Bronchiolitis treatment

SIGN guideline has now been withdrawn, as out of date.

Essentially supportive.  Oxygen, feeding, respiratory support if necessary.  Beware secondary bacterial infection, lobar collapse, pneumothorax, concomitant UTI.

Hypertonic saline

Cochrane 2010, patients treated with nebulized 3% saline had a significantly shorter mean length of hospital stay compared to those treated with nebulized 0.9% saline (MD -1.16 days, 95% CI -1.55 to -0.77, P < 0.00001).   No significant adverse events related to 3% saline inhalation were reported.  Not recommended for emergency departments as 2 doses didn’t seem to affect clinical scores.

But subsequent studies less impressive.  SABRE trial randomized 317 infants to 3% hypertonic saline nebulised every 6 h from admission compared with nothing (ie, standard care). No difference between the two arms of the study in time to discharge [Legg and Cunningham, Arch Dis Child 2015;100:1104-1105].

But AAP guidelines recommend nebulized hypertonic saline for infants hospitalized with bronchiolitis, with the expectation of reducing bronchiolitis scores and length of stay when it is expected to last more than 72 hours. Some think potentially an advantage for hypertonic saline in reducing admission rates from the emergency department [DOI: 10.5863/1551-6776-21.1.7]

High Flow

Franklin study of early high flow oxygen use – babies were randomized as soon as they needed oxygen.  Not generally what happens, of course.

  • Outcome was “escalation of care” ie signs requiring further intervention eg tachycardia, hypoxia. Intervention was high flow, of course.  Rate was 23%, but nearly a third of these did not meet the prespecified criteria (so doctor just decided they “needed” high flow anyway).
  • In sites without PICU, 28% of standard therapy group required escalation of care.  This is way in excess of the rate we would report in our unit.
  • No differences in length of stay or duration of O2 therapy.
  • Of 167 who “failed” on standard care, 61% responded to high flow.
  • No age effect.

So it seems to me that if you have facility to do high flow, you will find that at least a quarter of your oxygen dependent bronchiolitis babies “need” it.  I’m not sure this is a useful or meaningful study.  Babies may be more comfortable on high flow, and you may prevent the odd ICU admission, which is definitely worth considering. [N Engl J Med 2018 Mar 22;378(12):1121-1131.]

BIDS study

A study to see if safe to discharge babies with less than normal saturations.  RCT of 308 infants, no need to admit if sats >92% AND >50% feed requirements.

For those needing admission, start oxygen only if <90%, and only discharge once sats >90% continuously over 4hr period including sleep, and taking >75% feeds! Exclude babies with risk factors (<3/12, ex-prem, CLD etc– should have sats >92%)

Compared with standard pulse oximeter parameters (treat <94%), no difference in adverse events eg high dependency, readmission.  Excluded prems, recent oxygen therapy, CF or other chronic lung disease, immune deficit. [Edinburgh, Steve Cunningham, Lancet 2015; 386: 1041–48]