Table 1 Key recommendations of the adapted bronchiolitis CPG

1 a

In infants presenting to hospital or hospitalized, how can clinician diagnose

Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination

AAP [12]

Evidence B

Strong recommendation

1b

In infants presenting to hospital what factors in history and physical examination contribute to diagnosis of bronchiolitis?

The major factors which were predictive were fever, cough, tachypnea, retractions, and wheeze.

PREDICT [11]

Evidence C

Weak recommendation

2

In infants presenting to hospital with bronchiolitis, what are the risk factors for admission or severe disease

Clinicians should consider as risk factors for more serious illness: gestational age less than 37 weeks; chronological age at presentation less than 10 weeks; exposure to cigarette smoke; breast feeding for less than 2 months; failure to thrive; having chronic lung disease; having chronic heart and/or chronic neurological conditions.

PREDICT [11]

Evidence C

Grade: Conditional

3

In infants presenting to hospital or hospitalized with bronchiolitis, does performing a ChestX-ray beneficially change medical treatment or clinically relevant end-points?

When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic studies should not be obtained routinely

AAP [12]

Evidence B

4

In infants presenting to hospital or hospitalized with bronchiolitis, does performing laboratory tests (blood and/or urine) beneficially change medical treatment or clinically relevant end-points?

When clinicians diagnose bronchiolitis on the basis of history and physical examination, laboratory studies should not be obtained routinely

AAP [12]

Evidence B

5

In infants presenting to hospital or hospitalized with bronchiolitis, does performing virological investigations beneficially change medical treatment or clinically relevant end-points?

In infants with bronchiolitis, routine use of viral testing is not recommended for any clinically relevant end-points.

PREDICT [11]

Evidence C

6

For infants presenting to hospital or hospitalized with bronchiolitis, does use of a bronchiolitis scoring system beneficially change medical treatment or clinically relevant end-points?

For infants presenting to hospital or hospitalized with bronchiolitis, there is insufficient evidence to recommend the use of a scoring system to predict need for admission or hospital length of stay

PREDICT [11]

Evidence D

Grade: weak

7

For infants presenting to hospital or hospitalized with bronchiolitis, what criteria should be used for safe discharge?

Oxygen saturations, adequacy of feeding, age (infants younger than 8 weeks), and social support should be considered at the time of discharge as a risk for representation.

PREDICT [11]

Grade: Good Practice Point

8a

Does administration of B2 agonist improve clinically relevant outcome in infants and children with bronchiolitis?

Bronchodilators should not be used routinely in the treatment of bronchiolitis in infants and children.

PREDICT [11]

Evidence A

Strong recommendation

8b

In hospitalized infants with bronchiolitis, with personal or family history of atopy, does the use of B2 agonist improve clinically relevant outcome?

Inhaled bronchodilators should be continued only if there is a documented positive clinical response to the trail using an objective means for evaluation.

PREDICT [11]

Evidence A

Strong recommendation

9

Does the use of inhaled 3% saline improve clinical outcome in infants hospitalized with bronchiolitis?

Clinicians may administer nebulized hyper tonic saline to infants and children hospitalized for bronchiolitis

AAP [12]

Evidence: B

Moderate recommendation

10

Does the inhaled Epinephrine improve relevant outcome?

Do not administer Epinephrine to infants presenting to hospital or hospitalized with bronchiolitis.

PREDICT [11]

Evidence B

Strong recommendation

11

In hospitalized infants with bronchiolitis, does administration of combination of systemic or inhaled corticosteroids and adrenaline improve clinically relevant outcome?

Do not administer a combination of systemic or local steroids and nebulized epinephrine to infants presenting to hospital or hospitalized with bronchiolitis.

PREDICT [11]

Evidence D

Weak recommendation

12

Does the use of corticosteroids improve clinically relevant outcome?

Corticosteroid (systemic or local) medication should not be used in the treatment of bronchiolitis

PREDICT [11]

Evidence B

Strong recommendation

13

Does the use of antiviral treatment improve clinically relevant outcome?

The clinician should not use routinely Ribavirin in children with bronchiolitis?

AAP [12]

Evidence B

14a

In infants presenting to hospital or hospitalized with bronchiolitis, does administration of supplemental oxygen improve clinically relevant end-points?

Consider the use of supplemental oxygen in the treatment of hypoxic (oxygen saturations less than 92%) infants with bronchiolitis.

PREDICT [11]

Evidence C

14b

In infants presenting to hospital or hospitalized with bronchiolitis, what level of oxygen saturation should lead to commencement or discontinuation of supplemental oxygen to improve clinically relevant end-points?

In uncomplicated bronchiolitis oxygen supplementation should be commenced if the oxygen saturation level is sustained at a level less than 92%. At oxygen saturation levels of greater than or equal to 92%, oxygen therapy should be discontinued.

