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Bronchiolitis AAP 2021
Bronchiolitis AAP 2021
Bronchiolitis AAP 2021
5. Clinicians should not administer 29 weeks, 0 days or greater 12b. Clinicians should counsel care-
systemic corticosteroids to infants (Evidence Quality: B; Recom- givers about exposing the in-
with a diagnosis of bronchiolitis in mendation Strength: Strong fant or child to environmental
any setting (Evidence Quality: A; Rec- Recommendation). tobacco smoke and smoking
ommendation Strength: Strong Rec- 10b. Clinicians should administer cessation when assessing a
ommendation). palivizumab during the first child for bronchiolitis (Evidence
6a. Clinicians may choose not to ad- year of life to infants with he- Quality: B; Recommendation
minister supplemental oxygen if modynamically significant heart Strength: Strong).
the oxyhemoglobin saturation ex- disease or chronic lung disease 13. Clinicians should encourage ex-
ceeds 90% in infants and children of prematurity defined as pre- clusive breastfeeding for at least
with a diagnosis of bronchiolitis term infants <32 weeks 0 days’ 6 months to decrease the mor-
gestation who require >21%
preterm infants is similar to that of view encompasses the period from of Family Physicians, and American
term infants.12,13 2004 through May 2014. College of Emergency Physicians; other
The evidence-based approach to guide- outside organizations; and other in-
METHODS line development requires that the evi- dividuals identified by the subcom-
dence in support of a policy be identified, mittee as experts in the field. The
In June 2013, the AAP convened a new resulting comments were reviewed
appraised, and summarized and that an
subcommittee to review and revise the by the subcommittee and, when ap-
explicit link between evidence and rec-
2006 bronchiolitis guideline. The sub- propriate, incorporated into the guide-
ommendations be defined. Evidence-
committee included primary care physi- line.
based recommendations reflect the
cians, including general pediatricians,
quality of evidence and the balance of This clinical practice guideline is not
a family physician, and pediatric sub-
benefit and harm that is anticipated intended as a sole source of guidance
specialists, including hospitalists, pul-
be made. Most clinicians recognize rate in otherwise healthy children suggesting that it reliably detects hyp-
bronchiolitis as a constellation of clin- changes considerably over the first oxemia not suspected on physical
ical signs and symptoms occurring in year of life.22–25 In hospitalized children, examination36,40; however, few studies
children younger than 2 years, includ- the 50th percentile for respiratory rate have assessed the effectiveness of
ing a viral upper respiratory tract decreased from 41 at 0 to 3 months of pulse oximetry to predict clinical out-
prodrome followed by increased re- age to 31 at 12 to 18 months of age.26 comes. Among inpatients, perceived
spiratory effort and wheezing. Clinical Counting respiratory rate over the need for supplemental oxygen on the
signs and symptoms of bronchiolitis course of 1 minute is more accurate basis of pulse oximetry has been as-
consist of rhinorrhea, cough, tachypnea, than shorter observations.27 The pres- sociated with prolonged hospitaliza-
wheezing, rales, and increased respi- ence of a normal respiratory rate tion, ICU admission, and mechanical
ratory effort manifested as grunting, suggests that risk of significant viral ventilation.16,34,41 Among outpatients,
nasal flaring, and intercostal and/or
with bronchiolitis may have reversible EPINEPHRINE analysis by Hartling et al64 systemati-
airway obstruction resulting from Key Action Statement 3 cally evaluated the evidence on this
smooth muscle constriction, attempts topic and found no evidence for utility
Clinicians should not administer in the inpatient setting. Two large,
to define a subgroup of responders
epinephrine to infants and children multicenter randomized trials com-
have not been successful to date. If
with a diagnosis of bronchiolitis paring nebulized epinephrine to pla-
a clinical trial of bronchodilators is (Evidence Quality: B; Recommenda-
undertaken, clinicians should note that the cebo65 or albuterol66 in the hospital
tion Strength: Strong Recommen- setting found no improvement in LOS
variability of the disease process, the host’s dation). or other inpatient outcomes. A recent,
airway, and the clinical assessments, par-
large multicenter trial found a similar
ticularly scoring, would limit the clinician’s Action Statement Profile KAS 3 lack of efficacy compared with pla-
ability to observe a clinically relevant re-
the duration of stay typically exceeds 3 respiratory diseases, such as asthma why simultaneous administration of
days. It has not been shown to be effective and croup,82–84 the evidence on corti- these drugs could be synergistic.89–92
at reducing hospitalization in emergency costeroid use in bronchiolitis is nega- However, other bronchiolitis trials of
settings or in areas where the length tive. The most recent Cochrane corticosteroids administered by us-
of usage is brief. It has not been systematic review shows that cortico- ing fixed simultaneous bronchodila-
studied in intensive care settings, steroids do not significantly reduce tor regimens have not consistently
and most trials have included only outpatient admissions when compared shown benefit93–97; hence, a recommen-
patients with mild to moderate dis- with placebo (pooled risk ratio, 0.92; dation regarding the benefit of com-
ease. Most studies have used a 3% 95% CI, 0.78 to 1.08; and risk ratio, 0.86; bined dexamethasone and epinephrine
saline concentration, and most have 95% CI, 0.7 to 1.06, respectively) and therapy is premature.
