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
