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## Complete Summary

#### GUIDELINE TITLE

Evidence-based clinical practice guideline for medical management of
bronchiolitis in infants less than 1 year of age presenting with a first
time episode.

#### BIBLIOGRAPHIC SOURCE(S)

Cincinnati Children\'s Hospital Medical Center. Evidence based clinical
practice guideline for medical management of bronchiolitis in infants
less than 1 year of age presenting with a first time episode. Cincinnati
(OH): Cincinnati Children\'s Hospital Medical Center; 2006 May. 13 p.
\[85 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children\'s
Hospital Medical Center. Evidence based clinical practice guideline for
infant with bronchiolitis. Cincinnati (OH): Cincinnati Children\'s
Hospital Medical Center; 2001 Nov 28. 9 p.

The guideline was reviewed for currency in May 2006, using updated
literature searches and was determined to be current.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Bronchiolitis

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Nurses\
Patients\
Physician Assistants\
Physicians\
Respiratory Care Practitioners

#### GUIDELINE OBJECTIVE(S)

In children age less than 12 completed months and presenting for the
first time episode with bronchiolitis typical in presentation and
clinical course, the objectives of this guideline are to:

-   Decrease the use of unnecessary diagnostic studies

-   Decrease the use of medications and respiratory therapy without
    observed improvement

-   Improve the rate of appropriate admission

-   Decrease the rate of nosocomial infection

-   Improve the use of appropriate monitoring activities

-   Decrease length of stay

#### TARGET POPULATION

These guidelines are intended for use in children:

Age less than 12 completed months and presenting for the first time
episode with bronchiolitis typical in presentation and clinical course

***These guidelines are [not]{.underline} intended for use in
children***:

-   With a history of cystic fibrosis (CF)

-   With a history of bronchopulmonary dysplasia (BPD)

-   With immunodeficiencies

-   Admitted to an intensive care unit

-   Requiring ventilator care

-   With other severe comorbid conditions complicating care

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Prevention**

1.  Review of preventive measures with parents of newborns

2.  Respiratory and contact isolation precautions for patients with
    documented bronchiolitis

**Diagnosis/Evaluation**

1.  Clinical history and physical examination

2.  Laboratory and radiological studies (i.e., respiratory syncytial
    virus \[RSV\] swab, chest x-rays, cultures of blood or urine,
    capillary or arterial blood gases, rapid influenza or other rapid
    viral studies, pulse oximetry) not for routine use

**Management**

1.  Oxygen therapy

2.  Epinephrine or albuterol

    -   No routine scheduled or serial use of albuterol aerosol
        therapies

    -   Single administration trial inhalation using epinephrine or
        albuterol in selected patients

    -   Repeated or continued use only if improvement is documented

3.  Guideline developers considered but recommended against the
    following:

    -   Antibiotics (in the absence of an identified bacterial focus)

    -   Routine use of antihistamines, oral decongestants, and nasal
        vasoconstrictors

    -   Steroid therapy given as inhalations, intravenously (IV), orally
        (PO), or intramuscularly (IM)

4.  Respiratory care therapies

    -   Suctioning before feeds as needed (PRN) and prior to each
        inhalation therapy

    -   Normal saline drops prior to suctioning

> **Note**: Guideline developers considered but recommended against the
> following routine respiratory care therapies: chest physiotherapy,
> cool mist therapy, aerosol therapy with saline.

5.  Monitoring of clinical status

    -   Repeated clinical assessments

    -   Cardiac and respiratory rate monitoring during acute stage

    -   Spot checks of pulse oximetry

6.  Discharge planning

7.  Parent education

    -   Basic pathophysiology and expected clinical course of
        bronchiolitis

    -   Proper techniques for suctioning the nose and making breathing
        easier

    -   When to call primary care provider with signs of worsening
        clinical status

    -   Topics regarding prevention of respiratory infection

#### MAJOR OUTCOMES CONSIDERED

-   Clinical improvement

-   Hospitalization rates

-   Length of stay

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

To select evidence for critical appraisal by the group, the Medline,
EmBase, and the Cochrane databases were searched for dates of October
2001 through October 2004 to generate an unrefined, \"combined
evidence\" database using a search strategy focused on answering
clinical questions relevant to bronchiolitis and employing a combination
of Boolean searching on human-indexed thesaurus terms (Medical Subject
Heading \[MeSH\] headings using an OVID Medline interface) and \"natural
language\" searching on words in the title, abstract, and indexing
terms. The citations were reduced by eliminating duplicates, review
articles, non-English articles, and adult articles. The resulting
abstracts were reviewed by a methodologist to eliminate low quality and
irrelevant citations. During the course of the guideline development and
revision, additional clinical questions were generated and subjected to
the search process, and some relevant review articles were identified.
August 2001 was the last date for which literature was searched for the
previous version of the guideline. The details of previous review
strategies are not documented. However, all citations carried from an
earlier version were reviewed for appropriateness to this revision.

