A direct comparison of recommendations presented in the above guidelines for the prevention, diagnosis and treatment of pediatric bronchiolitis is provided below.
Areas of Agreement
Prevention/Transmission Reduction
CCHMC and SIGN agree that important measures parents can take to prevent bronchiolitis in infants include: breastfeeding; avoiding exposure to environmental tobacco smoke and pollution; limiting exposure to contagious settings and siblings; and washing hands frequently. In the hospital setting, both groups recommend that appropriate respiratory-contact isolation policies be observed and strictly complied with.
The guideline developers agree that routine use of the prophylactic therapy palivizumab is not recommended, but that it may be considered in selected infants with high risk factors such as prematurity, congenital heart disease, chronic lung disease or immune deficiency syndromes.
Assessment and Diagnosis
CCHMC and SIGN agree that the diagnosis of bronchiolitis should be made on the basis of history and physical examination, and that clinical signs and symptoms may include increased respiratory effort or shortness of breath, wheezing, rhinorrhea, tachypnea, and nasal flaring. SIGN also cites inspiratory crackles and cough as possible presenting symptoms; CCHMC also cites retractions, color change, and low oxygen saturation.
As the diagnosis of bronchiolitis is a clinical one, the groups further agree that diagnostic testing (chest x-rays, blood gas analysis, virological or bacteriological testing/cultures, rapid RSV testing) is not routinely recommended, but may be appropriate when diagnostic uncertainty exists or to aid decision-making regarding subsequent management. Both groups address factors to consider in determining the need for hospital admission. According to CCHMC, admission criteria remain a clinical judgment weighing numerous factors rather than applying a discrete set of criteria. SIGN recommends that the threshold for hospital referral be lowered in patients with significant comorbidities, those less than three months of age or infants born at less than 35 weeks gestation.
Management
The groups agree that the foundation of the management of typical bronchiolitis is keeping the patient clinically stable, well oxygenated, and well hydrated. Nasal suctioning is cited as an appropriate step by both groups to clear secretions in infants hospitalized with acute bronchiolitis. CCHMC specifies that the infant should be suctioned (when clinically indicated) before feedings, as needed, and prior to each inhalation therapy.
Both groups recommend performing pulse oximetry in infants presenting to hospital with acute bronchiolitis. CCHMC specifies that at its hospital, a spot check is performed when: a clinical need is assessed; pre-and post-suctioning; and before and after any inhalation to determine consistent oxygen level, or any improvement from therapies. The guideline developers agree that supplemental oxygen should be initiated for infants with oxygen saturation levels <91% (CCHMC) or ≤92% (SIGN).
The guideline developers agree that routine use of antibiotics, corticosteroids (oral and/or inhaled), and chest physiotherapy is not recommended. Recommendations regarding the use of inhaled beta-agonists and epinephrine differ—see Areas of Difference below.
Discharge Criteria
CCHMC and SIGN agree that, among other criteria, infants should not be discharged until they can maintain a daily oral intake at a level to prevent dehydration, and until they have achieved respiratory stability. Recommendations regarding the oxygen saturation level required for discharge differ, however. See Areas of Difference below for more information.
Education
The guideline developers agree that parents and carers should be educated on both the prevention of respiratory infection infections in infants and the care of a child with bronchiolitis.
Areas of Difference
Management
CCHMC recommends that a single trial inhalation with either nebulized epinephrine or albuterol (a beta2-adrenergic agonist) be considered on an individual basis, such as when there is a family history of allergy, asthma, or atopy. With regard to selection of agent, CCHMC states that nebulized racemic epinephrine demonstrates better short-term improvement in pulmonary physiology and clinical scores compared with albuterol or placebo. CCHMC emphasizes that if a trial inhalation is used, a measured clinical improvement must be demonstrated for this therapy to be continued. SIGN, in contrast to CCHMC, recommends against the use of inhaled beta2-agonist bronchodilators and nebulized epinephrine for the treatment of acute bronchiolitis in infants.
Discharge Criteria
Both groups cite adequate oxygen saturation as a discharge criterion. However, while CCHMC recommends that the patient's oxygen saturation remain >91% on room air, SIGN requires >94% on room air.
