Management Of Acute Bronchiolitis Research Articles

Practice Variations between Emergency Physicians and Pediatricians in Treating Acute Bronchiolitis in the Emergency Department: A Nationwide Study

BackgroundAlthough supportive care is the mainstay management for acute bronchiolitis, non–evidence-based diagnostic testing and medications remain common in emergency departments (EDs). ObjectiveOur aim was to compare emergency physicians (EPs) and pediatricians practice patterns in the management of acute bronchiolitis in the ED. MethodsA cross-sectional study was conducted by using registration and claims datasets from 2008 to 2011. Patients with acute bronchiolitis were divided into EP group and pediatrician group. ResultsA total of 2174 patients were enrolled. The diagnostic tests used, including chest x-ray (63.7% vs. 46%; adjusted odds ratio [OR] = 2.27; 95% CI 1.77–2.91), complete blood count (33.2% vs. 21.8%; adjusted OR = 1.74; 95% CI 1.33–2.26), C-reactive protein (35.1% vs. 22.6%; adjusted OR = 1.79; 95% CI 1.38–2.33), blood culture (23.9% vs. 14.3%; adjusted OR = 1.79; 95% CI 1.33–2.39), and arterial blood gas (3.7% vs. 1.8%, adjusted OR = 2.38; 95% CI 1.21–4.67), were higher in the EP group than in the pediatrician group. Intravenous fluid administration was also higher in the EP group (20.8% vs. 3.5%; adjusted OR = 7.49; 95% CI 5.12–10.8). In addition, EPs more frequently arranged for hospital admissions (36% vs. 19.5%; adjusted OR = 2.51; 95% CI 1.15–3.26). ConclusionsBoth EPs and pediatricians had high rates of ordering diagnostic testing for acute bronchiolitis patients in ED. Compared with pediatricians, EPs used more diagnostic tests for the patients with acute bronchiolitis in ED.

Role of antibiotic in bronchiolitis management

Introduction: Bronchiolitis is the most common illness among the patients attending the outpatient departments of CMH. It is predominantly a viral disease affecting the infants and young children. Though Antibiotic has little role, pediatricians frequently use them during bronchiolitis management. Very few randomized control trials without antibiotics in the management of bronchiolitis have so far been done. Objectives: To evaluate the outcome of bronchiolitis with or without antibiotics in a hospital setting. Methods: This prospective randomized control study was done in CMH Savar, during six months from October 2012 to March 2013. All the children below two years admitted in CMH Savar with first attack of Clinical Bronchiolitis were our study population. Exclusion criteria were: (i) atopic condition, (ii) congenital heart disease and/or (iii) known immunodeficiency. Study cases were randomly assigned into one of the two groups, AB group (Erythromycin/Amoxycilin) and NAB group (No Antibiotic).The NAB group was considered as control group. Supportive treatment was given according to the national guideline for management of bronchiolitis. Presenting symptoms and signs were followed-up twice daily while hospitalized and 7 days after discharge to determine the progress of disease. 70 JAFMC Bangladesh. Vol 9, No 2 (December) 2013 Outcome was determined by the progress of the variables in the structured follow-up format. Permission of commanding officer CMH Savar and verbal consent of the parents were taken before the study. Results: Fifty-four cases who could be followed up till after seven days of discharge were finally included in the study. Among them about half (25/54) received oral or intravenous antibiotic while rest (29/54) received only supportive therapy but no antibiotic (NAB group). Most of the cases were below six months of age. Male were about double of the female (37:17). The presenting features were cough, wheeze, fever and feeding difficulty. Clinical features of both groups progressed similarly in both the groups. With the given treatment 24 (96%) cases from AB group and 27 (93%) cases from NAB group improved and were discharged safely. 01 from AB and 02 from NAB group deteriorated and were then treated with broad spectrum antibiotics. There was no death. Mean hospital stay of AB group (5.6 days) was little longer than NAB group (4.2 days) and 16% (4/25) of them had respiratory symptoms at seven days follow up, but the difference of outcome between the two groups was not statistically significant. Conclusion: Antibiotics have no role in acute bronchiolitis management. DOI: http://dx.doi.org/10.3329/jafmc.v9i2.21833 Journal of Armed Forces Medical College Bangladesh Vol.9(2) 2013

