Bronchiolitis Clinical Practice Guideline QI Project Providing phone advice to caregivers whose child may have bronchiolitis Kathleen Berg, MD, FAAP Pediatric Hospital Medicine Children’s Mercy Hospital Assistant Professor UMKC School of Medicine

Objectives 1. Describe the signs and symptoms of bronchiolitis 2. Discuss management of the disease based on the American Academy of Pediatrics Clinical Practice Guideline for bronchiolitis. 3. Recognize when “cough and cold” may be concerning for other medical conditions. 4. Become familiar with online resources including clinical practice guidelines from local children’s hospitals.

Definition Bronchiolitis is a viral lower respiratory tract infection. It causes inflammation, edema, and mucous production in the bronchioles leading to cough, wheezing, crackles, and sometimes increased work of breathing and hypoxemia. Although RSV is the most common cause, rhinovirus, human metapneumovirus, parainfluenza virus, and many others may be implicated.

Epidemiology Common cause of clinic, urgent care, and ED visits (second only to URI) Most common cause of hospitalization of children under 2 year of age (~100K admissions/year)

AAP Recommendations (2014) Diagnosis AAP Recommendations (2014) “Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination. Clinicians should not routinely order laboratory and radiographic studies for diagnosis.” Viral testing, chest radiography, CBC, and blood cultures are not recommended. amanda

AAP Recommendations (2014) Treatment AAP Recommendations (2014) The following should not be used in the management of bronchiolitis: Bronchodilators Systemic corticosteroid Antibiotics

AAP Recommendations (2014) Treatment AAP Recommendations (2014) Nasal suctioning is the mainstay of treatment. Adequate hydration should be maintained. Supplemental oxygen may be needed for SpO2 < 90%. Hand hygiene is critical to reducing spread of disease. Tobacco smoke increases the risk and severity of illness.

High Value Care Despite the AAP guidelines, many diagnostic and therapeutic modalities continue to be over utilized. These interventions can lead to unnecessary medication side effects, blood draws, and radiation exposure. Respiratory panel PCR Antibiotics Rapid RSV Corticosteroids CXR Bronchodilators CBC Blood culture Reducing the routine use of these modalities can decrease length of stay and cost, without an increase in adverse events. amanda

Barrier to High Value Care Family expectation for tests and medications Caregivers’ knowledge of AAP guideline Health care culture – “I feel like I need to do something.” Interdisciplinary communication (Nursing, Respiratory Therapy clinic/ED/inpatient providers) Providers’ knowledge of cost

CMH Bronchiolitis QI

Case Scenarios

Case 1 Caregiver: “I have a 9 month old son who has had cough and runny nose for the past 2 days and now seems to be breathing faster and harder than usual. He is otherwise acting normally and drinking ok. He has no other medical problems.”

Case 2 Caregiver: “My 5 month old daughter won’t stop coughing. She gets into bad coughing fits and can’t seem to catch her breath. I haven’t given her anything because I only use homeopathic remedies. In fact, she does not get immunizations.”

Case 3 Caregiver: “My 18 month old son seemed fine until the last hour. I cleaned the dishes while he was playing in the living room. Since then he has been coughing. I guess he’s getting a cold, but he doesn’t have any fever or runny nose.”

Resources

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Family Engagement Handout Include pic of handout here…

References Children’s Mercy Hospital. Office of Evidence Based Practice. Bronchiolitis Clinical Practice Guideline (2017). https://www.childrensmercy.org/Health_Care_Professionals/Medical_Resources/Evidence_Based_Practice/Bronchiolitis/Bronchiolitis/ Children’s Mercy Hospital. Office of Evidence Based Practice. Bronchiolitis Outpatient Family Engagement Handout (2017). https://www.childrensmercy.org/Health_Care_Professionals/Medical_Resources/Evidence_Based_Practice/Bronchiolitis/Bronchiolitis_Family_Engagement_Education/ Friedman, J. et al. (2014). Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age. Paediatric Child Health, 19(9). National Institute for Health and Care Excellence (NICE) (2015). Bronchiolitis in children: Diagnosis and management. London: NICE. Ralston, S. et al. American Academy of Pediatrics (2014). Clinical practice guideline: The diagnosis, management, and prevention of bronchiolitis. Pediatrics, 134(5), e1474-1502.