BRONCHIOLITIS

SHANNA R. DOOLEY, BSN, RN, CPEN, BONNIE RODIO, RN, BSN, CEN, CPHQ, LISA TYLER, MS, RRT-NPS, CPFT, AND JOSEPH ZORC, MD, MSCE

BACKGROUND EPIDEMIOLOGY, EVIDENCE

Bronchiolitis is a common pediatric illness caused by infection of the lower respiratory tract with respiratory syncytial virus (RSV), rhinovirus, metapneumovirus, or other pathogens. About a third of children acquire bronchiolitis in the first 2 years of life, and it is the leading cause of hospitalization for infants in the United States. Rising hospitalization rates and costs due to bronchiolitis over recent decades have led to a focus on improving the quality of care, including guidelines published by the American Academy of Pediatrics.

Bronchiolitis visits peak during the winter respiratory viral epidemic and can consume high amounts of ED and hospital resources. Although inevitable, the severity and specific timing of RSV season vary each year, which is a challenge for planning. Another important concern is the potential for spread of nosocomial infection to high-risk children, such as premature infants and children with immunodeficiency or cardiac disease. Finally, assessment of infants with bronchiolitis is somewhat challenging, as status can change rapidly due to clearance of secretions from the airways or response to treatments such as suctioning. Although many bronchiolitis scores have been developed for research and clinical care, no single widely accepted approach exists to define a standard clinical assessment.

A key concern as a team develops a plan of care for bronchiolitis is the high degree of variation that researchers have observed across hospitals in the ordering of tests and treatments. As discussed in the AAP Guideline, diagnostic tests such as viral testing and chest radiographs are used widely in some settings without clear evidence that they assist in diagnosis or management decisions, beyond what is gained from a simple history and physical examination. Similarly, use of treatments such as bronchodilators and corticosteroids varies widely across settings, although clinical trials have not found benefit in children with typical bronchiolitis. Use of unnecessary tests and treatments increases costs, delays care, and introduces the potential for harm due to adverse effects. A successful bronchiolitis pathway needs to focus on a standard clinical assessment with clear indications for additional tests and treatments.

The bronchiolitis pathway presented here is based on an initial assessment of severity and classification as mild, moderate, or severe. Repeated reassessments and clear documentation are important to note change in clinical status and response to treatment. Standard supportive care such as suctioning is encouraged. We have embedded lists of indications and reminders about appropriate use of chest radiographs and viral testing in the pathway and associated order set. Regular review of performance and feedback from the quality team was successful in reducing use of chest radiographs in low-acuity patients as shown in Figure 85.2.