PREDICT [11]

Evidence C

14c

In infants hospitalized with bronchiolitis does the use of heated humidified high flow oxygen, or air, via nasal cannula improve clinically relevant end-points?

The clinician should use heated humidified high flow oxygen, or air, via nasal cannula for the inpatient setting in children with bronchiolitis with hypoxia (oxygen saturations < 92%).

PREDICT [11]

Evidence C

15

In infants hospitalized with bronchiolitis does continuous monitoring of pulse oximetry beneficially change medical treatment or clinically relevant endpoints?

Routine use of continuous pulse oximetry is not required for treatment of non-hypoxic infants (saturations ≥ 92%) not receiving oxygen, or stable infants receiving oxygen.

PREDICT [11]

Evidence C

16

In infants hospitalized with bronchiolitis, does chest physiotherapy improve clinically relevant end-points?

Chest physiotherapy is not recommended for routine use in infants with bronchiolitis.

PREDICT [11]

Evidence B

17a

In infants hospitalized with bronchiolitis, does suctioning of the nose or naso-pharynx improve clinically relevant end-points?

Nasal suction is not recommended as routine practice in the treatment of infants with bronchiolitis. Superficial suction may be considered to assist with feeding.

PREDICT [11]

Evidence D

17b

In infants hospitalized with bronchiolitis, does the use of nasal saline drops improve clinically relevant end-points?

Routine nasal saline drops are not recommended. Trial of intermittent saline drops may be considered at time of feeding.

PREDICT [11]

Evidence D

Weak recommendation

18

In infants hospitalized with bronchiolitis, does the use of CPAP improve clinically relevant end-points?

Nasal CPAP for infants with bronchiolitis may be considered for the treatment.

PREDICT [11]

Evidence C

19

In infants hospitalized with bronchiolitis, is provision of home oxygen a safe alternative for treatment?

After a period of observation, infants at low risk for severe bronchiolitis can be considered for discharge on home oxygen as part of an organized ‘Home Oxygen Program’ which has clear ‘Return to Hospital’ advice.

PREDICT [11]

Evidence C

20

Does the use of antibacterial medication is beneficial in treatment of bronchiolitis and improve clinically relevant outcome?

Antibacterial medication should be used only in children with bronchiolitis who have specific indications of coexistence of bacterial infection.

PREDICT [11]

Evidence B

21a

In infants presenting to hospital or hospitalized with bronchiolitis, does the use of oral or non-oral hydration improve clinically relevant end-points?

Supplemental hydration is recommended for infants who cannot maintain hydration orally.

AAP [12]

Evidence Quality: X

Recommendation Strength: Strong

21b

In infants presenting to hospital or hospitalized with bronchiolitis, what forms of non-oral hydration improve clinically relevant end-points

Both NG and IV routes are acceptable means for non-oral hydration in infants admitted to hospital with bronchiolitis.

AAP [12]

Evidence Quality: X

Recommendation Strength: Strong

21c

In infants presenting to hospital or hospitalized with bronchiolitis, does limiting the volume of non-oral hydration impact on clinical relevant end-points?

There is insufficient evidence to recommend a specific proportion of maintenance fluid. There is a risk of fluid overload. Judicious use of isotonic hydration fluid is recommended.

PREDICT [11]

Evidence D

Weak recommendation

22

What are the criteria for giving Palivizumab prophylaxis to infants and children by a clinician?

Clinicians may administer palivizumab prophylaxis to selected infants and children with chronic lung disease or a history of prematurity (less than 35 weeks gestation) or with congenital heart disease.

AAP [12]

Evidence A

23

How the clinicians prescribe the dose, frequency, and duration of the palivizumab prophylaxis to the selected infants?

The clinician should give prophylaxis with palivizumab in 5-monthly doses, usually beginning in November or December at a dose of 15 mg/kg per dose intramuscular.

AAP [12]

Evidence C

24

Does hand decontamination for clinician prevent nosocomial spread of RSV?

Hand decontamination is the most important step in preventing nosocomial spread of RSV. Hand should be decontaminated before and after direct contact with patients, after contact with inanimate objects in the direct vicinity of the patient, and after removing gloves

AAP [12]

Evidence B

Strong recommendation

25

What is the preferred disinfectant to be used by the clinician?

Alcohol-based rubs are preferred for hand decontamination. An alternative is hand-washing with antimicrobial soap

AAP [12]

Evidence B

26

Should the clinicians educate personnel and family members on hand sanitation?

Clinicians should educate personnel and family members on hand sanitation

AAP [12]

Evidence C

27

Does tobacco smoking affect the clinical outcome in treatment of bronchiolitis in infants and children?

Infants should not be exposed to passive smoking

AAP [12]

Evidence B

Strong recommendation

28

Does breastfeeding affect the risk of having lower respiratory tract disease in infants?

Breastfeeding is recommended to decrease a child’s risk of having lower respiratory tract infection

AAP [12]

Evidence C