Effect of montelukast on clinical score and cytokine levels of infants for clinically diagnosed acute bronchiolitis

BackgroundAcute bronchiolitis comprises a major cause for morbidity in infants with viral infection which induces an immune inflammatory response that may produce long lasting harmful effects. Currently, there is no effective therapy for bronchiolitis. ObjectiveOur aim was to investigate the efficacy of five-day montelukast therapy in acute bronchiolitis management. MethodsThe study included 50 infants with acute bronchiolitis. The infants with first episode of acute bronchiolitis were randomly assigned to receive daily montelukast dose of 4mg over five days after admission or no treatment. Plasma eotaxin, IL-4, IL-8 and IFN-gamma levels were evaluated before and after treatment by ELISA method. In the present study, the primary outcome measure was change in clinical severity score, whilst secondary outcome measures were changes in plasma eotaxin, IL-4, IL-8, IFN-gamma levels. ResultsNo significant differences was found in clinical severity score with five-day montelukast treatment (p>0.05, Mann–Whitney U test). There were no significant differences in plasma eotaxin, IL-4, IL-8, IFN-gamma levels between the groups (p>0.05 Mann–Whitney U test). There was significant decrease in plasma IFN-gamma levels following five-day montelukast treatment (p=0.027, Wilcoxon). There were no significant differences in plasma IL-4, IL-8, IFN-gamma levels between the groups after five-day montelukast treatment (p>0.05, Wilcoxon). There was significant increase in eotaxin levels after five-day montelukast treatment (p=0.009, Wilcoxon). ConclusionOur study showed that montelukast affected plasma IFN-gamma and eotaxin levels after five days of treatment. Further studies are needed to demonstrate effects of montelukast on chemokine levels in bronchiolitis.

Recent advances in the management of acute bronchiolitis.

Acute bronchiolitis is characterized by acute wheezing in infants or children and is associated with signs or symptoms of respiratory infection; it is rarely symptomatic in adults and the most common etiologic agent is respiratory syncytial virus (RSV). Usually it does not require investigation, treatment is merely supportive and a conservative approach seems adequate in the majority of children, especially for the youngest ones (<3 months); however, clinical scoring systems have been proposed and admission in hospital should be arranged in case of severe disease or a very young age or important comorbidities. Apnea is a very important aspect of the management of young infants with bronchiolitis. This review focuses on the clinical, radiographic, and pathologic characteristics, as well as the recent advances in management of acute bronchiolitis.

3% Hypertonic saline vs normal saline nebulization in children with acute bronchiolitis. Critical appraisal of an article “Hypertonic (3%) saline vs 0.9% saline nebulization for acute viral bronchiolitis: A randomized controlled trial. Sharma BS, Gupta MK, Rafik SP, Indian Pediatr. 2013 Aug;50(8):743–47”

QuestionNebulization with hypertonic saline have been shown to be effective in management of acute bronchiolitis in different studies. In the present study duration of hospital stay and clinical severity scores of children admitted with acute bronchiolitis were compared between two groups. One group received nebulization with 3% hypertonic saline while other group received nebulization with 0.9% normal saline. MethodsThis study was a double blinded randomized controlled trial conducted in a tertiary care teaching hospital in Jaipur, India from September 2009 to December 2010. Study population included 250 hospitalized children aged 1–24 months with clinical diagnosis of acute bronchiolitis of moderate severity as assessed by clinical severity score proposed by Wang et al. The study population was randomized into two groups to receive either nebulization of 4 ml of 3% hypertonic saline or 4 ml of 0.9% saline, along with 2.5 mg salbutamol in both groups, at 4 hourly intervals till the patients were fit for discharge. Fitness for discharge was defined by authors as “feeding well, no need of IV fluids and oxygen therapy, clinical severity scores ≤3, absence of accessory muscle use or tachypnoea (respiratory rate <31 breaths/min) and oxygen saturation >92% on air”. Main resultsThe results of the study were in three forms viz baseline characteristics, duration of hospital stay and improvement in clinical severity scores between above two groups. Baseline characteristics were similar in both groups. The clinical severity scores were recorded at the time of recruitment and twelve hourly thereafter till discharge. The median clinical severity scores of the two groups were similar at the time of recruitment and thereafter in two groups. The duration of hospital stay was 63.93 ± 22.43 h in 3% saline group which was similar to 63.51 ± 21.27 h in 0.9% saline group (P = 0.878). None of parents, caregivers or treating physicians were reported any adverse events in both groups. ConclusionNebulization with 0.9% normal saline or 3% hypertonic saline has got similar efficacy in terms of duration of hospital stay and improvement in clinical severity scores among the children admitted with acute bronchiolitis.