combined it with bronchodilators do not reduce LOS for inpatients (MD The systematic review of cortico-
first 2 days of hospitalization. AOM did chiolitis. One study found that food in- significant. In a larger open ran-
not influence the clinical course or take at less than 50% of normal for the domized trial including infants be-
laboratory findings of bronchiolitis. The previous 24 hours is associated with tween 2 and 12 months of age and
current AAP guideline on AOM177 rec- a pulse oximetry value of <95%.180 conducted in Australia and New
ommends that a diagnosis of AOM Infants with mild respiratory distress Zealand, there were no significant
should include bulging of the tympanic may require only observation, particu- differences in rates of admission to
membrane. This is based on bulging larly if feeding remains unaffected. ICUs, need for ventilatory support,
being the best indicator for the pres- When the respiratory rate exceeds 60 and adverse events between 381
ence of bacteria in multiple tympano- to 70 breaths per minute, feeding may infants assigned to nasogastric hy-
centesis studies and on 2 articles be compromised, particularly if nasal dration and 378 infants assigned to
comparing antibiotic to placebo ther- secretions are copious. There is limited intravenous hydration.188 There was
will provide protection for most in- tion for a total of 5 doses will provide fibrosis from 40 centers reported 1
fants for the duration of the season. protection into April.201 If prophylaxis is subject in each group was hospitalized
initiated in October, the fifth and final because of RSV infection. Although this
CONGENITAL HEART DISEASE dose should be administered in Febru- study was not powered for efficacy, no
Despite the large number of subjects ary, and protection will last into March clinically meaningful differences in
enrolled, little benefit from pal- for most children. outcome were reported.205 A survey of
ivizumab prophylaxis was found in cystic fibrosis center directors pub-
the industry-sponsored cardiac study SECOND YEAR OF LIFE lished in 2009 noted that palivizumab
among infants in the cyanotic group prophylaxis is not the standard of care
Because of the low risk of RSV hospi- for patients with cystic fibrosis.206 If
(7.9% in control group versus 5.6% in talization in the second year of life,
palivizumab group, or 23 fewer hos- a neonate is diagnosed with cystic fi-
palivizumab prophylaxis is not recom-
Other methods of infection control in child to environmental tobacco tis.222–225 The AAP issued a technical
viral bronchiolitis include education of smoke and smoking cessation report on the risks of secondhand
personnel and family members, surveil- when assessing a child for bron- smoke in 2009. The report makes rec-
lance for the onset of RSV season, and chiolitis (Evidence Quality: B; Rec- ommendations regarding effective ways
wearing masks when anticipating expo- ommendation Strength: Strong to eliminate or reduce secondhand
sure to aerosolized secretions while Recommendation). smoke exposure, including education of
performing patient care activities. Pro- parents.226
grams that implement the aforemen- Action Statement Profile KAS 12b Despite our knowledge of this impor-
tioned principles, in conjunction with Aggregate evidence quality B tant risk factor, there is evidence to
effective hand decontamination and Benefits Reinforces the suggest health care providers identify
