• Scottish Intercollegiate Guidelines Network (SIGN). Bronchiolitis in children. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2006 Nov. 41 p. (SIGN publication; no. 91). [110 references]

Bronchiolitis

Diagnosis
Evaluation
Management
Prevention
Treatment

Emergency Medicine
Family Practice
Infectious Diseases
Internal Medicine
Pediatrics
Pulmonary Medicine

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Patients
Pharmacists
Physicians
Public Health Departments

• To provide evidence based recommendations on the prevention, diagnosis, investigation, treatment and management of bronchiolitis in infants less than 12 months of age
• To reduce the use of unnecessary therapies and investigations in infants with acute disease
• To guide referral patterns from primary to secondary and tertiary care

Infants less than 12 months of age

As infants with significant comorbidities have increased susceptibility to bronchiolitis beyond twelve months of age, the following specific groups were considered up to 24 months of age:

• Those born prematurely (<37 weeks gestational age)
• Infants with congenital heart disease (CHD) or underlying respiratory disease.

Note: The guideline focuses on the clinically diagnosed condition of bronchiolitis in infants less than 12 months of age. This minimises any bias from reporting discrepancies associated with the diagnosis of bronchiolitis above this age.

Bronchiolitis in immunodeficient infants or those with rare ("orphan") disease was not considered.

Diagnosis/Assessment

1. Clinical history/presentation (i.e., fever, respiratory rate, age)
2. Physical examination, considering seasonality
3. Pulse oximetry
4. Virological testing for Respiratory Syncytial Virus (RSV)

Note: The following diagnostic interventions were considered but not recommended for routine use:

• Blood gases
• Chest x-ray
• Routine bacteriological testing (blood and urine)
• Haematology (full blood count)
• Biochemistry (urea, electrolytes and C-reactive protein)

5. Assessment of risk factors for disease severity
   • Age
   • Comorbidities
   • Social factors
6. Indicators for referral

Treatment/Management

1. Nasogastric feedings (hydration)
2. Supplemental oxygen
3. Nasal suction
4. Hospital discharge criteria
5. Prevention/transmission reduction
   • Staff and family member education (symptoms duration, transmission)
   • Hand decontamination (handwashing, alcohol based gels)
   • Ongoing infection control surveillance
   • Reduce exposure to second hand smoke
   • Breastfeeding
6. Provision of information for parents and carers

Guideline developers considered but did not recommend the following: Nebulized ribavirin, antibiotics, beta 2 bronchodilators, nebulized epinephrine, anti-inflammatories, chest physiotherapy, Palivizumab (not recommended for routine use) RSV hyperimmune globulin (RSVIG) (RSVIG therapy is not licensed for use in the United Kingdom (UK).

• Effectiveness of diagnostic interventions/tools
• Effectiveness of therapeutic interventions
• Cost effectiveness of prophylactic therapy
• Symptom improvement and short term clinical benefits
• Development of subsequent chronic respiratory symptoms
• Hospitalization rate and length of hospital stay
• Admission to paediatric intensive care unit (PICU)
• Health care related infection rates

Searches of Electronic Databases

The evidence base for this guideline was synthesised in accordance with Scottish Intercollegiate Guidelines Network (SIGN) methodology. A systematic literature review was carried out using an explicit search strategy devised by the SIGN Information Officer in collaboration with members of the guideline development group. Literature searches were initially conducted in Medline, Embase, Cinahl and the Cochrane Library, using the year range 2000-2005. The main searches were supplemented by material identified by individual members of the development group. All selected papers were evaluated using standard methodological checklists. The Medline version of the main search strategies can be found on the SIGN website.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias

1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3: Non-analytic studies (e.g. case reports, case series)

4: Expert opinion

Systematic Review with Evidence Tables

Expert Consensus

Grades of Recommendation

Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.