Utility of Hypertonic Saline in the Management of Acute Bronchiolitis in Infants: A Randomised Controlled Study

Background: Bronchiolitis is a common lower respiratory tract ailment usually affects infants. With few effective treatments, the health care cost of managing bronchiolitis is significant; Cochrane data base review has cited sufficient evidence regarding the usefulness of hypertonic saline in cystic fibrosis patients. Hypertonic saline has recently been given a trial in patients with acute bronchiolitis. We undertook the study to determine the efficacy and safety of hypertonic saline (3%) plus adrenaline nebulisation in bronchiolitis in infants and to compare it with normal saline (0.9%) plus adrenaline nebulisation. Methods: One hundred consecutive patients attending Paediatrics Emergency at GMSH, Sector-16, Chandigarh between the age group of 2 to 12 months and admitted with clinical diagnosis of acute bronchiolitis were enrolled for the study. Results: Baseline clinical symptoms and signs were comparable between the two groups. There was no significant difference found between 2 groups in relation to clinical signs (respiratory rate, RDAI, heart rate and SpO 2 ) pre and post nebulisation on day 1 as well as on day 2. The change in clinical parameters pre and post nebulisation in 2 groups was comparable. The mean ± SD length of stay in hospital in hypertonic saline and normal saline group was 3.92 ± 1.72 days and 4.08 ± 1.90 days respectively. There was no significant difference noted between two groups (P = 0.67). Conclusion: Nebulisation with hypertonic saline plus adrenaline and normal saline plus adrenaline are equally effective in the treatment of acute bronchiolitis in infants. Nebulisation with hypertonic saline is a safe option of treatment in acute bronchiolitis in children. doi: http://dx.doi.org/10.4021/ijcp96w

Impact of a bronchiolitis clinical care pathway on treatment and hospital stay

Aim Bronchiolitis is a common lower respiratory tract infection of infancy where management has varied considerably in the past. The aim of the present study was to determine whether patient treatment and outcomes changed after introduction of a clinical care pathway. Methods Infants aged up to six months admitted to hospital with bronchiolitis were identified as part of an annual audit of bronchiolitis management between winters 2003/4 and 2010/11. High risk infants, e.g. infants born prematurely or with cardiac defects, were excluded. The primary outcome, duration of stay (DOS), was compared before and after the clinical pathway was introduced before the winter 2005/6. Secondary outcomes were proportion requiring nasogastric feeds, supplemental oxygen and readmission within a week of discharge. Results There were 382 infants identified, mean age 68 days, 55% were male and respiratory syncitial virus was detected in 84%. After the clinical pathway was introduced, the proportion of infants prescribed salbutamol fell from 50% to 10% (p Conclusions A clinical pathway for the management of acute bronchiolitis can be implemented in the hospital setting and the conservative approach, in particular cautious prescribing of bronchodilators, is not associated with prolonged duration of stay.