**May 2006 Review**

A search using the above criteria was conducted for dates of November,
2004 through May, 2006. Thirty-one relevant articles were selected as
potential future citations for the guideline. However, none of these
references were determined to require changes to the 2005 version of the
recommendations.

#### NUMBER OF SOURCE DOCUMENTS

238

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review\
Review of Published Meta-Analyses

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Recommendations have been formulated by a consensus process directed by
best evidence, patient and family preference, and clinical expertise.
During formulation of these recommendations, the team members have
remained cognizant of controversies and disagreements over the
management of these patients. They have tried to resolve controversial
issues by consensus where possible and, when not possible, to offer
optional approaches to care in the form of information that includes
best supporting evidence of efficacy for alternative choices.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

The use of palivizumab has not been shown to be cost-effective in
children regardless of prematurity or the presence of congenital heart
disease due to the high cost of the medication and persistently low
mortality rates associated with respiratory syncytial virus
(RSV)-bronchiolitis.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines have been reviewed and approved by clinical experts not
involved in the development process, senior management, Risk Management
& Corporate Compliance, the Institutional Review Board, other
appropriate hospital committees, and other individuals as appropriate to
their intended purposes.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Each recommendation is followed by evidence classification (A-X)
identifying the type of supporting evidence. Definitions for the types
of evidence are presented at the end of the \"Major Recommendations\"
field.

**Prevention**

**General**

Infants less than three months of age, premature infants (\<35 weeks
gestation), and infants with chronic lung disease, congenital heart
disease, or immune deficiency syndromes who are diagnosed with
bronchiolitis may be at particular risk for hospitalization and
significant morbidity (Shay et al., 2001 \[D\]; Boyce et al., 2000
\[D\]; Joffe et al., \"Rehospitalization,\" 1999 \[D\]; Church et al.,
1984 \[D\]; Shay et al., 1999 \[O\]). Prevention of hospitalization and
significant morbidity is a high priority in the management of this lower
respiratory tract infection.

**Prevention Measures**

1.  It is recommended that measures to prevent acute bronchiolitis be
    reviewed with parents of newborns prior to discharge from the
    hospital and at follow-up visits in the first years of life. These
    specific measures include:

    -   Eliminating exposure to environmental tobacco smoke
        (Mahabee-Gittens, 2002 \[O\]).

    -   Limiting exposure to contagious settings and siblings (e.g.,
        daycare centers)

    -   An emphasis on handwashing in all settings

    -   Preventive medical therapies such as palivizumab (Synagis®,
        MedImmune) may be considered for selected high-risk patients
        (\"Palivizumab,\" 1998 \[A\]; Celedon et al., 1999 \[C\]; Aitken
        & Taylor, 1998 \[C\]; Wald, Guerra, & Byers, 1991 \[C\]).

> **Note**: A large, multicenter double-blind, randomized, controlled
> trial has shown that palivizumab (Synagis®, MedImmune) reduced the
> rates of hospitalization (not acute infection) for all infants
> studied, premature infants (\<35 weeks) less than six months of age,
> and infants with bronchopulmonary dysplasia (BPD) by 55%, 78%, and 39%
> respectively. The use of palivizumab has not been shown to be
> cost-effective in children regardless of prematurity or the presence
> of congenital heart disease due to the high cost of the medication and
> persistently low mortality rates associated with respiratory syncytial
> virus (RSV)-bronchiolitis (\"Palivizumab,\" 1998 \[A\]; Heikkinen et
> al., 2005 \[C\]; Wegner et al., 2004 \[C\]; Shay et al., 2001 \[D\];
> Yount & Mahle, 2004 \[Q\]; Joffe et al., \"Cost-effectiveness,\" 1999
> \[Q\]).

2.  It is recommended, in patients with documented bronchiolitis, that
    masks covering the nose and eyes be worn and that contact isolation,
    including vigorous handwashing, be performed before and after
    entering the exam room (Hall et al., 1981 \[C\]; Hall, 2001 \[S\];
    Local Expert Consensus \[E\]).

