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SGEM#167: The Management of Bronchiolitis in Community Hospitals

SGEM#167: The Management of Bronchiolitis in Community Hospitals

Podcast Link: SGEM167

Date: December 14th, 2016

Reference: Plint et al. Management of Bronchiolitis in Community Hospitals in Ontario: a Multicentre Cohort Study. CJEM November 2016

Guest Skeptic: Dr. Chris Bond. Chris is an emergency physician and clinical lecturer at the University of Calgary. He is currently the host of CAEP Casts, which highlights educational innovations from emergency medicine residency programs across Canada. Chris also has his own #FOAMed blog called Standing on the Corner Minding My Own Business (SOCMOB).

Case: Parents present to your community emergency department with their 6-month-old daughter. She has had a cough, fever, and “noisy breathing” for the past 24 hours. She is otherwise healthy, having had a previously uncomplicated prenatal, delivery, and post-natal course. Her immunizations are up to date. There is no family history of atopy or asthma.

On exam she is febrile at 38.4 Celsius, pulse 150bpm, respiratory rate 50bpm, and an oxygen saturation of 93% on room air. You even manage to get a blood pressure, which is 78/48. She has a lot of clear nasal discharge and mildly increased work of breathing, with subcostal indrawing. Her cardiac exam is unremarkable, but there is diffuse wheezing throughout the lungs bilaterally, which the parents say has never happened before. The remainder of her exam is reassuring.

Dr. Anthony Crocco SketchyEBM.com

Dr. Anthony Crocco
SketchyEBM.com

Background: It has been said that there are two seasons in North America… Bronchiolitis season and August. We know that bronchiolitis presents a significant burden of disease not only to patients and families, but the health-care system as well.

Although the vast majority of infants with bronchiolitis can be managed with supportive care at home, due to its high incidence, it is the number one reason for infants to be hospitalized (Njoo et al 2001, Langley et al 2003, Craig et al 2007 and Shay et al 1999).

Since bronchiolitis is a clinical diagnosis, there is no test, including viral testing and radiography, which rules it in or out (Schuh et al 2007).

Sadly, despite multiple guidelines (NICE, AAP, CPS), there has also been no “magic bullet” in terms of treatment.

Although there has been some benefit shown with inhaled hypertonic saline (Zhang et al 2015) and early research on combining nebulized epinephrine and systemic steroids is promising, there is concern about the ongoing use of unproven therapies such as beta-agonists, steroids alone and antibiotics.

Existing research has helped to quantify the bronchiolitis practice patterns of physicians in children’s hospitals. Plint et al, in 2004, found that Canadian pediatric emergency departments continued to use bronchodilators and steroids for children with bronchiolitis.

Since a number of these infants are seen in community hospital settings, the practice patterns of physicians in these environments needs further illumination.


Clinical Question: How is bronchiolitis managed in community hospitals?


Reference: Plint et al. Management of Bronchiolitis in Community Hospitals in Ontario: a Multicentre Cohort Study. CJEM November 2016

  • Population: Children aged less than 12 months of age treated in community emergency departments or inpatient wards with a discharge diagnosis of bronchiolitis.
  • Outcome:
    • Primary Outcome: Patient disposition (admission, discharge and transfer to other hospitals)
    • Secondary Outcomes: Emergency department and inpatient ward management (medication use, investigations and discharge medications) 
Dr. Amy Plint

Dr. Amy Plint

The SGEM HOP episodes always have one of the authors on the show. Dr. Amy Plint is a pediatric emergency physician at the Children’s Hospital of Eastern Ontario, a Professor of Pediatrics and Emergency Medicine, Senior Scientist at the Children’s Hospital of Eastern Ontario Research Institute, and the Faculty of Medicine Research Chair in Pediatric Emergency Medicine at the University of Ottawa. Her research focuses primarily on the emergency department management of respiratory illnesses, particularly bronchiolitis, musculoskeletal injuries, and patient safety in the emergency department.

Author’s Conclusions: Infants with bronchiolitis receive medications and investigations for which there is little evidence of benefit. This suggests a need for knowledge translation strategies directed to community hospitals.

Quality Checklist for Observational Study:checklist

  1. Did the study address a clearly focused issue? Yes.
  2. Did the authors use an appropriate method to answer their question? Yes.
  3. Was the cohort recruited in an acceptable way? Yes.
  4. Was the exposure accurately measured to minimize bias? Yes.
  5. Was the outcome accurately measured to minimize bias? Yes.
  6. Have the authors identified all-important confounding factors? Yes.
  7. Was the follow up of subjects complete enough? Yes.
  8. How precise are the results/is the estimate of risk? Unsure. There are wide confidence intervals for the admission rate as well as investigations and treatments because of the small number of children with bronchiolitis at each hospital and the variability in management among these hospitals.
  9. Do you believe the results? Yes.
  10. Can the results be applied to the local population? Yes.
  11. Do the results of this study fit with other available evidence? Yes.

Key Results: There were 543 children included in this study from 28 hospitals. The average age was 6 months and 60% of children were male. The mean gestational age was just under 39 weeks.