Management of acute bronchiolitis in emergency wards in Spain: variability and appropriateness analysis (aBREVIADo Project)

Most patients with acute bronchiolitis have a mild course and only require outpatient care. However, some of them have to go to emergency departments, because they have respiratory distress or feeding problems. There, they frequently receive diagnostic and therapeutic procedures. We want to know the variability and appropriateness of these procedures. A cross-sectional study (October 2007 to March 2008) was carried out on 2,430 diagnosed cases of bronchiolitis in hospital emergency departments, which required no hospitalization. An analysis of the appropriateness of the treatments was made in 2,032 cases gathered in ten departments with at least 100 cases, using as criterion the recommendations of a consensus conference. We estimated the adjusted percentages of each department. Most of the bronchiolitis were mild, in spite that they underwent multiple diagnostic and therapeutic procedures. In the acute phase, different treatments were used: inhaled beta 2 agonists (61.4%), antipyretics (17.1%), oral steroids (11.3%), and nebulized adrenaline (9.3%). In the maintenance phase, the most common treatments were: inhaled beta 2 agonists (50.5%), oral steroids (17%), oral beta 2 agonists (14.9%), and antibiotics (6.1%). The 64% of the treatments used in the acute phase and the 55.9% in the maintenance phase were considered inappropriate in the appropriateness analysis; a great heterogeneity among centers was found. There are discrepancies between clinical practice and evidence-based management of bronchiolitis in Spanish emergency departments. Inappropriate treatments were used in more than half of patients. The wide variation between centers shows the influence of local prescribing habits and reveals the scope for improvement.

Guía de práctica clínica sobre la bronquiolitis aguda: recomendaciones para la práctica clínica

There are scientific controversies about the management of acute bronchiolitis that generate a great variability in the approach to this entity. A clinical practice guideline (CPG) is a set of systematically developed recommendations to assist practitioners and patients to make decisions based on evidence. A working group (WG) of experts has been selected and they have developed the clinical questions. A systematic search for evidence on the acute bronchiolitis has been done and the evidence has been assessed. The information obtained has been summarized in evidence tables and recommendations have been done from them. The WG has produced a total of 46 clinical questions grouped into sections (diagnosis, complementary tests, treatment, monitoring, prevention and evolution), resulting in 133 recommendations. The CPG on acute bronchiolitis provides an opportunity to unify clinical practice based on scientific evidence, which could rationalize the use of health resources, improving health care quality and equity of access to services.

Estudio de variabilidad en el abordaje de la bronquiolitis aguda en España en relación con la edad de los pacientes

Introduction There are many studies on the controversial issues involved in the management of acute bronchiolitis (AB). The aim of this multicenter nationwide study in Spain was to find out the variability in the management of AB in various areas of clinical care (primary care, emergency and hospitalization) and to analyze the impact of patient age on diagnostic and therapeutic management. Material and methods A cross-sectional observational study (from October 2007 to March 2008) of all cases of BA (McConnochie criteria) treated in a sample of 31 hospitals and 60 health or primary care centers in 12 autonomous regions in Spain. A questionnaire was designed to collect study variables (general information, symptoms, risk factors, diagnostic tests and treatments) and to make a comparison of variables by age groups (newborns, 1–3 months, 3–12 months and >12 months). Results A total of 5647 cases of AB (51.2% from emergency services, 28.9% from hospitalization, 18.3% from primary care and 1.6% from ICU), whose average age was 0.34 years (95%CI 0.32 to 0.35), with 6.6% under 1 month, 23.5% between 1 and 3 months, 60.6% from 3 to 12 months and 522 over 12 months. There is an important use of diagnostic and therapeutic procedures not recommended in clinical practice guidelines. We also found differences related to age: younger infants showed an increased risk of admission, clinical differences (greater presence of rhinitis, vomiting, refusal of feedings, apnea and septic appearance and less fever and night cough; more tachypnea, retractions, hypoventilation and impaired consciousness, and lower presence of wheezing), increased number of diagnostic tests (oxygen saturation, chest x-ray, RSV test, CBC, etc.) and differences in patterns of treatment (less use of all medications before diagnosis and the maintenance phase; in the acute phase, increased use of epinephrine and parenteral corticosteroids and lower use of bronchodilators and oral corticosteroids, and more frequent use of supplemental oxygen, intravenous fluids, intravenous antibiotics, nasal washings, respiratory aspiration, chest physiotherapy, assisted ventilation and heliox). Conclusions There are discrepancies between routine practice and evidence-based management of AB in Spain (both inpatient and outpatient). There is a high percentage of cases in which diagnostic tests and therapeutic interventions (of unproven effectiveness and usefulness in the BA) are performed, where the use is higher in younger infants.

