Safely Doing Less and the New AAPBronchiolitis GuidelineRicardo A. Quinonez, MDa, Alan R. Schroeder, MDb

Since acute viral bronchiolitis is thus a self-limited disease of relatively goodprognosis, the principle of primum non nocere should temper frustrated anxiety todo something—anything—to relieve severe dyspnea. Simple physical exhaustion maydetermine the fate of an infant laboring to meet his metabolic requirements foroxygen. His energies should not be frittered away by the annoyance of unnecessary orfutile medications and procedures. Rest should be treasured.

F. Howell Wright and Marc O. Beem1

It was 1965 when Drs F. Howell Wright and Marc O. Beem put forththis advice in the pages of Pediatrics. Nearly 50 years later, the publicationof the 2014 American Academy of Pediatrics’ Clinical Practice Guidelineon the Diagnosis, Management, and Prevention of Bronchiolitis2

reminds us just how little things have changed.

Current evidence suggests that the sage advice of Drs Wright and Beemlargely has been ignored.3,4 “Doing something” has trumped watchfulwaiting. Medications, tests, and procedures continue to be used profuselyin spite of decades of research confirming their futility. In the updated2014 guidelines, which include recommendations based on literaturepublished since the last iteration, 10 of the 14 recommendations focus ontests or treatments to avoid. “Primum non nocere” appears to be theguiding principle behind these, with an emphasis on avoidance ofinterventions that lack a favorable risk-benefit ratio and with a focus onmeaningful outcomes, such as hospitalization, length of stay, and symptomduration. Two recommendations in particular, 1 regarding trials ofbronchodilators and 1 regarding continuous pulse oximetry, are sure tospark controversy.

THE ALBUTEROL “TRIAL”

The 2006 guidelines suggest that a “carefully monitored trial” ofbronchodilators is an option and that further use is warranted only ifimprovement in respiratory status is documented and sustained. In thenew update, the recommendation is simply to omit use of bronchodilatorsaltogether. The initial 2006 recommendation that allowed for a trialwas based in part on literature demonstrating a small reduction in theclinical score in patients who are given bronchodilators (in most recentmeta-analysis, standardized mean difference on a 17-point scale of 20.3

aDivision of Pediatric Hospital Medicine, Department of Pediatrics,Baylor College of Medicine, Children’s Hospital of San Antonio, SanAntonio, Texas; and bDepartment of Pediatrics, Santa Clara ValleyMedical Center, San Jose, California

Dr Quinonez participated in the development of the concept ofthis opinion piece and drafted the initial manuscript;Dr Schroeder participated in the development of the conceptof this opinion piece and reviewed and revised themanuscript; and both authors approved the final manuscriptas submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-3703

DOI: 10.1542/peds.2014-3703

Accepted for publication Dec 19, 2014

Address correspondence to Ricardo A. Quinonez, MD,Children’s Hospital of San Antonio, 315 N. San Saba St,Ste 1003, San Antonio, TX 78207. E-mail: quinonez@bcm.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2015 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicatedthey have no potential conflicts of interest to disclose.

PEDIATRICS Volume 135, number 5, May 2015 PEDIATRICS PERSPECTIVES at Sociedad De Lucha Contra El Cancer on May 6, 2015pediatrics.aappublications.orgDownloaded from

between treatment and controlgroups).5 Although this reduction isstatistically significant, the clinicalimpact is marginal. Regardless,although bronchodilators conclusivelydo not reduce admission risk orshorten length of stay, if there is evensome probability of short-term clinicalimprovement, why not give albuterola try?