> **Note 1**: Viral transmission occurs by direct inoculation of
> contagious secretions from the hands or by large-particle aerosols
> into the eyes and nose, but rarely the mouth (Hall et al., 1981 \[C\];
> Hall, 2001 \[S\]; Local Expert Consensus \[E\]).
>
> **Note 2**: Nosocomial infection may place medically fragile infants
> and children at increased risk for morbidity and mortality upon
> exposure to the hospital environment (Langley et al., 1997 \[C\].
>
> **Note 3**: Follow Respiratory/Contact precautions as described for
> bronchiolitis in the Cincinnati Children\'s Hospital Medical Center
> (CCHMC) Infection Control Manual (ICRM-735) (Local Expert Consensus
> \[E\]).

**Assessment and Diagnosis**

**Clinical History and Physical Examination**

3.  It is recommended that the clinical history and physical examination
    be the basis for a diagnosis of bronchiolitis.

> The diagnosis of bronchiolitis and its severity is rooted in the
> clinician\'s interpretation of the constellation of characteristic
> findings and is not dependent on any specific clinical finding or
> diagnostic test (Bordley et al., 2004 \[M\]). Infants with acute
> bronchiolitis may present with a wide range of clinical symptoms and
> severity, from mild upper respiratory infections (URI) to impending
> respiratory failure.
>
> Diagnostic criteria for bronchiolitis include, but are not limited to,
> the following:

-   Preceding upper respiratory illness and/or rhinorrhea

-   Signs of respiratory illness which may include the following common
    upper respiratory infection symptoms:

    -   wheezing

    -   retractions

    -   shortness of breath

    -   low oxygen (O~2~) saturation

    -   tachypnea

    -   color change

    -   nasal flaring

-   Signs of dehydration

-   Exposure to persons with viral upper respiratory infection

**Laboratory and Radiologic Studies**

4.  It is recommended that routine diagnostic studies (RSV swab, chest
    x-rays, cultures, capillary or arterial blood gases, rapid influenza
    or other rapid viral studies) **not** be performed to determine
    viral infection status or to rule out serious bacterial infections.
    Such studies are not generally helpful and may result in increased
    rates of unnecessary admission, further testing, and unnecessary
    therapies (Bordley et al., 2004 \[M\]; Swingler, Hussey, &
    Zwarenstein, 1998 \[A\]; El-Radhi, Barry, & Patel, 1999 \[C\];
    Kuppermann et al., 1997 \[C\]; Liebelt, Qi, & Harvey, 1999 \[D\];
    Antonow et al., 1998 \[D\]; Schwartz, 1995 \[S\]; Chiocca, 1994
    \[S\]; Lugo & Nahata, 1993 \[S\]; Stark & Busse, 1991 \[S\]).

> **Note 1**: Chest x rays may be obtained as clinically indicated when
> the diagnosis of bronchiolitis is not clear (Swingler, Hussey, &
> Zwarenstein, 1998 \[A\]; El-Radhi, Barry, & Patel, 1999 \[C\]).
>
> **Note 2**: Capillary or arterial blood gases and pulse oximetry may
> be obtained as clinically indicated for individual patients (Local
> Expert Consensus \[E\]).
>
> **Note 3**: In selected very young infants, establishing a source
> through rapid viral testing may prevent unnecessary additional workup
> (Bordley et al., 2004 \[M\]).

**Management**

**General**

The basic management of typical bronchiolitis is anchored in the
provision of therapies that assures that the patient is clinically
stable, well oxygenated, and well hydrated. The main benefits of
hospitalization of infants with acute bronchiolitis are:

-   The careful monitoring of clinical status

-   Maintenance of a patent airway (through positioning, suctioning, and
    mucus clearance)

-   Maintenance of adequate hydration

-   Parental education

(Klassen, 1997 \[S\]; Lugo & Nahata, 1993 \[S\]; Panitch, Callahan, &
Schidlow, 1993 \[S\]; Nicolai & Pohl, 1990 \[S\]; Local Expert Consensus
\[E\]).

**Medications and Oxygen**

5.  It is recommended to consider starting supplemental oxygen when the
    saturation is **consistently** less than 91% and consider weaning
    oxygen when **consistently** higher than 94% (National Institutes of
    Health (NIH), 1997 \[E\]; Local Expert Consensus \[E\]).

> Oxygen therapy is frequently required in the treatment of
> bronchiolitis. See Monitoring section for recommendation regarding
> oxygen saturation monitoring to maintain blood oxygen levels within a
> normal range. This range is variable in definition and
> patient-specific.

