institute for Health and Care Excellence (NICE) (2015) defines bronchiolitis as a lower respiratory tract infection affecting children under two years, peaking between three and six months. It affects about one in three infants in the first year of life, making it the most common respiratory infection in infants (NICE 2015, 2016). Of these infants, 2-3% will require admission to hospital (NICE 2016).

Respiratory syncytial virus (RSV) is the most common organism detected in the nasopharyngeal aspirate in hospitalised infants, although other viruses such as rhinovirus, parainfluenza virus, influenza virus, adenovirus and human metapneumovirus are increasingly being recognised (Paul et al 2016).

As most infants with bronchiolitis are managed at home, the data available from the literature is not reflective of the true incidence and may represent only the ‘tip of the iceberg’. Bronchiolitis is a clinical diagnosis. Parents and carers of children with bronchiolitis need to be given key information about what to expect and when to be concerned if caring for their child at home (NICE 2016). Infants requiring admission to hospital usually receive supportive care.

Risk factors for severe respiratory disease include:

  • History of chronic lung disease.
  • Congenital heart disease.
  • Premature birth.
  • Neuromuscular disorders.
  • Immunodeficiency.

Main issues addressed by NICE guidelines NICE guidelines (2015) on bronchiolitis offer best practice advice on the care of children with bronchiolitis. The guidelines address diagnosis and the red flag criteria that should prompt referral and admission to hospital (Box 1), guidance on appropriate investigations and management, as well as providing clear discharge criteria for the first time.

Box 1. Red flags for bronchiolitis
  • Increased work of breathing, such as grunting, nasal flaring, and marked chest recession.
  • Fluid intake of 50-75% of normal or less.
  • No wet nappy for more than 12 hours.
  • Signs of exhaustion, such as waking only with prolonged stimulation.
  • Any apnoeas or cyanosis.

(NICE 2015)

With the development of new therapeutic strategies, clinical practice had become varied across the UK. The NICE guidelines aim to streamline care in the NHS by giving recommendations for best practice. General recommendations from NICE (2015, 2016) of what should and should not be done in clinical practice are summarised in Table 1.

Table 1. What should and should not be done in clinical practice

What should be done in clinical practice

What should not be done in clinical practice

History

  • A prodrome of coryzal symptoms lasting 1-3 days, followed by a cough.
  • Difficulty feeding.
  • Fever (30% of cases).

Examination

  • Increased work of breathing (increased respiratory rate, chest wall recessions, head bobbing, and nasal flaring).
  • Signs of dehydration.
  • Wheeze or crackles on chest auscultation.

Admission criteria

  • SpO2 < 92%.
  • RR >60 per min.
  • Presence of risk factors for severe respiratory disease and red flags (Box 1).

Investigations

  • None indicated routinely.
  • Routine chest X-rays, nasopharyngeal aspirates, blood tests, including blood gas testing.

Treatment

  • Oxygen supplementation if SpO2 < 92.
  • Nasogastric tube feeding if unable to take sufficient fluids by mouth.
  • Continuous positive airway pressure (CPAP) if impending respiratory failure.
  • Intravenous fluids, unless there is impending respiratory failure or not tolerating nasogastric tube feeds.
  • Treatment with antibiotics, nebulized bronchodilators (including salbutamol, ipratropium and adrenaline), nebulized hypertonic saline, corticosteroids, high-flow humidified oxygen, heliox, surfactant, and montelukast.
  • Routine upper airway suctioning and chest physiotherapy.

Discharge criteria

  • Maintained SpO2 >92% in air for four hours, including a period of sleep.
  • Taking adequate oral fluids.
  • Clinically stable.

Source: (NICE 2015, NICE 2016)

Common interventions

Some of the common interventions used in clinical practice when managing infants with bronchiolitis are not included in the recommendations made in the NICE (2015) guidelines or quality standard (2016) and the discussion below highlights why these practices may be helpful.

Nasopharyngeal aspirate

RSV has been historically considered as the most common organism causing bronchiolitis. Guidelines in the past have suggested using nasopharyngeal aspirate (NPA) for cohorting purposes (Paul et al 2016). A cohort study identified multiple viruses in one in three affected children, and therefore cohorting on the basis of a positive RSV result is not evidence based (Mansbach et al 2012). Although anecdotal, our practice is to send NPA as a consultant-only investigation in cases needing advanced respiratory support in a high dependency unit (HDU). This may offer an explanation and some reassurance to parents, and may help avoid unnecessary interventions – such as chest X-rays and antibiotics.

Paediatric early warning scores (PEWS)

Recording of PEWS is used routinely in children admitted with bronchiolitis in UK hospitals. In a US study of 2,979 children, the PEWS tool was found to be a reliable and valid scoring system in identifying children at risk of clinical deterioration (Tucker et al 2009). In another study from Norway with 761 children, a PEWS ≥3 was associated with severe illness and a surrogate marker of cardiorespiratory compromise (Solevåg et al 2013). There is a need for further studies to establish its usefulness, especially in bronchiolitis.

Chest X-rays (CXRs)

Routine use of CXRs is not necessary in bronchiolitis. It should be noted that CXRs cannot differentiate between a viral and a bacterial cause. A systematic review with five studies involving 1,139 children noted that there is no single potential predictor for performing a CXR with airspace disease (Chao et al 2016). The authors provided a decision threshold model for bronchiolitis cases where a CXR may be helpful. This is based on the clinician needing to assess the benefit of using antibiotics in the context of the clinical picture. We suggest that in cases where an infant is deteriorating and needs advanced respiratory support, such as continuous positive airway pressure or ventilation, and antibiotic therapy is considered necessary, it may then be appropriate to request a CXR (NICE 2015).