The fact that close to two-thirds ofpatients hospitalized withbronchiolitis receive albuterol in theinpatient setting, for an average of4 to 7 doses per patient, wouldsuggest that positive “responses” toalbuterol in practice are extremelycommon.3 However, placebo-controlled trials of bronchodilatorshave demonstrated substantialimprovements in clinical scores inboth arms,5 leading to the question ofjust how often the “improvements”we seem to encounter so commonlyare truly medication-related.Because bronchiolitis is characterizedby a waxing and waning course,improvements are expected ina portion of infants even in theabsence of any intervention.Additionally, it is natural to behopeful that our interventions willwork, which may limit our ability toperform an unbiased assessment ofresponse. Finally, and perhaps mostimportantly, our interventions usuallyoccur with more than one therapy ata time. An infant who is providedsuctioning, antipyretics, intravenoushydration, and bronchodilators overa brief period is likely to improve,and subsequently be labeled asa “responder,” when in fact thebronchodilator only succeeded incausing tachycardia. The downsideof such misattributions of causalityis that the “albuterol responder”label may have untowardconsequences: more albuterol doses(and possibly other asthma therapies;eg, corticosteroids) during thecurrent illness, increased parentalexpectations during future illnesses,and strengthened physicianconvictions surrounding the positive

value of bronchodilators inbronchiolitis.

No intervention is benign, ashighlighted by a recent largerandomized trial that comparednebulized racemic epinephrine withsaline in children with bronchiolitisand showed no difference inoutcomes or side effects betweenthese 2 treatments. However, infantswho were given frequent “around-the-clock” nebulized treatments(epinephrine or saline) had anincreased length of stay and oxygenrequirement when compared withinfants who were given less frequent“on-demand” treatments, highlightingthe idea that excessive treatmentsof any kind can cause meaningfulharm.5 Whether infants are harmeddirectly by the well-documentedpharmacologic effects ofbronchodilators (tachycardia,tremors, and hypoxemia),6 or simplyby rest disruption and the “…annoyance of unnecessary or futilemedications and procedures,”1

avoidance of an albuterol trial staystrue to the principles espoused byWright and Beem nearly halfa century ago.

PULSE OXIMETRY: WHAT’S THE HARM?

Whereas the 2006 version of theguidelines suggested that continuouspulse oximetry is not “routinelyneeded” when a patient demonstratesclinical improvement, this newversion allows clinicians to omit itsuse altogether. Understandably, somepractitioners will be reluctant toavoid pulse oximetry, which is seenby many as a potentially life-savingdevice. However, this technologyintroduces the potential foroverdiagnosis of hypoxemia, whichcan be the main determinant foradmission and an important driverfor length of stay in bronchiolitis.4

In fact, in a recent publication notavailable to the guideline committeeat the time of their update, Schuh andcolleagues7 demonstrate that pulseoximetry can be the only factor

determining admission in children,regardless of their clinicalappearance. The authors randomizedchildren with bronchiolitis presentingto an emergency department toeither having true oximetry valuesversus values that were artificiallyincreased by 3 percentage pointsdisplayed to the treating physician.Those with falsely elevated valueswere 40% less likely to behospitalized, but had no differencein complication or unscheduledvisit rates. Although we mustacknowledge that the pulse oximetercan be a valuable tool in themanagement of children withbronchiolitis, especially those whoare critically ill, the heightenedemphasis on the potential harms ofthis widespread technology iswelcomed.

MOVING THE NEEDLE

The identification and correction ofphysiologic abnormalities is ingrainedin medical culture and has beenpervasive in the management ofbronchiolitis. Whether it’s thewheezing we identify with ourstethoscopes or the hypoxemia wedetect with our pulse oximeter, thedefault has been intervention.Implementation of guidelines thatrestrict these fundamental tendencieswill be challenging, requiringdetermination and consistentmessaging. The lessons that come outof implementation efforts will beconstructive by developing sharedbaselines, improving communication,and breaking down silos betweenoutpatient and inpatient providers.Demands from parents and othermedical providers, such as nurses orrespiratory therapists, will offera different, but equally significantchallenge. Efforts by groups, such asthe Value in Inpatient Pediatricsnetwork, the inpatient arm of theQuality Improvement andInnovations Network of the AmericanAcademy of Pediatrics, have alreadydemonstrated the ability to movethe needle in the direction of added