6.  It is recommended that scheduled or serial albuterol aerosol
    therapies **not** be **routinely** used (Kellner et al., 2005 \[M\];
    Flores & Horwitz, 1997 \[M\]; Kellner et al., 1996 \[M\]; Goh et
    al., 1997 \[A\]; Dobson et al., 1998 \[B\]; Chowdhury et al., 1995
    \[B\]; Lugo, Salyer, & Dean, 1998 \[C\]; Lenney & Milner, 1978
    \[D\]).

> **Note 1**: Although in some cases bronchiolitis may be a prelude to
> asthma (Martinez et al., 1995 \[C\]; Stark & Busse, 1991 \[S\]), in
> the majority of cases the use of inhalation therapies and other
> treatments effective for treating the bronchospasm characteristic in
> asthma will not be efficacious for treating the airway edema typical
> of bronchiolitis (Hall, 2001 \[S\]; Klassen, 1997 \[S\]).
>
> **Note 2**: Two meta-analyses of randomized, controlled trials have
> not shown dramatic effects on clinical scores or hospitalization rates
> from therapy with nebulized albuterol in children with bronchiolitis
> (Flores & Horwitz, 1997 \[M\]; Kellner et al., 1996 \[M\]).
>
> **Note 3**: Deterioration and desaturation has been associated with
> inhalation therapies (Flores & Horwitz, 1997 \[M\]; Ho et al., 1991
> \[B\]).

7.  It is recommended that a single administration trial inhalation
    using epinephrine or albuterol may be considered as an option,
    particularly when there is a family history for allergy, asthma, or
    atopy (Hartling et al., 2003 \[M\]; Klassen, 1997 \[S\]).

> **Note 1**: Nebulized racemic epinephrine was shown to result in
> better improvement in pulmonary physiology and clinical scores
> compared with albuterol or placebo in several studies and one
> systematic review. These effects predominated in mildly ill children
> and were transient (30 to 60 minutes) in duration (Hartling et al.,
> 2003 \[M\]; Wainwright et al., 2003 \[A\]; Numa, Williams, & Dakin,
> 2001 \[O\]).
>
> **Note 2**: See Respiratory Care Therapy section regarding the
> **importance of suctioning** before any inhalation therapy.
>
> **Note 3**: The expected disposition of a patient may influence the
> choice of beta-agonist when a single administration trial is given.
> There is a lack of research regarding the appropriateness of routine
> epinephrine use outside the acute care setting (Local Expert Consensus
> \[E\]).

8.  It is recommended that inhalation therapy **not** be repeated nor
    continued if there is no improvement in clinical appearance between
    15 to 30 minutes after a trial inhalation therapy (Klassen, 1997
    \[S\]; Bausch & Lomb Pharmaceuticals, 1999 \[O\]).

> **Note**: In order to determine appropriateness of repeated therapy,
> use the [Bronchiolitis Respiratory
> Sheet](http://www.cincinnatichildrens.org/NR/rdonlyres/B3EC347E-65AC-490A-BC4C-55C3AF4B76D5/0/BronchRS.pdf)
> to record pre- and post-clinical score (Conway et al., 2004 \[C\]).

9.  It is recommended that antibiotics **not** be used in the absence of
    an identified bacterial focus.

> **Note 1**: The incidence of serious bacterial illness (SBI) has been
> reported to be less than 2% in bronchiolitis patients 60 days of age
> or younger (Friis et al., 1984 \[B\]; Kuppermann et al., 1997 \[C\];
> Purcell & Fergie, 2004 \[D\]; Purcell & Fergie, 2002 \[D\]; Liebelt,
> Qi, & Harvey, 1999 \[D\]; Antonow et al., 1998 \[D\]). See the
> National Guideline Clearinghouse (NGC) summaries of the following
> CCHMC Evidence Based Clinical Practice Guidelines [Evidence Based
> Clinical Practice Guideline for Fever of Uncertain Source in Infants
> 60 Days of Age or
> Less](http://www.guideline.gov/summary/summary.aspx?doc_id=4130&nbr=3166)
> or [Evidence Based Clinical Practice Guideline for Fever of Uncertain
> Source in Children 2 to 36 Months of
> Age](http://www.guideline.gov/summary/summary.aspx?doc_id=5613&nbr=3783),
> [Evidence Based Clinical Practice Guideline for Medical Management of
> Acute Otitis Media in Children 2 Months to 13 Years of
> Age](http://www.guideline.gov/summary/summary.aspx?doc_id=6010&nbr=3958),
> and [Evidence-based Care Guideline for Medical Management of First
> Urinary Tract Infection in Children 12 Years of Age or
> Less](http://www.guideline.gov/summary/summary.aspx?doc_id=10163&nbr=5348).
>
> **Note 2**: In almost 75% of patients with RSV infections, the virus
> may be isolated from the middle ear (Heikkinen, Thint, & Chonmaitree,
> 1999 \[C\]; Andrade et al., 1998 \[C\]; Pitkaranta et al., 1998
> \[C\]). In patients with RSV and otitis media, a bacterial pathogen
> has been isolated in 25 out of 26 (Andrade et al., 1998 \[C\]) and one
> out of eight (Pitkaranta et al., 1998 \[C\]) middle ear fluid
> specimens after tympanocentesis.
>
> **Note 3**: Antibiotics have little, if any, effect on outcomes from
> otitis media (Glasziou et al., 2005 \[M\]; Marcy et al., 2001 \[M\];
> Del Mar, Glasziou, & Hayem, 1997 \[M\]; Rosenfeld et al., 1994 \[M\]).