A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D: Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group

Cost Effectiveness of Rapid Virological Testing for RSV

Rapid virological testing can be of benefit in relation to guiding isolation and allocating patients into cohorts in hospital. Rapid testing for RSV, which can be performed at the point of care in order to facilitate this, has been shown to have acceptable performance in comparison to laboratory based tests despite reduced diagnostic sensitivity.

A case control study found that rapid diagnosis of respiratory viral infections in infants was cost effective by reducing length of hospital stay, antibiotic use and number of microbiological tests performed compared to a matched group of patients from the previous year who were diagnosed by virus culture.

There may be a reduction in unnecessary interventions associated with knowledge of RSV status. In a postal survey, physicians reported that a definitive viral diagnosis was important to patients.

Cost Effectiveness of Palivizumab Prophylaxis

A well conducted systematic review identified seven United Kingdom RSV related cost studies. The studies consistently concluded that the costs of palivizumab prophylaxis were far in excess of any likely savings achieved by decreasing hospital admission rates. One of the studies performed a sensitivity analysis and found that the probability of hospital admission would have to be >31% for palivizumab to be cost effective. The non-societal perspective of most studies was acknowledged.

Another systematic review encompassing UK and non-UK studies reported diverse results ranging from cost savings to considerable incremental costs per hospitalisation avoided. The diversity was attributed to the range of different infant groups, study methods and assumptions and also to the poor quality of some of the studies In general palivizumab was not cost effective if administered to all infants for whom it was approved.

External Peer Review
Internal Peer Review

The national open meeting is the main consultative phase of Scottish Intercollegiate Guidelines Network (SIGN) guideline development. The national open meeting for this guideline was held on 9th December 2005 and was attended by 150 representatives of all the key specialties relevant to the guideline.

The draft guideline was also available on the SIGN website for a limited period at this stage to allow those unable to attend the meeting to contribute to the development of the guideline.

Peer Review

All SIGN guidelines are reviewed in draft form by independent expert referees, who are asked to comment primarily on the comprehensiveness and accuracy of interpretation of the evidence base supporting the recommendations in the guideline. A number of general practitioners (GPs) and other primary care practitioners also provide comments on the guideline from the primary care perspective, concentrating particularly on the clarity of the recommendations and their assessment of the usefulness of the guideline as a working tool for the primary care team. The draft is also sent to a lay reviewer in order to obtain comments from the patient's perspective. The comments received from peer reviewers and others are carefully tabulated and discussed with the chairman and with the guideline development group. Each point must be addressed and any changes to the guideline as a result noted or, if no change is made, the reasons for this recorded.

As a final quality control check prior to publication, the guideline and the summary of peer reviewers' comments are reviewed by the SIGN Editorial Group for that guideline to ensure that each point has been addressed adequately and that any risk of bias in the guideline development process as a whole has been minimised. Each member of the guideline development group is then asked formally to approve the final guideline for publication.

Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.

The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.

Diagnosis

Diagnostic Value of Clinical Characteristics

Fever

D - The absence of fever should not preclude the diagnosis of acute bronchiolitis.

D - In the presence of high fever (axillary temperature >39°C) careful evaluation for other causes should be undertaken before making a diagnosis.

Respiratory Rate

D - Increased respiratory rate should arouse suspicion of lower respiratory tract infection, particularly bronchiolitis or pneumonia.

Summary of Diagnostic Characteristics

D - A diagnosis of acute bronchiolitis should be considered in an infant with nasal discharge and a wheezy cough, in the presence of fine inspiratory crackles and/or high pitched expiratory wheeze. Apnoea may be a presenting feature.

Seasonality

D - Healthcare professionals should take seasonality into account when considering the possible diagnosis of acute bronchiolitis.

Risk Factors for Severe Disease

Significant Comorbidities

Summary of Effect of Comorbidity

C - Healthcare professionals should be aware of the increased need for hospital admission in infants born at less than 35 weeks gestation and in infants who have congenital heart disease or chronic lung disease of prematurity.

Social Factors

Breastfeeding

C - Breast feeding reduces the risk of respiratory syncytial virus (RSV)-related hospitalisation and should be encouraged and supported.

