Joseph J. Zorc

Diagnosis and Management of Bronchiolitis

Bronchiolitis is a disorder most commonly caused in infants by viral lower respiratory tract infection. It is the most common lower respiratory infection in this age group. It is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm. The American Academy of Pediatrics convened a committee composed of primary care physicians and specialists in the fields of pulmonology, infectious disease, emergency medicine, epidemiology, and medical informatics. The committee partnered with the Agency for Healthcare Research and Quality and the RTI International-University of North Carolina Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to the diagnosis, management, and prevention of bronchiolitis. The resulting evidence report and other sources of data were used to formulate clinical practice guideline recommendations. This guideline addresses the diagnosis of bronchiolitis as well as various therapeutic interventions including bronchodilators, corticosteroids, antiviral and antibacterial agents, hydration, chest physiotherapy, and oxygen. Recommendations are made for prevention of respiratory syncytial virus infection with palivizumab and the control of nosocomial spread of infection. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent comprehensive peer review before it was approved by the American Academy of Pediatrics. This clinical practice guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with this condition. These recommendations may not provide the only appropriate approach to the management of children with bronchiolitis.

Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis

This guideline is a revision of the clinical practice guideline, “Diagnosis and Management of Bronchiolitis,” published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows:

Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection

Palivizumab was licensed in June 1998 by the Food and Drug Administration for the reduction of serious lower respiratory tract infection caused by respiratory syncytial virus (RSV) in children at increased risk of severe disease. Since that time, the American Academy of Pediatrics has updated its guidance for the use of palivizumab 4 times as additional data became available to provide a better understanding of infants and young children at greatest risk of hospitalization attributable to RSV infection. The updated recommendations in this policy statement reflect new information regarding the seasonality of RSV circulation, palivizumab pharmacokinetics, the changing incidence of bronchiolitis hospitalizations, the effect of gestational age and other risk factors on RSV hospitalization rates, the mortality of children hospitalized with RSV infection, the effect of prophylaxis on wheezing, and palivizumab-resistant RSV isolates. This policy statement updates and replaces the recommendations found in the 2012 Red Book.

Bronchiolitis: Recent Evidence on Diagnosis and Management

Viral bronchiolitis is a leading cause of acute illness and hospitalization of young children. Research into the variation in treatment and outcomes for bronchiolitis across different settings has led to evidence-based clinical practice guidelines. Ongoing investigation continues to expand this body of evidence. Authors of recent surveillance studies have defined the presence of coinfections with multiple viruses in some cases of bronchiolitis. Underlying comorbidities and young age remain the most important predictors for severe bronchiolitis. Pulse oximetry plays an important role in driving use of health care resources. Evidence-based reviews have suggested a limited role for diagnostic laboratory or radiographic tests in typical cases of bronchiolitis. Several large, recent trials have revealed a lack of efficacy for routine use of either bronchodilators or corticosteroids for treatment of bronchiolitis. Preliminary evidence suggests a potential future role for a combination of these therapies and other novel treatments such as nebulized hypertonic saline.

Electronic health record-based decision support to improve asthma care: a cluster-randomized trial.

OBJECTIVE: Asthma continues to be 1 of the most common chronic diseases of childhood and affects ∼6 million US children. Although National Asthma Education Prevention Program guidelines exist and are widely accepted, previous studies have demonstrated poor clinician adherence across a variety of populations. We sought to determine if clinical decision support (CDS) embedded in an electronic health record (EHR) would improve clinician adherence to national asthma guidelines in the primary care setting. METHODS: We conducted a prospective cluster-randomized trial in 12 primary care sites over a 1-year period. Practices were stratified for analysis according to whether the site was urban or suburban. Children aged 0 to 18 years with persistent asthma were identified by International Classification of Diseases, Ninth Revision codes for asthma. The 6 intervention-practice sites had CDS alerts imbedded in the EHR. Outcomes of interest were the proportion of children with at least 1 prescription for controller medication, an up-to-date asthma care plan, and the performance of office-based spirometry. RESULTS: Increases in the number of prescriptions for controller medications, over time, was 6% greater (P = .006) and 3% greater for spirometry (P = .04) in the intervention urban practices. Filing an up-to-date asthma care plan improved 14% (P = .03) and spirometry improved 6% (P = .003) in the suburban practices with the intervention. CONCLUSION: In our study, using a cluster-randomized trial design, CDS in the EHR, at the point of care, improved clinician compliance with National Asthma Education Prevention Program guidelines.