10. It is recommended that antihistamines, oral decongestants, and nasal
    vasoconstrictors **not** be used for routine therapy.

> **Note 1**: There is no evidence to date for efficacy of these
> medications in reduction of cough or congestion in infants with upper
> and lower respiratory tract infections (Clemens et al., 1997 \[B\];
> Hutton et al., 1991 \[B\]; \"Use of codeine,\" 1997 \[S\]; Gadomski &
> Horton, 1992 \[O\]).
>
> **Note 2**: Some components of these medications have been shown to be
> harmful to humans (Kernan et al., 2000 \[D\]).

11. It is recommended that steroid therapy **not** be given (as
    inhalations, intravenously, orally, or intramuscularly) (King et
    al., 2004 \[M\]; Garrison et al., 2000 \[M\]).

> **Note**: One well-conducted systematic review found a reduction in
> length of stay of 0.43 days (95% confidence interval \[CI\] 0.8 to
> 0.05) with steroid therapy for bronchiolitis (Garrison et al., 2000
> \[M\]). However, when only the more methodologically rigorous studies
> with more specific definitions of bronchiolitis were analyzed in this
> meta-analysis, there was no significant effect of steroids on clinical
> status or length of stay.

**Respiratory Care Therapy**

12. It is recommended the infant be **suctioned**, when clinically
    indicated:

    -   Before feedings

    -   As needed (PRN)

    -   Prior to each inhalation therapy

> (Local Expert Consensus \[E\])
>
> In order to appropriately measure improvement in clinical status due
> to the therapeutic effects of the medication, the following reasons
> for suctioning are considered:

-   Suctioning itself may improve respiratory status such that
    inhalation therapy is not necessary. Thus, it is important to
    document the pre-and post-suction clinical score prior to treatment.

-   Suctioning may improve the delivery of the inhalation treatment.

> (Local Expert Consensus \[E\]).
>
> **Note**: Normal saline nose drops may be used prior to suctioning
> (Local Expert Consensus \[E\]).

13. It is recommended that other routine respiratory care therapies
    **not** be used, as they have not been found to be helpful. These
    include:

    -   Chest physiotherapy (CPT) (Perrotta, Ortiz, & Roque, 2005 \[M\])

    -   Cool mist therapy (Gibson, 1974 \[S\])

    -   Aerosol therapy with saline (Gadomski et al., 1994 \[A\];
        Chowdhury et al., 1995 \[B\]; Ho et al., 1991 \[B\]).

**Monitoring**

14. It is recommended that repeated **clinical** assessment be
    conducted, as this is the most important aspect of monitoring for
    deteriorating respiratory status (Local Expert Consensus \[E\]).

15. It is recommended to consider cardiac and respiratory rate
    monitoring in hospitalized patients during the acute stage of
    bronchiolitis when the risk of apnea and/or bradycardia is greatest
    (Anas et al., 1982 \[C\]; Church et al., 1984 \[D\]).

> **Note 1**: Premature infants, infants with underlying chronic
> conditions, and infants less than three months of age who contract RSV
> are at particular risk of severe complications such as apnea and
> mechanical ventilation (Wang, Law, & Stephens, 1995 \[C\]; Anas et
> al., 1982 \[C\]; Krasinski, 1985 \[D\]; Church et al., 1984 \[D\]).
>
> **Note 2**: Several studies have reported more severe progression of
> disease in children with bronchiolitis who present with low initial
> oxygen saturations (Wang, Law, & Stephens, 1995 \[C\]; Shaw, Bell &
> Sherman, 1991 \[C\]; Mulholland, Olinsky, & Shann, 1990 \[D\]).