Application de la Conférence de consensus sur la bronchiolite aiguë du nourrisson en médecine générale : évolution entre 2003 et 2008

The 2000 French Consensus Conference for Acute Viral Bronchiolitis management underlined clinical practice recommendations. To assess the impact of these guidelines on management of acute bronchiolitis, 3 and 8 years after publication. A standardized questionnaire was mailed to 762 general practitioners (GPs) in 2003 and 800 GPs in 2008. It described two clinical case scenarios (moderate acute viral bronchiolitis and severe acute bronchiolitis) and inquired about the physician's conduct in each case. The primary outcome was the percentage of responders who described patient management in accordance with current guidelines: correct diagnosis and treating the patient symptomatically in an outpatient setting in the first case and correct diagnosis in addition to requiring an inpatient setting for the second case. Secondary outcome was the percentage of responders who would have given unnecessary or potentially harmful treatments. Physician responses in 2003 and 2008 were compared using the Student t-test and the Chi(2) test. Multivariate analysis was conducted to assess the potential factors associated with good adherence to guidelines. Nearly 25% of the questionnaires were returned in 2003 and 2008. Patient management was described in accordance with the guidelines in only 6% in 2003 and 20% in 2008 (p< or =0.001). Unnecessary treatments were prescribed in 77% in 2003 vs 60% in 2008 (p<0.001) and potentially dangerous treatments in 38% in 2003 vs 22 % in 2008 (p=0.006). Using multivariate analysis, the GP's age was inversely correlated with adherence to clinical recommendations (adjusted odds ratio [adOR]=0.93; 95% CI=0.87-0.98; p=0.01). Fifty-four percent of GPs reported knowing these guidelines, but only 57% of them declared that the latter has modified their practice. GPs are still prescribing unnecessary or even potentially dangerous treatments for bronchiolitis. On the other hand, severe cases are correctly diagnosed and well managed in an inpatient setting. Three and 8 years after their publication, adherence to guidelines is insufficient.

Management of acute bronchiolitis: can evidence based guidelines alter clinical practice?

Background:Acute bronchiolitis is the most common lower respiratory tract infection in infants and there is no evidence that drug treatment alters its natural course. Despite this, most Swiss paediatricians reported...

Efficacy of Salbutamol and Ipratropium Bromide in the Management of Acute Bronchiolitis – A Clinical Trial

Background: A wide range of drugs are commonly used to treat bronchiolitis, but evidence of their effectiveness is limited. Objectives: To investigate the efficacy of ipratropium bromide and salbutamol in the treatment of patients with moderate-severe bronchiolitis. Methods: Sixty-nine infants with moderate-severe bronchiolitis hospitalized at their first episode of wheezing or crepitations in the chest were enrolled in a prospective, double-blind, placebo-controlled trial. Patients were randomly assigned to receive nebulized salbutamol, ipratropium bromide or placebo. Main outcome measures were changes in oxygen saturation rates and clinical scores and duration of hospitalization. Results: In the bronchodilator groups, clinical scores were better compared to the placebo group at 30 min (8.4 ± 1.3 vs. 7.5 ± 0.8, p < 0.05). Bronchodilator groups had also significantly lower clinical scores (7.3 ± 1.2 vs. 5.9 ± 1.1, p < 0.0001, and 5.3 ± 1.4 vs. 4.5 ± 1.6, p = 0.006, respectively) and higher oxygen saturation rates compared to the placebo group at 8 and 24 h (89.6 ± 2.4 vs. 94.3 ± 4.4, and 92.2 ± 2.6 vs. 95.9 ±4.4, respectively, p < 0.0001). Improvement rates and duration of hospitalization were not statistically different among groups. Conclusions: Clinical scores and oxygen saturation levels improved more rapidly in the bronchodilator groups than in the placebo group up to 24 h, but these drugs did not have a sufficient effect to change the natural course of the disease.

Phenotype specific treatment of obstructive airways disease in infancy and childhood: new recommendations of the Swiss Paediatric Pulmonology Group.