Parental Smoking

C - Healthcare professionals should inform families that parental smoking is associated with increased risk of RSV-related hospitalisation.

Investigations

Oxygen Saturation

C - Pulse oximetry should be performed in every child who attends hospital with acute bronchiolitis.

Chest X-ray

C - Chest X-ray should not be performed in infants with typical acute bronchiolitis.

Virological Testing

D - Unless adequate isolation facilities are available, rapid testing for RSV is recommended in infants who require admission to hospital with acute bronchiolitis, in order to guide cohort arrangements.

Bacteriological Testing

C - Routine bacteriological testing (of blood and urine) is not indicated in infants with typical acute bronchiolitis. Bacteriological testing of urine should be considered in febrile infants less than 60 days old.

Haematology

D - Full blood count is not indicated in assessment and management of infants with typical acute bronchiolitis.

Biochemistry

D - Measurement of urea and electrolytes is not indicated in the routine assessment and management of infants with typical acute bronchiolitis but should be considered in those with severe disease.

Treatment

Antiviral

B - Nebulised ribavirin is not recommended for treatment of acute bronchiolitis in infants.

Inhaled Bronchodilators

B - Inhaled beta 2 agonist bronchodilators are not recommended for the treatment of acute bronchiolitis in infants.

Nebulised Epinephrine

A - Nebulised epinephrine is not recommended for the treatment of acute bronchiolitis in infants.

Anti-inflammatories

Inhaled Corticosteroids

A - Inhaled corticosteroids are not recommended for the treatment of acute bronchiolitis in infants.

Systemic Corticosteroids

A - Oral systemic corticosteroids are not recommended for the treatment of acute bronchiolitis in infants.

Hospital Based Supplementary Therapies

Physiotherapy

A - Chest physiotherapy using vibration and percussion is not recommended in infants hospitalised with acute bronchiolitis who are not admitted to intensive care.

Nasal Suction

D - Nasal suction should be used to clear secretions in infants hospitalised with acute bronchiolitis who exhibit respiratory distress due to nasal blockage.

Maintaining Fluid Balance/Hydration

D - Nasogastric feeding should be considered in infants with acute bronchiolitis who cannot maintain oral intake or hydration.

Oxygen

D - Infants with oxygen saturation levels <92% or who have severe respiratory distress or cyanosis should receive supplemental oxygen by nasal cannulae or facemask.

Symptom Duration and Hospital Discharge

Duration of Symptoms Following Acute Bronchiolitis

B - Parents and carers should be informed that, from the onset of acute bronchiolitis, around half of infants without comorbidity are asymptomatic by two weeks but that a small proportion will still have symptoms after four weeks.

Limiting Disease Transmission

Education

D - Healthcare professionals should be educated about the epidemiology and control of RSV where appropriate.

Ward-Based Strategies

D - Staff should decontaminate their hands (with soap and water or alcohol gel) before and after caring for patients with viral respiratory symptoms.

D - Gloves and plastic aprons (or gowns) should be used for any direct contact with the patient or their immediate environment.

D - Infected patients should be placed in single rooms. If adequate isolation facilities are unavailable, the allocation of patients into cohorts should be based on laboratory confirmation of infection in all inpatients less than two years of age with respiratory symptoms.

D - Both service providers and staff should be aware of the risk that those with upper respiratory tract infections pose for high-risk infants.

D - Local policies should restrict hospital visiting by those with symptoms of respiratory infections.

D - There should be ongoing surveillance by control of infection staff to monitor compliance with infection control procedures.

Information for Parents and Carers

Information Provision

D - Parents and carers should receive information about their child's condition, its treatment and prognosis.

Definitions:

Grades of Recommendation

Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.

