4. Discussion
Significant variations in the management of bronchiolitis are often
recorded, and, in parallel, to recommend a univocal clinical approach it
is difficult and is still questioned. This study aimed to evaluate the
diagnostic and therapeutic management of bronchiolitis in children
adopted by Italian paediatricians in accordance with the national
guidelines. Our survey showed a significant practice variation in the
management of acute bronchiolitis among Italians physicians.
Nationally developed evidence-based guidelines are required to reduce
practice variation, minimize nonevidence-based practices, and promote
cost-effective standardization of care6. Nevertheless,
a significant practice variation persists, and it has been previously
reported that several guideline recommendations have been poorly
incorporated into the real clinical settings after their development and
dissemination7,8. Accordingly, several international
studies have detected considerable variation in the management of acute
bronchiolitis9. A significant practice variation in
the monitoring, treatment, and discharge of the children hospitalized
with bronchiolitis among physicians across Italian paediatric hospitals
has also been founding5. Therefore, given the high
risk of inappropriate and unnecessary medicalization and
hospitalizations of patients with bronchiolitis and, consequently, the
bronchiolitis-related high-financial burden, it is important to examine
the diagnostic and therapeutic interventions administered in infants
presenting with bronchiolitis. In this regard, the SIAIP conducted a
national survey to evaluate the behaviours of Italian paediatricians in
the diagnostic and therapeutic management of infants and children with
acute bronchiolitis and their adherence to the current national
recommendations. To the best of our knowledge, a similar investigation
had not yet been conducted in Italy, making this study essential for
understanding the Italian management of patients suffering from
bronchiolitis. This information would also clarify the use of
evidence-based supportive therapies as compared with those that are not
evidence-based, aiming to improve the management of bronchiolitis in
children and standardize the behaviour of physicians.
The diagnosis of bronchiolitis is based on clinical history and physical
examination1. In accordance to the national
guidelines1, <50% participants agreed on
the diagnostic criteria, and the most common criteria for bronchiolitis
diagnosis were onset with rhinorrhea and/or upper respiratory tract
infections; the first episode of respiratory distress associated with:
crackles and/or wheezing, use of accessory muscles or lower chest wall
retractions, low O2 saturation levels, high respiratory rate relative to
age, skin colour changes, nasal flaring, fever; exposure to persons
presenting with upper respiratory tract viral infections; and
presentation during the epidemic season. Marked discrepancies could be
observed between the remaining respondents as well as inappropriateness
in the answer.
National guidelines include as criteria for hospital admission the
following: O2 saturation persistently lower than 90-92%, the entity of
respiratory distress, presence of apnea, dehydration, and moderate to
severe bronchiolitis1. Other important factors should
be taken into consideration are prematurity (gestational
age < 37 weeks or birth age < 6–12 weeks),
responsivity and alertness, poor hydration and feeding (defined as less
than 50% of usual fluid intake in preceding 24 h), social and
environmental factors, and presence of pre-existing risk
factors1.
The decision to hospitalize a child affected by bronchiolitis is a
complex process impacted by the course of the illness and other
clinical, socio-cultural and geographic factors as well as by the
possibility to access to the follow-up1,10. Moreover,
the local culture of care can influence the decision-making process,
irrespective of disease severity. Thus, although inpatient observation
is recommended for selected infants affected by bronchiolitis,
physicians are more likely to hospitalize infants with milder
bronchiolitis, taking improper advantage of the use of inpatient
resources. On the other hand, the variability in admission criteria
among guidelines may alter unavoidably the hospitalization criterion. In
this regard, it must be considered that some institutions have protocols
that require the ordering of diagnostic tests (e.g., complete blood
count, chest X-ray) on admission. However, a priori reasons to
support this clinical practice are not currently supported by
evidence-based medicine (EBM)11. Moreover, this
practice could lead both to perform costly and unnecessary
testing/procedure cascade as well as inappropriate outpatient/inpatient
antibiotic prescriptions.
The administration of non-recommended interventions in our study
occurred at a moderate-to-high rate, as follows: inhaled epinephrine
(21.30%), ICS (17.16%), systemic CS (64.52%), respiratory
physiotherapy (8.88%), antibiotics (4.73%), intravenous SABA (0.59%).
