Reducing Unnecessary Tests And Interventions for Bronchiolitis

Bronchiolitis is a viral airway infection that is very common in young children, caused mainly by the respiratory syncytial virus (RSV). Whereas RSV can affect anyone and causes mainly the symptoms of a common cold in adults and older children, younger children can be affected more seriously.

In young children, especially infants less than one-year-old, RSV causes a build-up of phlegm and a narrowing of the very small airways (also called the bronchioli) deep inside the lung. This results in “trapping” of “used” air inside the lung and difficulties filling the lung with fresh air rich in oxygen. As a result, affected young children may find it hard to breathe, the breathing becomes fast and shallow, and they may get very tired. In addition, because of the hard effort to breathe, infants may stop feeding, which in turn makes them get tired even faster and could also lead to dehydration. Some young children, particularly those who have underlying problems with the lungs, the heart, or the immune system, may need pediatric intensive care treatment, but fortunately, the vast majority fully recover without long-term consequences.

Bronchiolitis occurs worldwide: In the temperate climate zones of the Northern and Southern hemispheres in the form of regular large outbreaks mainly in the winter months, whilst the disease is present in tropical climates on a more constant basis at a lower level of intensity. These epidemiological patterns have been very stable for many decades.

No laboratory test is necessary to diagnose bronchiolitis – the diagnosis is made by a doctor or nurse by asking about the history and symptoms of the child and examining the chest with a stethoscope.  There are tests that can identify the RSV virus from secretions, and many children undergo a chest x-ray. Nevertheless, these investigations have not been deemed useful.

At present, there is no established prevention or treatment for the cause of bronchiolitis that would be effective and well-tolerated. Previous vaccinations and antiviral drugs for bronchiolitis were withdrawn due to either little effect, strong side effects, or a combination of both. Nevertheless, new types of vaccines and specific antiviral drugs are currently undergoing research and may be of use in the future to stop outbreaks or reduce the severity of the illness.

Therefore, the treatment of bronchiolitis at this time is “supportive,” meaning to stabilize and support the core body functions like breathing, circulation, and nutrition, in order to allow and help the self-healing powers of the body (the immune system) to overcome the infection. The only interventions that have proven to be effective are giving oxygen (to help the breathing), fluids, and nutrition (to keep the child hydrated and provide energy).

Health professionals strongly feel that they should provide more symptomatic relief to children suffering from bronchiolitis, and a wide range of measures have been tried and investigated: Nebulised medicines that widen the bronchioli (bronchodilators, same as used for asthma) or making secretions more lose (so they can be removed easier by coughing), steroids (to reduce inflammation), chest physiotherapy (to loosen secretions), and antibiotics (to fight infection). The research did not identify clear benefits for any of these interventions. There was either contradictory data, lack of evidence of benefit, or even evidence of potential harm, resulting in these interventions not to be recommended by guidelines based on best available evidence from the medical literature.

In the United Kingdom, the National Institute for Clinical Excellence (NICE), an authority within the National Health System (NHS), assesses literature evidence for treatments, evaluates effectiveness and cost-efficiency within the UK context, and makes recommendations to healthcare providers in the form of guidelines. The first version of the NICE guideline for the management of bronchiolitis was published in 2015.

NICE recommends not to use diagnostic tests and treatments that do not have a proven benefit, acknowledging though that the evidence for most interventions is of low quality, neither proving or disproving effectiveness and cost efficiency. The guideline lays out criteria for referral, admission, and discharge (to ensure appropriate referrals and ensure an adequate time of inpatient stay), emphasises that the diagnosis is clinical and tests (such as chest x-rays) should be avoided, and specifies treatments (steroids, nebulized bronchodilators and saline, antibiotics, and physiotherapy) that are probably unhelpful and should not be given.

A District General Hospital in the northeast of England was the first to report data of the impact that the introduction of the NICE bronchiolitis guideline, accompanied by an educational programme, had on the use of diagnostic tests and treatments (1).

For collecting baseline data, during the winter 2014-2015, we performed an audit of diagnostic and treatment practice before any intervention. This showed that the use of measures not indicated, such chest x-rays (20% of all patients), antibiotics (22%) and inhaled treatments (26% and 30% for different medications) was high. In preparation of the following winter season, the NICE bronchiolitis guideline was formally implemented, and department staff at all levels and disciplines (including nursing staff, pediatric trainees, and pediatric specialists) underwent a series of teaching sessions which introduced the new guidance and explained the rationale. This was supported by posters placed on nursing and doctor stations, in treatment and handover rooms across the department. Finally, through the winter season repeated quick briefings during nursing and medical handovers reiterated the key messages on a weekly basis.

The guideline implementation and educational intervention was then evaluated by a data collection over the same winter season (2015-2016). The inappropriate use of chest X-rays (4%), antibiotics (6%) and inhaled treatments (16% and 16% for each medication) had improved significantly, showing that this approach has been successful in reducing unnecessary tests and interventions. This improvement reduced patient exposure to potentially harmful radiation, antibiotics, and inhaled medicines, and was likely to save substantial costs although no formal economic analysis was done.

To consolidate this progress, further interventions are necessary. These should focus on criteria for admission and discharge to optimize the use of inpatient beds, avoiding both unnecessary admissions as well as inappropriately early or late discharges. Although the NICE guideline does lay out some criteria for this, these need to be adjusted to the needs of the local population. The population of this study is comprised largely from a rural, socio-economically deprived area, where thresholds for admission may have to be lower because access to transport and community support are lower. A hospital in a more urban area may have a higher threshold for admission or may discharge a patient earlier because transport and support are more readily available.

References:

1. Breakell R, Thorndyke B, Clennett J, Harkensee C. Reducing unnecessary chest X-rays, antibiotics and bronchodilators through implementation of the NICE bronchiolitis guideline. Eur J Pediatr. 2018 Jan; 177(1):47-51

These findings are described in the article entitled Reducing unnecessary chest X-rays, antibiotics and bronchodilators through implementation of the NICE bronchiolitis guideline, recently published in the journal European Journal of Pediatrics. This work was conducted by Richard Breakell, Benjamin Thorndyke, Julie Clennett, and Christian Harkensee from The Department of Paediatrics, University Hospital North Tees.