Bronchiolitis diagnosis, treatment, and prevention in children: an evidence-based clinical practice guideline adapted for the use in Egypt based on the ‘Adapted ADAPTE’ Methodology

Abstract

Background

The presented evidence-based clinical practice guideline (CPG) is proposed as a National CPG using an evidence-based and formal CPG adaptation methodology. The purpose of this study was to adapt the international CPGs’ recommendations for children with bronchiolitis to suit the healthcare system in the Egyptian context. This CPG, ‘diagnosis, treatment, and prevention of Bronchiolitis’, applies to children from 1 through 23 months of age. Other exclusions are noted. The quality of evidence, benefit-harm relationship, and strength of recommendations are indicated. This study is part of a larger collaborative initiative with the faculty staff of pediatric departments of 15 Egyptian universities and a national research center to formulate a national Committee (EPG) that aims to define the topics of, assign authors to, and assist in the adaptation of pediatric evidence-based CPGs according to a national strategic plan. The committee is guided by a formal CPG adaptation methodology: the ‘Adapted ADAPTE’.

Results

The Bronchiolitis Guideline Adaptation Group (BGAG) reviewed the results of the AGREE II assessment and decided to adapt mainly the Australasian (PREDICT) CPG and for the questions not answered in PREDICT we adapted the relevant recommendations from the American Academy of Pediatrics (AAP) CPG. Seven implementation tools were included: a care pathway for assessment of severity, a clinical algorithm for treatment of acute bronchiolitis in the emergency room, a separate flowchart for assessing babies with bronchiolitis, a power point slide presentation lecture for treatment of acute bronchiolitis, patient information in Arabic, a clinical score (Modified Tal Score) for prediction of bronchiolitis severity, and the criteria for admission and discharge in the hospital. A comprehensive set of multifaceted CPG implementation strategies was provided for the clinicians, patients, nurses, and other relevant stakeholders contextualized to the national settings

Conclusion

Our experience with this adaptation methodology provides useful insight into its utilization on a national level in Egypt. The BGAG recommended the next review of this adapted CPG to be after 3 years from its publication (i.e., 2022) after checking for updates in the original CPG.

Background

Bronchiolitis is the leading cause of hospital admission for respiratory diseases among infants < 1 year of age and is associated with an estimated 1 of every 13 primary care visits. It is most commonly presenting in the first 2 years of life, and the diagnosis is based on clinical signs [1].

Acute bronchiolitis refers to airway inflammation and obstruction of the lower respiratory tract and is caused almost exclusively by viral infection in children younger than 2 years. Commonly, symptoms of bronchiolitis begin with rhinitis or congestion and cough and may develop into symptoms of increasing respiratory distress (tachypnea, wheezing, and accessory muscle use). Severity of bronchiolitis can vary from mild symptoms that can be managed at home to acute respiratory failure requiring invasive ventilation [2].

A subcommittee of the American Academy of Pediatrics together with the European Respiratory Society (ERS) defined bronchiolitis as a constellation of clinical symptoms and signs including a viral respiratory prodroma followed by increased lower respiratory effort and wheezing in infants < 2 years of age with a peak in infants aged 3–6 months. It is a self-limiting condition but may be severe and life-threatening [3].

History and physical examination findings are essential for the diagnosis of bronchiolitis. Hyperinflation is the most reliable clinical sign in bronchiolitis. Fever is not a constant feature of bronchiolitis. Fever above 38.5 °C is seen in 50% of the patients. Infants younger than 6 weeks may be hypothermic [2].

In Egypt, a study by El-Sadek et al. revealed that bronchiolitis represents 27.1% of children with wheezy chest admitted to El-Hussein University Hospital, Cairo, from January to December 2012 using a pre-designed questionnaire [4].

Clinical Practice Guidelines (CPGs) are defined as ‘statements that include recommendations intended to optimize patient care, which are informed by a systematic review of evidence and an assessment of the benefit and harm of alternative care options [5, 6]. CPGs are considered as tools for improving the quality and safety of healthcare services [5,6,7].

Adaptation of CPGs is a valid and efficient alternative to de novo development of CPGs especially in resource-limited healthcare settings in order to avoid duplication of efforts, to use the available resources in a cost-effective manner, and to encourage trans-contextual customization of the CPG prepared for different economic and healthcare settings reflecting the local context and system [5,6,7,8].