Antibiotics

Bacteraemia is infrequent in RSV infection, but should be considered in more severe cases of bronchiolitis (Cebey-López et al 2016). A Spanish study with 66 children with RSV positive respiratory illness found a bacterial presence in 10.6% cases: Haemophilus infl uenzae (n=4) and Streptococcus pneumoniae (n=2) (Cebey-López et al 2016). These infants with a bacterial growth had a more severe illness. Antibiotics may be considered for patients with bronchiolitis needing advanced respiratory care in the HDU or paediatric intensive care unit, as there may be a greater risk of secondary bacterial infection.

Intravenous fluids

Adequate hydration is vital in the management of bronchiolitis, and therefore oral feeding and breastfeeding need to be encouraged. If an infant does not have an adequate oral intake, enteral feeding using nasogastric or orogastric tubes should be commenced (NICE 2015). An Israeli study of 51 infants with bronchiolitis assigned 31 to gastric tube feeding and 20 to intravenous fluids. It was demonstrated that gastric tube feeding is feasible and had comparable outcomes (Kugelman et al 2013). Three of the 31 infants receiving gastric tube feeding were changed to intravenous fl uids due to vomiting (Kugelman et al 2013). The American Academy of Pediatrics suggests using 0.9% sodium chloride with glucose in infants who do not tolerate gastric tube feeding due to vomiting, or if there is impending respiratory failure in severe bronchiolitis (Ralston et al 2014).

High-flow nasal cannula oxygen

Devices delivering high-flow humidified oxygen (such as Optiflow®) are increasingly being used in clinical practice across the UK to manage infants with bronchiolitis, with an aim of delivering oxygen effectively while maintaining airway humidity. However, there is limited evidence of its effectiveness and some evidence suggests that this approach can give false reassurance in infants who are beginning to decompensate (Hilliard et al 2012).

An Italian study involving 27 infants showed encouraging results (Bressan et al 2013). A prospective randomised control trial is still being conducted to evaluate the clinical benefi ts and costeffectiveness of high-flow humidified oxygen versus standard oxygen supplementation (Franklin et al 2015).

Nebulisers

Nebulised bronchodilators, such as salbutamol and ipratropium bromide, are not recommended for infants with bronchiolitis. The American Academy of Paediatrics (AAP), however, does recommend nebulised hypertonic saline in hospitalised infants (Ralston et al 2014). Results from a Portuguese randomised controlled trial of 68 children with bronchiolitis does not support the use of nebulised hypertonic saline or salbutamol (Flores et al 2016).

An Indian study of 100 children concluded that nebulisation with 3% hypertonic saline (without additional bronchodilators) is an effective and safe treatment for non-asthmatic, moderately ill patients with acute bronchiolitis (Gupta et al 2016). We suggest that nebulisation with hypertonic saline may be used for symptom relief, but this needs to be done with caution and only be continued if appreciable benefit is demonstrated (Paul et al 2016).

Surfactant

Infants with acute viral bronchiolitis may have reduced surfactant content and function. This was demonstrated in a controlled cross-sectional study of 32 infants receiving mechanical ventilation: 16 with acute viral bronchiolitis and 16 with normal lung function (Hartman et al 2014). Favourable effects of surfactant administration in mechanically ventilated critically ill infants with bronchiolitis was noted in a Cochrane systematic review with 79 participants. However, its translation into clinical practice needs further research (Jat and Chawla 2015).

Palivizumab immunoprophylaxis

Although not included in the NICE (2015) guidelines, administration of intramuscular Palivizumab (monoclonal antibody) in high-risk groups of infants (such as those with acyanotic congenital heart disease and chronic lung disease) has been recommended in the AAP guidelines (Ralston et al 2014). Use of Palivizumab in high risk infants has also been recommended by the Joint Committee on Vaccination and Immunisation in the UK (Public Health England (PHE) 2013). Palivizumab has a half-life in the body in the range of 18 to 21 days and therefore monthly administration during the RSV season (October to February) is required to maintain its concentration at a protective level (PHE 2013).

In a Spanish study of 952 children with bronchiolitis, 60 infants from high-risk groups who had received Palivizumab showed a lower rate of RSV infection, despite having more risk factors associated with a higher risk of infection or complications (Narbona-Lopez et al 2016). Palivizumab was found to be cost-effective compared with no prophylaxis in a cost-effectiveness analysis of RSV prophylaxis in infants in the UK (Bentley et al 2013).

Conclusion

The NICE (2015) guideline is a comprehensive document streamlining the management of bronchiolitis in infants, giving clear and objective recommendations. It provides evidence-based best practice guidelines, and health professionals should use these as their overarching framework when managing infants with bronchiolitis. By following these guidelines inappropriate investigations and potentially harmful interventions, which may have previously been part of routine clinical practice, will be minimised, hopefully streamlining care across the UK.

However, it is acknowledged that the use of high-flow nasal cannula oxygen on acute children’s wards is becoming more common. At present there is little evidence to support its use for the treatment of bronchiolitis, and this is area where more research is needed.


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About the authors

Eleanor Rogers, Karen Greaves and Siba Prosad Paul

Eleanor Rogers is Foundation Trainee, Year 1 at St Marys Hospital, Paddington, London




Karen Greaves is modern matron in paediatrics at Torbay Hospital, Torquay, Devon




Siba Prosad Paul is consultant paediatrician, Torbay Hospital, Torquay, Devon


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