Defining Cerebrospinal Fluid White Blood Cell Count Reference Values in Neonates and Young Infants

OBJECTIVE: Cerebrospinal fluid (CSF) white blood cell (WBC) counts for neonates and young infants are usually interpreted on the basis of values reported in reference texts or handbooks; however, current reference texts either present normal CSF parameters without citation or cite studies with significant limitations. The objective of this study was to determine accurate, age-specific reference values for CSF WBC counts in a large population of neonates and young infants. METHODS: This cross-sectional study included patients who were aged ≤56 days and had a lumbar puncture performed in the emergency department from January 1, 2005, to June 30, 2007. Patients were excluded from analysis for conditions that are suspected to cause CSF pleocytosis, including traumatic lumbar puncture, serious bacterial infection, congenital infection, seizure, and presence of a ventricular shunt. Children who tested positive for enterovirus (EV) in the CSF by polymerase chain reaction were also excluded. Two-sample Wilcoxon rank-sum tests were used to compare median CSF WBC values of those who had negative EV testing with those who did not have EV testing. RESULTS: A total of 380 (36%) of 1064 patients met inclusion criteria; 54% were male, 15% were preterm, and 39% presented during EV season. The median CSF WBC count was significantly higher in infants who were aged ≤28 days (3/μL, 95th percentile: 19/μL) than in infants who were aged 29 to 56 days (2/μL, 95th percentile: 9/μL; P < .001). In both age groups, infants with a negative EV PCR had a higher upper bound of the 95% confidence interval of the mean values compared with infants who did not have EV testing performed. CONCLUSIONS: We determined age-specific CSF WBC reference values in a large cohort of neonates and young infants that can be used to interpret accurately the results of lumbar punctures in this population.

Family Presence During Pediatric Trauma Team Activation: An Assessment of a Structured Program

OBJECTIVE. When a child presents to a trauma center with a serious injury, family members are often excluded from the initial trauma team evaluation. The objective of this study was to evaluate the outcomes of a structured program of family presence during pediatric trauma team activations by measuring (1) the need for termination of family presence, (2) times to completion of key parts of the trauma evaluation, and (3) the opinions of staff surveyed immediately after conclusion of family presence. METHODS. This was a cross-sectional study that combined prospectively obtained data and surveys from trauma team evaluations in which family presence occurred, with retrospective chart review of all trauma activations during an 18-month study period. The study was conducted at a level 1 pediatric trauma center with a preestablished family presence program that assigns a staff member to screen family members for family presence, provide support, and record events. Times to completion of key components of the trauma evaluation were calculated and compared for cases with and without family presence. Cross-sectional surveys were performed immediately after each trauma team evaluation. RESULTS. A total of 197 family members participated in family presence. There were no cases of interference with medical care by family members. Seven family members were asked to leave the trauma area by staff after initiation of family presence for various reasons. Times to completion of key components of the trauma evaluation did not differ significantly between enrolled patients with family presence and those without family presence. Surveys were completed for 136 cases, and the majority of providers reported that family presence either had no effect on or improved medical decision-making (97%), institution of patient care (94%), communication among providers (92%), and communication with family members (98%). CONCLUSIONS. This prospective study suggests that there is an overall low prevalence of negative outcomes associated with family presence during pediatric trauma team evaluation after implementation of a structured family presence program. Excluding family members as a routine because of provider concerns about negative impact on clinical care does not seem to be indicated.

Variation in Emergency Department Diagnostic Testing and Disposition Outcomes in Pneumonia

OBJECTIVE: To describe the variability across hospitals in diagnostic test utilization for children diagnosed with community-acquired pneumonia (CAP) during emergency department (ED) evaluation and to determine if test utilization is associated with hospitalization and ED revisits. METHODS: We conducted a retrospective cohort study of children aged 2 months to 18 years with ED visits resulting in CAP diagnoses from 2007 to 2010 who were seen at 36 hospitals contributing data to the Pediatric Health Information System. Children with complex chronic conditions, recent hospitalization, trauma, aspiration, or perinatal infection were excluded. Primary outcomes included diagnostic testing, hospitalization, and 3-day ED revisit rates across hospitals. We examined variation in diagnostic testing among hospitals by using multivariable mixed-effects logistic regression. RESULTS: A total of 100 615 ED visits were analyzed. Complete blood count (median: 28.7%), blood culture (27.9%), and chest radiograph (75.7%) were the most commonly ordered ED diagnostic tests. After adjustment for patient characteristics, significant variation (P < .001) was found for each test examined across hospitals. High test-utilizing hospitals had increased odds of hospitalization compared with low-utilizing hospitals (odds ratio: 1.86 [95% confidence interval: 1.17–2.94]; P = .008). However, differences in the odds of ED revisit between the low- and high-utilizing hospitals were not significant (odds ratio: 1.21 [95% confidence interval: 0.97–1.51]; P = .09). CONCLUSIONS: Emergency departments that use more testing in diagnosing CAP have higher hospitalization rates than lower-utilizing EDs. However, ED revisit rates were not significantly different between high- and low-utilizing EDs. These results suggest an opportunity to reduce diagnostic testing for CAP without negatively affecting outcomes.