cohorting of patients, have been shown detrimental fewer than half of children exposed to
effects of
Incidence of true AOM in bron- SUBCOMMITTEE ON BRONCHIOLITIS Infectious Diseases Representative (no con-
(OVERSIGHT BY THE COUNCIL ON flicts)
chiolitis by using 2013 guideline Eneida A. Mendonca, MD, PhD, FAAP, FACMI:
QUALITY IMPROVEMENT AND PATIENT
definition SAFETY, 2013–2014) Informatician/Academic Pediatric Intensive
More studies on deep suction- Shawn L. Ralston, MD, FAAP: Chair, Pediatric Care Physician, Partnership for Policy Imple-
Hospitalist (no financial conflicts; published mentation Representative (no conflicts)
ing and nasopharyngeal suction- Kieran J. Phelan, MD, MSc: General Pedia-
research related to bronchiolitis)
ing trician (no conflicts)
Allan S. Lieberthal, MD, FAAP: Chair, General
Strategies for monitoring oxygen Pediatrician with Expertise in Pulmonology (no Joseph J. Zorc, MD, MSCE, FAAP: Pediatric
conflicts) Emergency Physician, AAP Section on Emergency
saturation Medicine Representative (no financial conflicts;
Brian K. Alverson, MD, FAAP: Pediatric Hos-
Use of home oxygen pitalist, AAP Section on Hospital Medicine published research related to bronchiolitis)
Appropriate cutoff for use of oxy- Representative (no conflicts) Danette Stanko-Lopp, MA, MPH: Methodolo-
gist, Epidemiologist (no conflicts)
Jill E. Baley, MD, FAAP: Neonatal-Perinatal
Use of palivizumab in special olitis including Cochrane review of bronchodilators) Elizabeth Rosenblum, MD: Academic Family
David W. Johnson, MD, FAAP: Pediatric Emer- Physician, American Academy of Family Physi-
populations, such as cystic fib- gency Medicine Physician (no financial conflicts; cians liaison (no conflicts).
rosis, neuromuscular diseases, published research related to bronchiolitis) Stephen Sayles, III, MD, FACEP: Emergency
Down syndrome, immune defi- Michael J. Light, MD, FAAP: Pediatric Pulmo- Medicine Physician, American College of
nologist, AAP Section on Pediatric Pulmonology Emergency Physicians Liaison (no conflicts)
ciency Sinsi Hernández-Cancio, JD: Parent/Consumer
Representative (no conflicts)
Emphasis on parent satisfaction/ Nizar F. Maraqa, MD, FAAP: Pediatric In- Representative (no conflicts)
patient-centered outcomes in all fectious Disease Physician, AAP Section on In-
research (ie, not LOS as the only fectious Diseases Representative (no conflicts) STAFF
H. Cody Meissner, MD, FAAP: Pediatric In- Caryn Davidson, MA
measure) fectious Disease Physician, AAP Committee on Linda Walsh, MAB
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APPENDIX 1 SEARCH TERMS BY *Upper Respiratory Infection Symp- Bronchiolitis AND (bronchodilator OR
TOPIC toms epinephrine OR albuterol OR salbuta-
mol OR corticosteroid OR steroid)
Introduction
MedLine *Hypertonic Saline
MedLine (exp Bronchiolitis/ OR exp Bronchioli-
((“bronchiolitis”[MeSH]) OR (“respira- tis, Viral/) AND exp *Respiratory Tract MedLine
tory syncytial viruses”[MeSH]) NOT Infections/ ((“bronchiolitis”[MeSH]) OR (“respira-
“bronchiolitis obliterans”[All Fields]) Limit to English Language tory syncytial viruses”[MeSH]) NOT
1. and exp Natural History/ Limit to “all infant (birth to 23 “bronchiolitis obliterans”[All Fields])
2. and exp Epidemiology/ months)” OR “newborn infant (birth AND (exp Saline Solution, Hypertonic/
to 1 month)” OR “infant (1 to 23 OR (aerosolized saline.mp. OR (exp