794 QUINONEZ and SCHROEDER at Sociedad De Lucha Contra El Cancer on May 6, 2015pediatrics.aappublications.orgDownloaded from

value through the elimination ofunnecessary care via multicenterquality improvement collaboratives.3

This new and updated guideline forbronchiolitis is a true reflection of thepast 50 years of research andclinical practice for this most vexingof pediatric illnesses. It is courageousin its bold, yet strongly evidence-based pronouncements to avoidcare where the benefits do not clearlyoutweigh the harms. We hopethat clinicians embrace thesenew recommendations that put thefocus back on the patient andencourage practitioners to safelydo less.

REFERENCES

1. Wright FH, Beem MO. Diagnosis andtreatment: management of acute viralbronchiolitis in infancy. Pediatrics. 1965;35(2):334–337

2. Ralston SL, Lieberthal AS, Meissner HC,et al; American Academy of Pediatrics.Clinical practice guideline: the diagnosis,management, and prevention ofbronchiolitis. Pediatrics. 2014;134(5).Available at: www.pediatrics.org/cgi/content/full/134/5/e1474

3. Ralston S, Garber M, Narang S, et al.Decreasing unnecessary utilizationin acute bronchiolitis care: resultsfrom the value in inpatientpediatrics network. J Hosp Med. 2013;8(1):25–30

4. Quinonez RA, Garber MD, Schroeder AR,et al. Choosing wisely in pediatric hospitalmedicine: five opportunities for improvedhealthcare value. J Hosp Med. 2013;8(9):479–485

5. Skjerven HO, Hunderi JO, Brügmann-Pieper SK, et al. Racemic adrenalineand inhalation strategies in acutebronchiolitis. N Engl J Med. 2013;368(24):2286–2293

6. Gadomski AM, Scribani MB.Bronchodilators for bronchiolitis.Cochrane Database Syst Rev. 2014;(6):CD001266

7. Schuh S, Freedman S, Coates A, et al.Effect of oximetry on hospitalization inbronchiolitis: a randomized clinical trial.JAMA. 2014;312(7):712–718

PEDIATRICS Volume 135, number 5, May 2015 795 at Sociedad De Lucha Contra El Cancer on May 6, 2015pediatrics.aappublications.orgDownloaded from

DOI: 10.1542/peds.2014-3703; originally published online April 6, 2015; 2015;135;793Pediatrics

Ricardo A. Quinonez and Alan R. SchroederSafely Doing Less and the New AAP Bronchiolitis Guideline

  

ServicesUpdated Information &

mlhttp://pediatrics.aappublications.org/content/135/5/793.full.htincluding high resolution figures, can be found at:

References

ml#ref-list-1http://pediatrics.aappublications.org/content/135/5/793.full.htat:This article cites 6 articles, 1 of which can be accessed free

Permissions & Licensing

tmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtables) or in its entirety can be found online at: Information about reproducing this article in parts (figures,

Reprints http://pediatrics.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Grove Village, Illinois, 60007. Copyright © 2015 by the American Academy of Pediatrics. All and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elkpublication, it has been published continuously since 1948. PEDIATRICS is owned, published, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Sociedad De Lucha Contra El Cancer on May 6, 2015pediatrics.aappublications.orgDownloaded from

DOI: 10.1542/peds.2014-3703; originally published online April 6, 2015; 2015;135;793Pediatrics

Ricardo A. Quinonez and Alan R. SchroederSafely Doing Less and the New AAP Bronchiolitis Guideline

  

  http://pediatrics.aappublications.org/content/135/5/793.full.html

located on the World Wide Web at: The online version of this article, along with updated information and services, is

 

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2015 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Sociedad De Lucha Contra El Cancer on May 6, 2015pediatrics.aappublications.orgDownloaded from