In 2003 and 2004 the Swiss Paediatric Pulmonology Group (SAPP) revised the recommendations for the management of obstructive airways disease in infancy and childhood (Paediatrica 2004;15:13-28) and published recommendations for the management of acute bronchiolitis in infancy (Paediatrica 2003;14:18-21). The concept underlying these new guidelines is the fact that childhood wheezing illness encompasses a range of disorders or phenotypes with a similar clinical manifestation (wheeze, cough and breathlessness) but varying pathology, aetiology, prognosis and response to treatment. Based on the available scientific evidence, phenotype-specific and age-dependent management of wheezing illness is advocated in the revised guidelines. Major changes compared to earlier recommendations include a stepwise approach to management depending on age, phenotype and severity of disease and use of beta 2-agonists purely on an on-demand basis. Comparison of these recommendations with epidemiological data on current treatment practice of obstructive airways disease in Swiss children suggests that many children with bronchiolitis and mild viral wheeze might be overtreated while management of children with severe persistent symptoms could be improved.

Current management of acute bronchiolitis in Switzerland.

Acute bronchiolitis is the most common lower respiratory tract infection in the first year of life. Current expert opinion and scientific data suggest that pharmaceutical agents have little impact on the natural course of the disease. Postal questionnaires were sent to all Swiss paediatricians to assess their current practice for treating acute bronchiolitis in children. Of a total of 937 questionnaires, 541 (58%) were returned. Of the respondents, 422 (78%) treat children with acute bronchiolitis. Up to 99% of paediatricians used bronchodilators in the outpatient and inpatient management, either routinely (up to 62%) or occasionally (37%). Steroids were used by 41% of the respondents in outpatient management and by 57% in inpatient management. The paediatric respiratory physicians tended to use bronchodilators and corticosteroids less frequently than the general paediatricians. A wide variation in the treatment of bronchiolitis was noted. Despite lack of evidence of benefit most Swiss paediatricians use pharmaceutical agents in the management of acute bronchiolitis. In particular, bronchodilators and corticosteroids were used in inpatient management in Switzerland much more frequently than recently reported for Australian paediatricians. National guidelines could be helpful in reducing the variations in the management of acute bronchiolitis in our country.

Current management of acute bronchiolitis in Switzerland.

Acute bronchiolitis is the most common lower respiratory tract infection in the first year of life. Current expert opinion and scientific data suggest that pharmaceutical agents have little impact on the natural course of the disease. Postal questionnaires were sent to all Swiss paediatricians to assess their current practice for treating acute bronchiolitis in children. Of a total of 937 questionnaires, 541 (58%) were returned. Of the respondents, 422 (78%) treat children with acute bronchiolitis. Up to 99% of paediatricians used bronchodilators in the outpatient and inpatient management, either routinely (up to 62%) or occasionally (37%). Steroids were used by 41% of the respondents in outpatient management and by 57% in inpatient management. The paediatric respiratory physicians tended to use bronchodilators and corticosteroids less frequently than the general paediatricians. A wide variation in the treatment of bronchiolitis was noted. Despite lack of evidence of benefit most Swiss paediatricians use pharmaceutical agents in the management of acute bronchiolitis. In particular, bronchodilators and corticosteroids were used in inpatient management in Switzerland much more frequently than recently reported for Australian paediatricians. National guidelines could be helpful in reducing the variations in the management of acute bronchiolitis in our country.

Comparison Of Two Different Bronchodilators In The Treatment Of Acute Bronchiolitis

