Emphasis continues on adopting watchful waiting and supportive care approach.

bronchiolitisEach year, a multidisciplinary group at St. Louis Children’s Hospital (SLCH) reviews the hospital’s guidelines for inpatient treatment of bronchiolitis. This year, the group began meeting in October.

“As a result of our discussions, we will continue to support the revisions we made last year to our bronchiolitis guidelines,” says Washington University physician Christine Hrach, MD, a pediatric hospitalist at SLCH. “Those revisions were influenced by the American Academy of Pediatrics’ 2014 updated clinical practice guidelines for the diagnosis, management and prevention of bronchiolitis in children aged 1 – 23 months.”

The AAP changed its guidelines because of numerous studies that supported eliminating a number of routine treatments prescribed for children with bronchiolitis and instead adopting more of a watchful waiting and supportive care approach.

The AAP treatment recommendations include:

  • Not administering albuterol unless condition is deteriorating
  • Not administering systemic corticosteroids
  • Not administering antibacterial medications unless there is a concomitant bacterial infection or strong suspicion of one
  • Administering nasogastric or intravenous fluids for children who cannot maintain hydration orally
  • Not routinely obtaining radiographic or laboratory studies when diagnosing bronchiolitis but instead relying on history and physical examination

SLCH has been proactive about keeping up with published literature. Prior to the AAP updates, the hospital already had been reducing the use of albuterol and imaging and particularly discouraging the use of antibiotics. Instead, emphasis has been placed on, as needed, supporting hydration with nasogastric or IV fluids, supplementing oxygen to prevent hypoxia, and giving a fever reducer to make patients more comfortable. Unless patients develop a complication, it has become a matter of letting the bronchiolitis run its course.

New this year is SLCH’s participation in a national collaborative project called Stewardship in Improving Bronchiolitis (SIB). The project is supported and managed by the Value in Inpatient Pediatrics (VIP) Network, part of the Quality Improvement Innovation Networks (QuIIN) at the American Academy of Pediatrics (AAP). Washington University physicians Fahd Ahmad, MD, pediatric emergency medicine, and Andrea Rivera, MD, pediatric hospitalist medicine, are co-leaders of the multidisciplinary SLCH SIB team.

The SIB project provides strategies, tools and resources necessary to assess and improve the quality of care delivered to pediatric patients with bronchiolitis across the continuum of care. The focus will be on bronchiolitis treatment in the emergency department as well as inpatient setting. The SIB team will apply quality improvement methodology to improve utilization of recommendations from the hospital and AAP guideline.

As part of this initiative, a respiratory score—Children’s Asthma/Bronchiolitis Score (CAB)—will be used in the emergency department and inpatient areas to assess respiratory status and help assess use and effect of bronchodilator treatments on children who come to the hospital with bronchiolitis.

Another focus of SIB will be to address avoidance of tobacco smoke exposure for children who present to the hospital with bronchiolitis. “When patients are identified as being exposed to second-hand smoke, our goal is to counsel family members about the dangers of tobacco smoke to children and provide them with resources for smoking cessation,” says Dr. Hrach.

For a copy of the SLCH inpatient guideline, contact Anne Borgmeyer, DNP, RN, CPNP, AE-C, pediatric nurse practitioner, Asthma Intervention Model (AIM) Project, anneeb@bjc.org, or Dr. Hrach at hrach_c@wustl.edu. For a copy of the emergency department guideline for bronchiolitis, contact Dr. Ahmad at ahmad_f@kids.wustl.edu. For questions call Children’s Direct at 800.678.HELP (4357).