The current literature does not recommend the diagnostic testing for
children with bronchiolitis, except for conducting epidemiological
studies. Moreover, very few data support the impact of testing on
patient outcomes and quality of care, and they do not provide clear
indications for such testing or the impact of testing on relevant
patient outcomes1,5,12. Moreover, the overuse of
instrumental diagnostic tests does not comply with patient safety and,
also, weighs on the healthcare economy.
Elsewhere, the guidelines developed by a panel of experts aim to
minimize overtreatment by recommending against the use of noneffective
interventions13-19. Nevertheless, authors of inpatient
bronchiolitis studies published after the 2006 American Academy
Pediatrics (AAP) bronchiolitis guideline have found disappointingly high
use of the non recommended resources20,21. We found a
surprising number of children were treated with medications. Following
the Italian guidelines1, supplemental oxygen
(O2) should be administered if O2saturation levels are persistently below 90–92% at ambient
air1,22.
A recent trial has suggested that outcomes may not differ significantly
when an O2saturation target of ≥90% is
used23. Whether an increased respiratory effort is
occurring, high-flow oxygen therapy with humidified and heated oxygen
(high-flow nasal cannula, HFNC) should be considered. However, different
O2 saturation thresholds are recommended for hospital
management and for starting O2 therapy. Thus, it is
reasonable to hypothesize that both the difference in the evidence
provided by the literature as well as context-specific factors may be
key reasons for the differences in clinical practice. In children with
bronchiolitis who cannot maintain oral hydration intravenous or
nasogastric fluids may be considered1,22. There is
sparse evidence supporting the routine use of hypertonic solution,
nebulized adrenaline, salbutamol, respiratory physiotherapy, systemic or
inhaled or systemic CS, and antibiotics1,22. However,
authors support the use of hypertonic saline to decrease airway oedema
and improve mucociliary clearance in infants1,22.
Unlikely to other respiratory diseases in which CS show a beneficial
effect, their use does not improve the short- and long-term prognosis in
infants with bronchiolitis1,22.
Similarly, the association of systemic CS with epinephrine or SABA does
not produce a significant benefit1,22. The
administration of bronchodilators in managing bronchiolitis is still
contentious and, although evidence is against their routine use, several
guidelines still recommended a trial of bronchodilators in treating
infants with acute bronchiolitis5. Despite the absence
of evidence suggesting a benefit of the use of antibiotic in acute
bronchiolitis, their prescription in primary care settings is commonly
reported1,22. Evidence supporting the use of nebulized
adrenaline, antivirals, antileukotrienes, and chest physiotherapy
(vibration and percussion techniques) during the acute phase of
bronchiolitis is insufficient1.
Surprisingly, regarding the discharge criteria, the healthcare
professional behaviour was in line with the national
guidelines1. An appropriate discharge requires
evaluation of multiple factors including medical (clinical conditions,
adequate feeding, improved respiratory effort), psychosocial (carer
ability), logistic (possibility to arrange follow-up), and economic
(adequate social circumstances) considerations. Discharge planning must
involve both the health care team and patient/family caregivers to
develop a patient-centred plan ensuring that the patient is safely
discharged home and minimizing the risk of adverse events and/or
unplanned readmissions22.
Except for the data on the discharge criteria, we formulated different
hypotheses to explain the striking differences between the findings of
our study and the guideline-related recommendations of nonintervention.
Acute bronchiolitis significantly causes pressures in health service and
throughout the region. Probably, the parental expectation “to do
something” might be in part responsible for these results, also
increasing the local practice differences. In a previous study, authors
reported that bronchiolitis hospitalization caused significant
emotional, physical and organizational consequences both on parents and
siblings persisting up to 3 months after hospital
discharge25. Moreover, it is possible that primary
care paediatricians, who may have limited experience with managing acute
bronchiolitis in advanced stage of disease, are influenced wrongly by
the medical literature showing benefit of SABA and/or ICS in other
respiratory diseases22,26. Furthermore, there is
evidence that exposure to a few cases of patients with bronchiolitis is
associated with the increased use of investigations and
medications27. Lastly, the difficulty and/or the
impossibility to arrange follow-up care can affect disease management.