Acute bronchiolitis is an acute inflammatory respiratory illness of children less than two years of age. Classically adequate hydration, supplementary oxygen, bronchodilators, and corticosteroids may be used in the treatment of acute bronchiolitis. In this study, we aimed compare salbutamol to ipratropium bromide in the management of acute bronchiolitis. We enrolled 34 infants hospitalized for bronchiolitis to evaluate the efficacy of these two different bronchodilators. Thirty-four infants under 2 years of age were randomized to receive either nebulized salbutamol (group I) or nebulized ipratropium bromide (group II). Clinical severity was scored on admission and 12-hour intervals after the start of nebulization. The symptom score evaluated five items: respiratory rate, presence of wheezing, presence of recession, presence of nasal flaring and general appearance. No difference was observed in clinical improvement between the two groups on hospital admission and at 12, 24, 36 and 48 hours during treatment. The mean duration of hospital stay was not significantly different between two groups. Both groups showed a significant improvement following 48hours of treatment. We conclude from our work on infant with acute bronchiolitis that there is no difference between the clinical scores of infants receiving ipratropium bromide or salbutamol. Because of the possible side effects of salbutamol, ipratropium bromide may be preferred as bronchodilator in infants with acute bronchiolitis.

Differences in management of bronchiolitis between hospitals in The Netherlands. Dutch Paediatric Respiratory Society.

To study the variation in management of acute bronchiolitis in the Netherlands, a questionnaire on the use of diagnostic and therapeutic procedures and prescription of drugs after discharge was mailed to all 110 hospital-based paediatric practices in the Netherlands. A 100% response rate was achieved. There was a great deal of variation in management of bronchiolitis between respondents. The most commonly applied diagnostic procedures were immunofluorescence staining of nasopharyngeal secretions for respiratory syncytial virus (100% of respondents), blood gas analysis (93%), leucocyte count/differentiation and serum C-reactive protein levels (92%), and chest X-rays (83%). Most respondents used supplemental oxygen (100%) and tube feeding (96%) when needed, and gave nebulized bronchodilators, either as a trial (59%) or in a fixed schedule (33%). Antibiotics for suspected bacterial co-infection were used by 69% of respondents. Corticosteroids were used for severe cases by 35% of respondents; ribavirin was only used in 11% of hospitals for treatment of children from high-risk groups. When children had responded favourably to bronchodilators during admission, these drugs were continued after discharge by 69% of respondents; more than half of these also prescribed inhaled corticosteroids to these children. Considerable variation in management of bronchiolitis exists between hospitals in the Netherlands. Several diagnostic and therapeutic approaches are used which are not evidence based, probably reflecting the lack of therapeutic options with proven clinical efficacy for this condition.

An Evaluation of Chest Physiotherapy in the Management of Acute Bronchiolitis: Changing clinical practice

Summary Aims A clinical trial was undertaken to test the hypothesis that CPT may be of benefit to those infants with acute viral bronchiolitis whose disease on admission was severe enough to require nasogastric or intravenous feeding. The clinical impression that CPT does not increase respiratory distress was also investigated. Method The treatment group (n = 26) receiving physiotherapy was compared with a control group (n = 24). Subjects in the control group were nursed in modified postural drainage positions with suction as required. Outcome was assessed by comparison of clinical score, duration of hospital stay, requirement for oxygen, and nasogastric feeding. Results There was no significant difference in overall outcomes between the two groups. Analysis of clinical scores suggested that less severely ill infants (score Conclusions There was no increase in the respiratory distress of infants who received CPT according to the protocol, but chest physiotherapy is of no benefit in the management of acute viral bronchiolitis in the absence of other pathologies.

Management of acute bronchiolitis

The onset of winter heralds the annual influx of babies with acute bronchiolitis requiring admission to paediatric wards all over the country, resulting in the familiar severe pressure on cots and consequent high stress levels in medical and nursing staff. In our district general hospital, with a birth rate of 4000 per year and serving a child population of 70 000, we admit about 150 such babies each winter, the vast majority of whom (90-96%) are respiratory syncytial virus (RSV)-positive. Bronchiolitis can cause significant morbidity in previously healthy infants and is potentially lethal, especially to babies with severe cardiorespiratory disease or immunological compromise. Despite a global effort and enormous resources devoted to research into both the RSV itself and various treatments for bronchiolitis, we are little further advanced in our management of the condition than in 1963 when Reynolds and Cook made the much cited observation that 'oxygen is vitally important in bronchiolitis and there is little convincing evidence that any other therapy is consistently or even occasionally useful'? There are, however, a number of treatments that are promoted; with more or less evidence to justify their use, and it is on these treatments that this review will concentrate.