A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D: Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group

Levels of Evidence

1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias

1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3: Non-analytic studies (e.g. case reports, case series)

4: Expert opinion

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Improved prevention, diagnosis, investigation, treatment and management of bronchiolitis in infants 12 months or younger

Not stated

This guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement must be made by the appropriate healthcare professional(s) responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgement should only be arrived at following discussion of the options with the patient, covering the diagnostic and treatment choices available. It is, however, advised that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient's case notes at the time the relevant decision is taken.

Implementation of national clinical guidelines is the responsibility of each National Health Service (NHS) Board and is an essential part of clinical governance. It is acknowledged that every Board cannot implement every guideline immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed. These discussions should involve both clinical staff and management. Local arrangements may then be made to implement the national guideline in individual hospitals, units and practices, and to monitor compliance. This may be done by a variety of means including patient-specific reminders, continuing education and training, and clinical audit.

Key points for audit are identified in the original guideline document.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• Scottish Intercollegiate Guidelines Network (SIGN). Bronchiolitis in children. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2006 Nov. 41 p. (SIGN publication; no. 91). [110 references]

Not applicable: The guideline was not adapted from another source.

2006 Nov

Scottish Intercollegiate Guidelines Network - National Government Agency [Non-U.S.]

Scottish Executive Health Department

Not stated

Guideline Development Group: Dr. Steve Cunningham (Chair), Consultant Respiratory Paediatrician, Royal Hospital for Sick Children, Edinburgh; Dr. Peter W Fowlie (Secretary), Consultant Paediatrician, Ninewells Hospital, Dundee; Dr. Jack Beattie, Consultant Paediatrician, Royal Hospital for Sick Children, Glasglow; Dr. Richard Brooker, Consultant Paediatrician, Royal Aberdeen Children's Hospital; Dr. Donna Corrigan, Consultant Paediatrician, Wishaw General Hospital; Dr. Jonathan Coutts, Consultant Paediatrician, Royal Hospital for Sick Children, Glasglow; Ms Sue Danby, Nursing Sister, Paediatrics, Royal Aberdeen Children's Hospital; Ms. Elaine Dhouieb, Senior Respiratory Physiotherapist, Royal Hospital for Sick Children, Edinburgh; Ms. Jeannette Fitzgerald, Senior Paediatric Nurse, Ninewells Hospital, Dundee; Ms. June Grant, Pharmacist, Princess Royal Maternity Hospital, Glasglow; Dr. Nick Hallam, Consultant Virologist, Royal Infirmary of Edinburgh; Ms. Mareth Irvine, Lay Representative, Dumfries and Galloway; Ms. Pamela Joannidis, Senior Nurse, Infection Control, Royal Hospital for Sick Chidren, Glasglow; Dr. Andrew MacIntyre, Consultant in Paediatric Intensive Care Medicine, Royal Hospital for Sick Children, Glasglow; Dr. Peter Mackie, Consultant Clinical Scientist (Virology), Aberdeen Royal Infirmary; Dr. Jillian McFadzean, Consultant in Anaesthesia and Intensive Care, Royal Hospital for Sick Children, Edinburgh; Dr. Maeve Mc Phillips, Consultant Paediatric Radiologist, Royal Hospital for Sick Children, Edinburgh; Dr. Angela Oglesby, Consultant in Accident and Emergency, Royal Hospital for Sick Children, Edinburgh; Dr. Ronald Seiler, Retired General Practitioner, Edinburgh; Ms. Ailsa Stein, Information Officer, SIGN; Dr. Caroline Stimpson, General Practitioner and Clinical Assistant in Accident and Emergency, Edinburgh; Dr. Lorna Thompson, Programme Manager, SIGN; Ms. Moira Walls, Case Manager, Neonatal Unit, Ninewells Hospital, Dundee; Dr. Louise Wilson, Specialist Registrar in Public Health, NHS Lanarkshire, Dr. Alan Woodley, General Practitioner, Dundee

Declarations of interests were made by all members of the guideline development group. Further details are available from the Scottish Intercollegiate Guidelines Network (SIGN) Executive.

This summary was completed by ECRI on March 6, 2007.