MANAGEMENT OF BRONCHIOLITIS: REASONS FOR PRACTICE BEHAVIOURS AND A PROPOSED ALTERNATIVE APPROACH

BACKGROUND: Bronchiolitis is a common childhood respiratory illness leading to hospitalization of 1–3% of all children under the age of two ¹. 
There are guidelines for the management of bronchiolitis established by various institutions including the Canadian Paediatric Society. It is common knowledge that there are variations in the management of bronchiolitis in spite of standard guidelines ².

OBJECTIVES: We sought to find out the reasons for such variations and the possibility of an alternative approach to management. This was done by reviewing practices in a secondary level referral centre.

DESIGN/METHODS: 61 charts of children (0–24 months) admitted for bronchiolitis between November 2014 and April 2016 were reviewed. Interviews were conducted with 24 attending clinicians (8 Pediatricians, 14 Emergency Physicians and 2 Nurse Practitioners) on the management of bronchiolitis based on guidelines of the Canadian Paediatric Society ³. 
Exclusion criteria included extreme prematurity and chronic lung conditions.

RESULTS: 3766 pieces of information were obtained relating to various interventions including the use of salbutamol, epinephrine, steroids, and oxygen supplementation. 63.9% of patients were prescribed bronchodilators, 42% prescribed steroids, 78% prescribed nebulized saline, 65.6% received supplemental oxygen and 11.7% were prescribed epinephrine. Most interventions have no evidence for their effectiveness.

Reasons for variations from guidelines included a perceived passive guideline, limitations of evidence-based medicine in clinical practice, nursing and parental pressures, similarity between the presentation of asthma and bronchiolitis, non-consideration of the disease process, and some physicians positive experience with the use of steroids in patients with a personal or immediate family history of atopy. There was difficulty differentiating between bronchiolitis and the first episode of asthma.

CONCLUSION: The lack of adherence to the guidelines may be due to the perception that it is inadequate. Based on the experience of some Pediatricians (level 4 evidence), a personal or immediate family history of atopy may be pivotal in directing treatment with steroids. Whilst some studies suggest the non-effectiveness of steroids in the treatment of bronchiolitis ⁴, 
no studies have specifically looked at the treatment of bronchiolitis in this subgroup of children with a history of atopy ⁵. We acknowledge the limiting power of this exercise, and that further studies are needed to validate the effectiveness of steroids and bronchodilators in the atopic subgroup.