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.