Primary Outcome: 30% Admitted, 3% Transferred and 7% Returned


  • Primary Outcome: Patient Disposition
    • Admissions: 30% of patients were admitted to hospital (28% on index visit and 2% on repeat visit within 21 days).
    • Transferred: 3% were transferred to another hospital
    • Return Visit: 7% returned to the Emergency department within 21 days
  • Secondary Outcomes:  For a full list with all the details please see Table 3 and 4 in the manuscript.
    • 80% received bronchodilators in the emergency department and 45% were prescribed them at discharge
    • 31% received corticosteroids in the emergency department and 24% were prescribed them at discharge
    • 5% received antibiotics in the emergency department and 13% were prescribed them at discharge
    • 55% had a chest x-ray
    • 23% had a nasal viral studies swab
    • 7% had blood work
    • 3% had a urine studies

This study also examined community inpatient management of children with bronchiolitis and found that almost all received bronchodilators (94%) and half received corticosteroids. Inpatients had more investigations than children seen in the emergency department except for chest x-rays. Inpatients also received more bronchodilators (49%), corticosteroids (36%) and oral antibiotics (19%) at discharge.

Screen Shot 2015-04-25 at 3.11.12 PM

Listen to the podcast to hear Dr. Plint’s responses to our questions.

  1. Participation Rate: Only 28 out of 76 community hospitals agreed to participate. How do you think this impacted the results if at all?
  2. Hypertonic Saline: Zhang et al 2015 showed that inhaled hypertonic saline not only benefits inpatients with bronchiolitis, but also significantly reduced the risk of hospitalization from the emergency department.  We notice that the use of inhaled hypertonic saline was not studied in this research.  Could you please explain why?
  3. Site Differences: You had very different types of community hospitals participate. They ranged from <10,000 visits/year to >100,000 visits/year. Some were less than 40km from a pediatric referral site while one was more than 1,500km away. Seven sites had clinical practice guidelines for managing patients with bronchiolitis. Can you comment on the strengths and weaknesses of such a diverse participating community hospitals and do you think the results would have been different from a referral hospital?
  4. Old Data: Data was collected from two bronchiolitis seasons about 10 years ago (December 2005 to April 2006 and December 2006 to April 2007). Do you still think the management of bronchiolitis is the same in 2016-2017 bronchiolitis season?
  5. Knowledge Gap: We are always talking about how it can take over ten years for high-quality, clinically relevant information to reach the patient’s bedside. What do you think is the main reason for a knowledge gap observed for the management of bronchiolitis and how do you think this gap could be closed?

Comment on authors conclusion compared to SGEM Conclusion: We agree with the authors’ conclusion.


SGEM Bottom Line: There seems to be a knowledge gap when it comes to managing bronchiolitis in the community hospital setting.


Dr. Chris Bond

Dr. Chris Bond

Case Resolution: After a thorough history and careful physical exam, you reassure the parents that their child has bronchiolitis without any ancillary tests or treatments. The child is feeding well in the emergency department and is discharged home with advice around supportive care, including nasal toileting, and appropriate return to emergency department instructions.

Clinical Application: In children with bronchiolitis, clinicians should not be tempted to perform investigations and prescribe treatments that have little benefit or are unproven. Bronchiolitis is a clinical diagnosis and does not require any specific investigations or treatment.

Although it was not discussed in this article, there has been some benefit shown with the use of hypertonic saline. However, conservative treatment with supportive therapy alone is the mainstay.

What do I tell my patient (in this case the parents):  Your child has a very common virus infection in their chest that is making them congested and wheezy. I wish there was a medicine that I would know could make this better but there doesn’t seem to be much that works for children like yours. The good news is that almost all children with this infection get fine at home. We are going to teach you how to keep your child’s nose clear. If your child gets worse, starts to have more trouble breathing, isn’t drinking, is becoming tired or unresponsive, or if you’re just worried they look sicker we want you to return to the emergency department.

sgemhop-cjemThank you to PedsEM super hero Dr. Anthony Crocco from SketchyEBM for filling in on this SGEMHOP episode. We are really interested in engaging the EM community and to find out what you think about this SGEMHOP episode? What questions do you have for Dr. Amy Plint and her team on the management of bronchiolitis? Join the conversation on Twitter (#SGEMHOP), Facebook or the SGEM blog. The best social media feedback will be published in CJEM.

Keener Kontest: The last winner was Hector Singson from Grand Bahama who knew it was 1910 when the abnormal blood cells in sickle cell disease were first described. It was a Chicago physician named Ernest Iron that saw the elongated shape in the blood smears of a student from Grenada suffering from anemia.

Listen to the podcast on iTunes for this weeks’ keener contest question. If you know the answer then email it to me at TheSGEM@gmail.com and the first correct answer will receive a cool skeptical prize.

FOAM logoOther FOAMed Resources:


Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.


SkiBEEM 2017

DasSMACC

  • D. Beam

    Okay I have a nerdy question , it’s related to pharmacology. I understand that beta 2 agonists : eg. Salbutamol ( ventolin ) are out for bronchiolitis, and nebulized epinephrine is probably worth a shot. But are we just targeting the Beta 2 effects of the inhaled epi? And getting some alpha as well?

