Routine use of beta-2 agonists, glucocorticoids, adrenaline, hypertonic saline and antibiotics have been ruled out in the first Australasian bronchiolitis guidelines.
The guidelines, on behalf of the Paediatric Research in Emergency Departments International Collaborative (PREDICT) Network, involved an extensive literature review and the expertise of medical and nursing staff from emergency and paediatric disciplines across Australia and New Zealand.
The guidelines apply to management of infants presenting or admitted to hospital but not those managed in primary or intensive care.
In particular, the guidelines emphasise there is high level evidence for no benefit in terms of hospital admission, oxygen saturation or length of hospital stay from products such as salbutamol.
Similarly, a number of systematic reviews confirm infants do not benefit from glucocorticoids or nebulised adrenaline in terms of reduced rates of hospitalisation or lengths of stay.
“The routine use of nebulised hypertonic saline in the ED to reduce admissions is not supported by the current evidence, and nebulised hypertonic saline should only be used in infants with bronchiolitis as part of an RCT,” the guidelines said.
Based on the low risk of secondary infections, and the potential harm from adverse reactions and increased antibiotic resistance, the routine use of antibiotics was not recommended.
However the Guideline Development Committee recommended commencing oxygen therapy in infants with oxygen saturation less than 92%.
It also found against routine use of urine or blood tests for most infants.
“However, both retrospective and prospective cohort studies of infants with bronchiolitis have shown an increased risk of concurrent urinary tract infections in infants aged younger than 2 months of age.”
They therefore suggested clinicians might consider urine microscopy, culture and sensitivity in infants with fever and clinical uncertainty.
Viral testing and cohorting of patients with bronchiolitis was ruled out.
“Hand hygiene is the most effective intervention to reduce hospital-acquired infections and is recommended. There is inadequate evidence for benefits in cohorting infants with bronchiolitis,” the guidelines said.
The committee said they were disappointed that so many recommendations were based on relatively weak evidence.
“A notable evidence gap is the possible synergy between glucocorticoids and adrenaline, which is a high priority for a definitive RCT. The evidence gaps identified by the systematic review and critical appraisal will be useful for setting out the agenda for bronchiolitis research.”