The Eastern Mediterranean Regional Office of the World Health organization recommended a set of actions to help advance guideline development and/or adaptation and implementation in the region [9].

Till date, there were no published unified CPGs for management of bronchiolitis in Egypt, the presented evidence-based CPG is proposed as a National CPG using an evidence-based and formal CPG adaptation methodology. The aim of this study was to adapt the international CPGs’ recommendations for children with bronchiolitis to suit the healthcare system in the Egyptian context.

This study is part of a major project by a National Egyptian Pediatrics Clinical Practice Guidelines Committee (EPG) which was formulated by an initiative in collaboration with the Faculty Staff of the Pediatrics Departments of 15 Egyptian Universities and a National Research Centre. EPG was affiliated later to the Supreme Council of the Egyptian University Hospitals aiming to define the topics of, assign authors to, and assist in the adaptation of pediatric evidence-based CPGs according to a national strategic plan (http://epg.edu.eg ). The committee is guided by a formal CPG adaptation methodology: the ‘Adapted ADAPTE’ [5].

Methods

We utilised the ‘Adapted ADAPTE’ CPG adaptation methodology that was proposed to enhance the utilization of the original ADAPTE method [5, 8]. This formal CPG adaptation process consists of three phases (i.e., set-up, adaptation, and finalization) and 24 steps with modifications in the steps and tools to suit the local general healthcare setting in health systems with limited resources like Egypt [5, 6, 8].

Set-up phase

In phase 1(set-up), bronchiolitis was selected by the EPG National Committee as one of the priority health topics for the EPG adaptation projects. An initial search was conducted to identify whether there were existing published and accessible bronchiolitis CPGs.

The Bronchiolitis Guideline Adaptation Group (BGAG) was formulated with 20 members. The BGAG was composed of faculty professors and consultants of Pediatrics from five Egyptian universities. Two members of BGAG had previous expertise in CPG adaptation methodologies and were involved in the development of the Adapted ADAPTE. There was active involvement of a Multidisciplinary Review Committee during the process of this CPG adaptation.

The target patient population for this CPG project is infants less than 2 years of age presenting with bronchiolitis in primary health care centers or emergency departments in hospitals. Excluded population include patients with life-threatening bronchiolitis necessitating intensive care unit admission, patients who have underlying respiratory illnesses such as recurrent wheezing, chronic neonatal lung disease (also known as bronchopulmonary dysplasia), neuromuscular disease, or cystic fibrosis and those with hemodynamically significant congenital heart disease. The intended users include physicians (specifically paediatricians, primary healthcare physicians, and family practitioners) and nurses, and clinical pharmacists.

Adaptation phase

In phase 2, we identified 28 clinical questions, using the PIPOH model, including 7 questions for diagnosis, 14 for treatment, and seven for prevention (Appendix Table 1). The PIPOH model included the target patient population (P), intervention(s) (I), professionals and clinical specialties (P), outcomes (O), and healthcare setting or context (H) [16]. The literature search was conducted using MEDLINE/PubMed and Google Scholar portals. Eligible Source CPGs were then critically appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Instrument [10]. AGREE II is a valid and reliable instrument with 23 items organized into six domains and is considered the gold standard for quality assessment of CPGs [19]. The first draft of the adapted CPG marks the last step of this phase.

Finalization phase

In phase 3, the first draft of the adapted CPG was finalized including assessing whether it is acceptable and applicable to Egyptian healthcare context. The draft was then disseminated to a panel of external reviewers of topic experts. Afterwards, the feedback of reviewers was revised and discussed within the BGAG with consideration of the national context. The finalized version of the adapted CPG included relevant practical implementation tools and strategies.

