Not only has the COVID-19 pandemic killed millions of people, it has also caused disruption in every conceivable aspect of our lives. One of them is the seasonality of other illnesses like influenza and respiratory syncytial virus infection. RSV infection is typically a winter illness, but here we are entering the summer months and our pediatric emergency department is inundated with RSV-infected infants.
Three years ago, I expressed concern about the American Academy of Pediatrics’ 2014 guidelines on bronchiolitis. (REM. 2019;41:31; http://bit.ly/2TlwNj9.) These comments have proven to have real clinical relevance, now more than ever. It’s not possible to review all of the current evidence-based research, but watch a video on my blog for references to some of the new evidence at bit.ly/EMNMellick.
These problematic AAP guidelines boldly recommended cease and desist with treatment mainstays, leaving clinicians with essentially nothing but nasal aspirating. (Pediatrics. 2014;134:e1474.) Here are some text excerpts:
- Clinicians should NOT administer albuterol (or salbutamol) to infants and children diagnosed with bronchiolitis (evidence level: B; strength of recommendation: strong recommendation).
- Clinicians should NOT administer epinephrine to infants and children diagnosed with bronchiolitis (evidence level: B; strength of recommendation: strong recommendation).
- Nebulized hypertonic saline solution should NOT be given to infants diagnosed with bronchiolitis in the emergency department (grade of evidence: B; strength of recommendation: moderate recommendation).
Their recommendations come off as embarrassing, although they call them “strong”, with the evidence rated at level B or good quality. The guidelines used the Agency for Health Care Quality and Research definition of bronchiolitis. (Agency for Healthcare Research and Quality. Management of Bronchiolitis in Infants and Children. Evidence Report/Technology Assessment No. 69. Rockville, MD. 2003. AHRQ Publication No. 03-E014. Abstract: https://bit.ly/3AC2rlt.)
He reiterates that signs and symptoms usually begin with rhinitis and cough, which may progress to tachypnea, wheezing, rales, use of accessory muscles and nasal throbbing. Unfortunately, the clinical diagnosis of bronchiolitis is the description of dozens of other wheezing viral illnesses that present in the emergency department. The differentiation of these diseases resembling bronchiolitis requires trials of therapies prohibited by the guidelines. (Pediatric emergency care. 2019;35:654.)
The fact that bronchiolitis itself is a heterogeneous disease with different profiles and ‘phenotypes’ based on age at presentation, personal and family history of atopy, etiology and pathophysiological mechanism is also growing. supported. (front pediatrician. 2022;10:865977; https://bit.ly/3RkGzRy.) There is growing evidence that drug treatment is effective in some, if not most of them. Clinically, it is rare to see no improvement in patients with our treatments, regardless of the severity or purity of the bronchiolitis.
Guidelines are not infallible even if they come from a national or international organization, and they are vulnerable to the error of trying to give exact guidance on incomplete evidence. Echoing what has been said elsewhere, future guidelines on bronchiolitis should avoid advising against potentially useful treatments until more conclusive evidence is available. (pediatrician. 2021;175:1182.)
I appreciate that criticizing national AAP guidelines and over 30 other international guidelines is a David and Goliath scenario, but it is increasingly clear that these organizations miscalculated, and it had serious implications for frontline clinicians. Others have also criticized these guidelines. An article titled, “A systematic review of clinical practice guidelines for the diagnosis and management of bronchiolitis,” made these comments:
“Thirty-two clinical practice guidelines met the selection criteria. The quality assessment revealed significant shortcomings in a number of guidelines, including the lack of systematic guideline formulation processes, the lack of conflict of interest declarations, and the lack of consultation with the families of the children concerned. There was broad consensus on a number of aspects, such as avoiding the use of unnecessary diagnostic tests, risk factors for serious illness, indicators for hospital admission, criteria for discharge and control of nosocomial infections.
“However, there was variability, even within consensus areas, on specific recommendations, such as variable thresholds for oxygen therapy. The guidelines showed significant variability in recommendations for the pharmacological management of bronchiolitis, with conflicting recommendations as to whether the use of nebulized epinephrine, hypertonic saline, or bronchodilators should be routinely tested.
The authors of this systematic review concluded: “Future guidelines should aim to conform to international standards for clinical guidelines in order to improve their quality and clarity and promote their adoption in practice. Varying recommendations between guidelines may reflect the evolving evidence base for the management of bronchiolitis, and platforms should be created to understand this variability and promote evidence-based recommendations. (J Infect Dis. 2020;222[Suppl 7]:S672; https://bit.ly/3c5cXre.)
What lessons have we learned from the bronchiolitis guidelines disaster?
- Even national and international guidelines can be challenged by a complex and heterogeneous disease with a nebulous clinical description or definition that overlaps with that of many similar diseases and infections.
- Guidelines should avoid advising against potentially useful treatments until the evidence is conclusive, as the actual clinical consequences can be dangerous and devastating.
- Guideline-related mishaps can cause significant clinical conflict and confusion among providers, affecting the care of millions of patients.
- Finally, if violations of a guideline are more common than routine, it may simply mean that the guidelines have missed the mark, and one should not automatically assume that the violators are unenlightened rebels.
Dr. Mellickis professor of emergency medicine, vice president of academic affairs in emergency medicine, section chief of pediatric emergency medicine, and associate director of the residency program at the University of South Alabama in Mobile. Read his monthly blog athttp://bit.ly/EMN-Mellick, and follow him on Twitter@Lmellick.