Beliefs and Barriers to Follow-up After an Emergency Department Asthma Visit: A Randomized Trial

BACKGROUND: Studies in urban emergency departments (EDs) have found poor quality of chronic asthma care and identified beliefs and barriers associated with low rates of follow-up with a primary care provider (PCP). OBJECTIVES: To develop an ED-based intervention including asthma symptom screening, a video addressing beliefs and a mailed reminder; and measure the effect on PCP follow-up and asthma-related outcomes. METHODS: This randomized, controlled trial enrolled children aged 1 to 18 years who were discharged after asthma treatment in an urban pediatric ED. Control subjects received instructions to follow-up with a PCP within 3 to 5 days. In addition, intervention subjects (1) received a letter to take to their PCP if they screened positive for persistent asthma symptoms, (2) viewed a video featuring families and providers discussing the importance of asthma control, and (3) received a mailed reminder to follow-up with a PCP. All subjects were contacted by telephone 1, 3, and 6 months after the ED visit, and follow-up was confirmed by PCP record review. Asthma-related quality of life (AQoL), symptoms, and beliefs about asthma care were assessed by using validated surveys. RESULTS: A total of 433 subjects were randomly assigned, and baseline measures were similar between study groups. After the intervention and before ED discharge, intervention subjects were more likely to endorse beliefs about the benefits of follow-up than controls. However, rates of PCP follow-up during the month after the ED visit (44.5%) were similar to control subjects (43.8%) as were AQoL, medication use, and ED visits. CONCLUSIONS: An ED-based intervention influenced beliefs but did not increase PCP follow-up or asthma-related outcomes.

Nebulized Hypertonic Saline for Bronchiolitis in the Emergency Department: A Randomized Clinical Trial

IMPORTANCE Acute bronchiolitis is the most frequent lower respiratory tract infection in infants, yet there are no effective therapies available. Current evidence is unclear about the role of hypertonic saline (HS) for the acute treatment of bronchiolitis. OBJECTIVE To determine whether nebulized 3% HS compared with normal saline (NS) improves respiratory distress in infants with bronchiolitis not responding to standard treatments in the emergency department. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial with blinding of investigators, health care providers, and parents was conducted at a single urban pediatric ED. The participants included children aged 2 to less than 24 months with their first episode of bronchiolitis and a Respiratory Distress Assessment Instrument score of 4 to 15 after nasal suctioning and a trial of nebulized albuterol. INTERVENTIONS Patients were randomized to receive either nebulized 3% HS (HS group) or NS (NS group). MAIN OUTCOMES AND MEASURES The primary outcome was change in respiratory distress at 1 hour after the intervention, as measured by the Respiratory Assessment Change Score (a decrease indicates improvement). Secondary outcomes included vital signs, oxygen saturation, hospitalization, physician clinical impression, parental assessment, and adverse events. RESULTS The 31 patients enrolled in each treatment arm had similar baseline demographic and clinical characteristics. At 1 hour after the intervention, the HS group demonstrated significantly less improvement in the median Respiratory Assessment Change Score compared with the NS group (HS, -1 [interquartile range, -5 to 1] vs. NS, -5 [interquartile range, -6 to -2]; P = .01). There were no significant differences in heart rate, oxygen saturation, hospitalization rate, or other outcomes. There were no adverse events. CONCLUSIONS AND RELEVANCE Infants with bronchiolitis and persistent respiratory distress after standard treatment in the emergency department had less improvement after receiving 3% HS compared with those who received NS. Based on these results and the existing evidence, administration of a single dose of 3% HS does not appear to be indicated to treat bronchiolitis in the acute care setting. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01247064.