16. It is recommended that scheduled spot checks of pulse oximetry be
    utilized in infants with bronchiolitis (Local Expert Consensus
    \[E\]).

> **Note 1**: Continuous oximetry measurement has been associated with
> increased length of stay of 1.6 days (95% CI, 1.1 to 2.0) on average
> (Schroeder et al., 2004 \[D\]).
>
> **Note 2**: Wide variability has been demonstrated in the manner in
> which clinicians use and interpret pulse oximetry readings in children
> with bronchiolitis. This variability has been shown to be associated
> with increased preferences for hospital admission and increased length
> of stay for children admitted with bronchiolitis (Schroeder et al.,
> 2004 \[D\]; Mallory et al., 2003 \[O\]).
>
> **Note 3**: In a prospective study of healthy, term infants, transient
> oxygen desaturation episodes were documented and were determined to be
> representative of normal breathing and oxygenation behavior. This
> study excluded any decreases in oxygen saturation related to the
> infants\' movement which would interfere with measurement (Hunt et
> al., 1999 \[C\]).

**Discharge Criteria**

17. It is recommended to begin discharge planning on admission (Local
    Expert Consensus \[E\]). Discharge criteria are:

> **Respiratory Status**

-   Respirations less than 70 per minute and no clinical evidence of
    increased work of breathing

-   Parent can clear the infant\'s airway using bulb suctioning.

-   Patient is either on room air or on stable oxygen therapy that is at
    a level considered consistent with being able to effectively
    continue the therapy at home.

> **Nutritional Status**

-   The patient is on oral feedings at a level to prevent dehydration.

> **Social**

-   Home resources are adequate to support the use of any necessary home
    therapies.

-   Parent or guardian is confident they can provide care at home.

-   Family education complete

> **Follow Up**

-   When indicated, home care and durable medical supply (DMS) agencies
    have been notified and arrangements for visits finalized.

-   Primary care provider identified, notified, and agrees with
    discharge decision

-   Follow-up appointments have been scheduled.

**Education**

18. It is recommended that the family be educated on the following
    topics regarding the care of a child with bronchiolitis:

    -   Basic pathophysiology and expected clinical course of
        bronchiolitis

> **Note**: The median duration of illness for children \<24 months with
> bronchiolitis is 12 days; after 21 days approximately 18% will remain
> ill, and after 28 days 9% will remain ill (Swingler, Hussey, &
> Zwarenstein, 2000 \[C\]).

-   Proper techniques for suctioning the nose and making breathing
    easier (Local Expert Consensus \[E\])

-   To call their primary care provider when the following signs of
    worsening clinical status are observed (Local Expert Consensus
    \[E\]).

    a.  increasing respiratory rate and/or work of breathing as
        indicated by accessory muscle use

    b.  inability to maintain adequate hydration

    c.  worsening general appearance

19. It is recommended that the family be educated on the following
    topics regarding prevention of respiratory infection in infants:

    -   Eliminating exposure to environmental tobacco smoke
        (Mahabee-Gittens, 2002 \[O\])

    -   Limiting exposure to contagious settings and siblings (e.g.,
        daycare centers) (Celedon et al., 1999 \[C\])

    -   An emphasis on handwashing in all settings (Hall et al., 1981
        \[C\])

**Definitions**:

**Evidence Grading Scale**:

A: Randomized controlled trial: large sample\
B: Randomized controlled trial: small sample\
C: Prospective trial or large case series\
D: Retrospective analysis\
E: Expert opinion or consensus\
F: Basic laboratory research\
S: Review article\
M: Meta-analysis\
Q: Decision analysis\
L: Legal requirement\
O: Other evidence\
X: No evidence

#### CLINICAL ALGORITHM(S)

An algorithm is provided in the original guideline document for the
medical management of bronchiolitis in infants less than 1 year of age
presenting with a first time episode.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=9528)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified for the recommendations
(see \"Major Recommendations\" field).