    • Amy Plint

      Great question. Epinephrine, with both alpha and beta adrenergic activity, has been hypothesized to be more effective than beta adrenergic agents alone, purportedly due to the added benefit of vasoconstriction resulting in reduced mucosal edema.

  • david schindler

    I work at one of the community hospitals near CHEO, the authors hospital. What happens in this situation in our hospital is an x-ray is obtained, which shows the characteristic hilar thickening seen with bronchiolitis. The x-ray is read as “pneumonia” by our radiologists, and the patient is treated (usually post hoc), with antibiotics. The parents are told “your child has “pneumonia”, and for years after, the parents return to the ER insisting “my child is prone to pneumonia”, and demanding antibiotics. 100% of the time I look back and the child never had pneumonia, they had bronchiolitis. Perhaps the teaching here needs to be with the radiologists?

    • Amy Plint

      You raise a good point about x-rays and bronchiolitis. Interesting work by Dr. Suzanne Schuh at Sick Kids has shown that x-rays in children with typical symptoms of bronchiolitis have limited utility, increase the risk of antibiotic prescribing, and increase health care costs (J Pediatr. 2007 Apr;150(4):429-33 and Pediatr Pulmonol. 2009 Feb;44(2):122-7).

  • Tim Horeczko

    “Ken! Where’s Ken?” Crocco, nice job. Thank you, Drs Bond and Plint!

    Great team effort, everyone. The rattling noises around the topic of bronchiolitis are the prototypical rallying call for the need for knowledge translation.

    Bronchiolitis highlights the idea that knowledge translation requires knowledge interpretation as well as its application. That is to say, it is all about managing expectations — in ourselves, our admitting team, and in parents.

    Bronchiolitis, in its pure sense, is like the pneumonia you can’t treat. Necrotic sludge and secretions fill lower airways and alveoli in what is often a dynamic process. Trying to find the one silver suction bullet that clears all wheezing is just asking to be disappointed, hence the mill of papers on the subject. We expect too much from any one modality.

    That said, if there is a possibility for an aggregate clinical benefit, and the risk is low, my attitude is neb and let neb.

    Waning are the days when clinics handed out liquid albuterol/salbutamol (all the side effects, none of the benefit). We have brilliant physicians out there on the front lines who use their judgement to differ respectfully from monolithic guidelines. We have to support them — with latest developments and new studies to be sure, but also with our respect and trust for their care for the wheezing undifferentiated little patient in front of them. Since there is a subgroup (usually over 1 year of age) that may respond to a trial of bronchodilators, surely there is room in the tent for a practice option of a trial, coupled with a skeptical reassessment for effect.

    Hospitalists understand that we try supportive care, serial exams, and observation before admission. We try to help parents understand what to expect at home, if the child can be safely discharged.

    As long as we all know our roles and what to expect of the patient, of ourselves, and of each other, then we can communicate and coordinate the best care possible.

    These discussions are great — in blog or podcast form — they really help to wheeze out the nuances in what can be a complex management scheme.

    Thanks everyone!

  • Kirsty Challen

    Thanks for a great discussion – good job Dr Crocco!
    I think in the UK we probably don’t do quite as many steroids – but CXR often happens if the child looks “sick” (maybe not to confirm bronchiolitis, but to “exclude pneumonia”) https://uploads.disquscdn.com/images/399fb0926ca153d614e5d14200ff508381ce75164a0883aa2397df4e97f228a5.png .
    #paperinapic

    • Amy Plint

      Nice infographic!!

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  • Andrew Tagg

    As we enter our summer in the southern hemisphere I’m glad to have have survived our bronchiolitis season relatively unscathed. We seem to have the standard incidence of the illness in our community (around 2% of all paeds presentations) and it is very interesting to me to see the differences in management.

    Whilst I agree the need for a chest x-ray (or ultrasound) to rule out an alternative diagnosis in the sick appearing bronch the majority of ours fall into the mild to moderate category where the main reasons for admission seem to be for supplemental oxygenation and/or supplemental hydration (commonly nasogastric). A simple QI project drastically reduced radiographs for us.

    Those children that are brought in by ambulance have often already received a dose of bronchodilator en route and so very few of our infants are likely to receive either further bronchodilators or steroids.

    What this article highlights is the disparity between production of guidelines and the translation of that knowledge to the real world. This occurs, not just with infant specific diseases such as bronchiolitis but also asthma. I’m often astounded by how we continue to practice based on 7 or 8 year old textbooks, but also test to that level too.

    Vive le FOAM

    Andy

    • Amy Plint

      I agree. Knowledge translation can be a complex endeavour. Congratulations on reducing x-rays at your institution. The evidence is strong that in the typical bronchiolitic child (for example, the 5 month old first time wheezer presenting during the winter viral season) does not need an x-ray. May I ask what was the intervention that helped?

      • Andrew Tagg

        It was a simple QI project. In a way we did a local level investigation similar to yours – audited our practice, provided education with educational champions in the department then re-audited.

        It’s something we are going to try and roll out to the rest of Victoria (the one in the South) next year. Rather than trying implement change on a massive scale it may be more effective to do so on a smaller local scale.

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