Ethics approval and consent to participate

Not applicable

Results

The BGAG was formulated by 18 Professors of Pediatric Pulmonology in addition to a Professor of Pediatrics and a general pediatrician who are well versed in evidence-based CPG adaptation methodologies. We studied several Source CPGs for diagnosis, treatment, and prevention of bronchiolitis. Two eligible Source CPGs, the Australasian (PREDICT) Guideline 2016 (http://www.predict.org.au/download/Australasian-bronchiolitis-bedside-clinical-guideline.pdf) [11] and the American Academy of Pediatrics (AAP) Guideline 2014–2018 (http://pediatrics.aappublications.org/content/134/5/e1474) [12] were identified and assessed using the AGREE II instrument. The AGREE II domains standardized domain score were presented in Appendix Table 2. BGAG reviewed the results of the AGREE II assessment and decided to adapt mainly the Australasian (PREDICT) CPG and for the questions not answered in PREDICT we adapted the relevant recommendations from the AAP CPG. We met nine times, face-to-face meetings, throughout the development of these CPGs to discuss and finalize the recommendations.

Three professors of pediatric pulmonology, a public health faculty, a head nurse, and a clinical pharmacist participated as an independent external review panel from the target audience of the CPG. Members of the BGAG and the external review groups were a good representation of multiple universities and university hospitals in Egypt.

The summary recommendations of the adapted CPG are highlighted in Table 1.

Table 1 Key recommendations of the adapted bronchiolitis CPG

A set of CPG implementation tools were attached to the finalized adapted CPG. These tools were developed and revised by the BGAG group to be used by healthcare providers and families of children with bronchiolitis for education and awareness. Seven implementation tools (i.e., four adopted or modified and three new tools) included: a care pathway and criteria for assessment of severity (Appendix Table 3), a clinical algorithm for treatment of acute bronchiolitis in the emergency room (Fig. 1), a separate flowchart for assessing babies with bronchiolitis, a power point slide presentation lecture for treatment of acute bronchiolitis, patient information in Arabic, a clinical score (Modified Tal Score) for prediction of bronchiolitis severity (Appendix Table 4), and the criteria for admission and discharge in the hospital.

Fig. 1

Algorithm for treatment of acute bronchiolitis in the emergency room (designed by the BGAG according to the key recommendations)

Appendix Table 5 summarized the decision support record for the BGAG throughout the different phases of the Adapted ADAPTE method.

A comprehensive set of multifaceted CPG implementation strategies was provided for the clinicians, patients, nurses, and other relevant stakeholders to the national settings.

The BGAG recommended the next review of this adapted CPG to be after 3 years from its publication (i.e., 2022) after checking for updates in the original CPG, and consulting the experts on the updated evidence and recommendations published in bronchiolitis. Moreover, the results of the national implementation should inform the content of the next update.

Discussion

A strength of this project is the use of the ‘Adapted ADAPTE’ method as it is clearly structured and includes a set of tools to support the process [5,6,7,8].

Involvement of multi-disciplinary groups, including pediatrics, clinical pharmacy, nursing, and public health, from multiple universities and several governorates in the CPG adaptation process is expected to promote the adherence to this adapted CPG at the national level. Moreover, we expect more collaboration and integration of services for care of children with bronchiolitis as a result of the adoption of these adapted recommendations.

The aim of this study coincides with the initiative of the World Health Organization of the Regional Office of the Eastern Mediterranean to promote CPG adaptation in the region [9]. One identified limitation was the lack of a patient or parent representative in the BGAG.

The BGAG has identified several expected facilitators and barriers to implementation and discussed their proposed solutions.

The identified barriers to implementation included the financial support to help in preparation of educational tools, also to develop a multidisciplinary working group due to shortage of the working time for the trained persons to educate healthcare providers to improve their awareness, knowledge, and understanding of the CPG recommendations.

The facilitators of implementation included the presence of CPG adaptation tools using the ‘Adapted ADAPTE’ approach created by Alexandria University based on the ADAPTE Manual and Resource Toolkit-Version 2.0 that was released by the Guidelines International Network-Adaptation Working Group [5, 6], and the initiative to formulate the National Pediatric CPG Committee in collaboration with the relevant faculty staff of several Egyptian universities as well as a National Research Center.

Conclusions

The ‘Adapted ADAPTE’ as a formal CPG adaptation method is rigorous, practical, and intensive tool has been demonstrated to be feasible and user-friendly for national CPG projects. Our experience with this adaptation methodology provides useful insight into its utilization on a national level in Egypt. Further context-based modifications to this method is accepted with the proper rationale and documentation.