**Evidence Grading Scale**:

A: Randomized controlled trial: large sample\
B: Randomized controlled trial: small sample\
C: Prospective trial or large case series\
D: Retrospective analysis\
E: Expert opinion or consensus\
F: Basic laboratory research\
S: Review article\
M: Meta-analysis\
Q: Decision analysis\
L: Legal requirement\
O: Other evidence\
X: No evidence

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Decreased use of unnecessary diagnostic studies

-   Decreased use of medications and respiratory therapy without
    observed improvement

-   Improved rate of appropriate admission

-   Decreased rate of nosocomial infection

-   Improved use of appropriate monitoring activities

-   Decreased length of stay

#### POTENTIAL HARMS

Wide variability has been demonstrated in the manner in which clinicians
use and interpret pulse oximetry readings in children with
bronchiolitis. This guideline\'s recommendations seek to reduce this
variability in order to limit the associated increased preferences for
hospital admission and increased length of stay for children admitted
with bronchiolitis, but with the trade-off of not observing or managing
transient hypoxia.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

These recommendations result from review of literature and practices
current at the time of their formulations. This protocol does not
preclude using care modalities proven efficacious in studies published
subsequent to the current revision of this document. This document is
not intended to impose standards of care preventing selective variances
from the guidelines to meet the specific and unique requirements of
individual patients. Adherence to this pathway is voluntary. The
physician in light of the individual circumstances presented by the
patient must make the ultimate judgment regarding the priority of any
specific procedure.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Appropriate companion documents have been developed to assist in the
effective dissemination and implementation of the guideline.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms\
Clinical Algorithm\
Patient Resources\
Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Cincinnati Children\'s Hospital Medical Center. Evidence based clinical
practice guideline for medical management of bronchiolitis in infants
less than 1 year of age presenting with a first time episode. Cincinnati
(OH): Cincinnati Children\'s Hospital Medical Center; 2006 May. 13 p.
\[85 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1996 (revised 2005 Oct 15; reviewed 2006 May)

#### GUIDELINE DEVELOPER(S)

Cincinnati Children\'s Hospital Medical Center - Hospital/Medical Center

#### SOURCE(S) OF FUNDING

Cincinnati Children\'s Hospital Medical Center

#### GUIDELINE COMMITTEE

Bronchiolitis Team

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

**Bronchiolitis Team Members 2005**

*Community Physician*: \*Chris Bolling, MD, Chair, Community Physician

*Cincinnati Children\'s Hospital Medical Center Physicians*: \*Michael
Farrell, MD, Gastroenterology, Chief of Staff; \*Scott Reeves, MD,
Emergency Medicine; Julia Kim, MD, Chief Resident; Indi Trehan, MD, MPH,
Resident; Amy Cenedella, MD, Chief Resident

*Nursing/Patient Services*: \*Shirley Salway, RN, Inpatient Unit

*Respiratory Therapy*: \*Scott M. Pettinichi, MEd, RRT, RCP (Clinical
Director, Respiratory Care); \*Edward Conway, RRT (Certified Asthma
Educator)

*Division of Health Policy Clinical Effectiveness Support*: Edward
Donovan, MD, Neonatology, Med. Dir., Clin. Eff.; \*Kieran Phelan, MD,
General Pediatrics; \*Eloise Clark, MPH, MBA, Facilitator; Eduardo
Mendez, RN, MPH, Dir. Evidence Based Care; Detrice Barry, RN, MSN,
Education Coordinator; Deborah Hacker, RN, Medical Reviewer; \*Kate
Rich, Analyst

All Team Members and Clinical Effectiveness support staff listed above
have signed a conflict of interest declaration.

*Ad hoc Advisors*: \*Beverly Connelly, MD, Infectious Diseases,
Assistant Director; \*Richard Ruddy, MD, Emergency Medicine, Director;
\*Dorine Seaquist, RN, Patient Services, Senior VP; Mel Rutherford, Esq.
Risk Management & Corp. Compliance; \*Barbarie Hill, Manager, Pratt
Library

\* Member of previous Bronchiolitis Team

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The guideline was developed without external funding. All Team Members
and Clinical Effectiveness support staff listed have declared whether
they have any conflict of interest and none were identified.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Cincinnati Children\'s
Hospital Medical Center. Evidence based clinical practice guideline for
infant with bronchiolitis. Cincinnati (OH): Cincinnati Children\'s
Hospital Medical Center; 2001 Nov 28. 9 p.

The guideline was reviewed for currency in May 2006, using updated
literature searches and was determined to be current.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Cincinnati Children\'s Hospital Medical Center Web
site](http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/).

Print copies: For information regarding the full-text guideline, print
copies, or evidence-based practice support services contact the
Children\'s Hospital Medical Center Health Policy and Clinical
Effectiveness Department at <HPCEInfo@cchmc.org>.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Bronchiolitis. Guideline highlights. Cincinnati (OH): Cincinnati
    Children\'s Hospital Medical Center; 2005 Nov. 1 p. Electronic
    copies: Available in Portable Document Format (PDF) from the
    [Cincinnati Children\'s Hospital Medical Center Web
    site](http://www.cincinnatichildrens.org/NR/rdonlyres/7C591A09-2F25-4CEF-832A-96BB9A5C98A7/0/BronchHL.pdf).

-   Bronchiolitis respiratory sheet. Cincinnati (OH): Cincinnati
    Children\'s Hospital Medical Center; 2005 Oct. 1 p. Electronic
    copies: Available in Portable Document Format (PDF) from the
    [Cincinnati Children\'s Hospital Medical Center Web
    site](http://www.cincinnatichildrens.org/NR/rdonlyres/B3EC347E-65AC-490A-BC4C-55C3AF4B76D5/0/bronchiolitisrespiratory.pdf).

-   Emergency department algorithm. Cincinnati (OH): Cincinnati
    Children\'s Hospital Medical Center. 2003. 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [Cincinnati
    Children\'s Hospital Medical Center Web
    site](http://www.cincinnatichildrens.org/NR/rdonlyres/D9F98525-30AC-40BA-9280-98B406FD9E47/0/BronchEDA.pdf).

Additional implementation tools, including computerized provider order
entry forms can be found in the [original guideline
document](http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/bronchiolitis.htm).

#### PATIENT RESOURCES

The following Health Topics are available:

-   Bronchiolitis \-- essential facts. Cincinnati Children\'s Hospital
    Medical Center, 2004 Sep. Electronic copies: Available from the
    [Cincinnati Children\'s Hospital Medical Center Web
    site](http://www.cincinnatichildrens.org/health/info/chest/diagnose/bronchiolitis-facts.htm).

-   Bronchiolitis. Cincinnati Children\'s Hospital Medical Center, 2004
    Sep. Electronic copies: Available from the [Cincinnati Children\'s
    Hospital Medical Center Web
    site](http://www.cincinnatichildrens.org/health/info/chest/diagnose/bronchiolitis.htm).

-   Suctioning the nose with a bulb syringe. Cincinnati Children\'s
    Hospital Medical Center, 2004 Aug. Electronic copies: Available from
    the [Cincinnati Children\'s Hospital Medical Center Web
    site](http://www.cincinnatichildrens.org/health/info/newborn/home/suction.htm).

-   Second hand smoke dangers. Cincinnati Children\'s Hospital Medical
    Center, 2005 Jun. Electronic copies: Available from the [Cincinnati
    Children\'s Hospital Medical Center Web
    site](http://www.cincinnatichildrens.org/health/info/chest/diagnose/second-smoke.htm).

The following is also available:

-   Bronchiolitis: patient/family pathway. Cincinnati Children\'s
    Hospital Medical Center, 2 p. Electronic copies: Available from the
    [Cincinnati Children\'s Hospital Medical Center Web
    site](http://www.cincinnatichildrens.org/NR/rdonlyres/BFB707EE-C794-402B-922B-595AB6B66F42/0/BronchPPW.pdf).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on September 1, 1998. The information
was verified by the guideline developer on December 1, 1998. This
summary was updated on September 13, 2005. The updated information was
verified by the guideline developer on September 26, 2005. This summary
was updated by ECRI on July 14, 2006. The updated information was
verified by the guideline developer on July 21, 2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original full-text guideline, which is
subject to the following copyright restrictions:

Copies of [Cincinnati Children\'s Hospital Medical Center
(CCHMC)](http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/default.htm)
Evidence-Based Clinical Practice Guidelines (EBCG) are available online
and may be distributed by any organization for the global purpose of
improving child health outcomes. Examples of approved uses of CCHMC\'s
EBCG include the following:

-   Copies may be provided to anyone involved in the organization\'s
    process for developing and implementing evidence-based care
    guidelines.

-   Hyperlinks to the CCHMC website may be placed on the organization\'s
    website.

-   The EBCG may be adopted or adapted for use within the organization,
    provided that CCHMC receives appropriate attribution on all written
    or electronic documents.

-   Copies may be provided to patients and the clinicians who manage
    their care.

Notification of CCHMC at <HPCEInfo@cchmc.org> for any EBCG adopted,
adapted, implemented or hyperlinked to by a given organization and/or
user, is appreciated.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008