It seems strange to bring up bronchiolitis during the summer, let alone after experiencing the pandemic and the mitigation strategies that not only reduced spread of the SARS-CoV-2 virus but other respiratory viruses as well. As masking and other prevention strategies are relaxed, parts of the world are experiencing more respiratory infections in young children, including bronchiolitis—and the expectation is that the same will occur in the United States if it hasn’t already at the time this blog is posted.
So, with the expected increase in post-pandemic bronchiolitis, AAP Guidelines published in 2006 (10.1542/peds.2014-2742) and updated in 2014 remind us to focus on what works and not engage in overuse of diagnostic tests and treatment that are not helpful—i.e. getting a complete blood count, chest radiography, viral testing, bronchodilator use, steroids, and antibiotics. Yet these 6 non-recommended tests and treatments continue to be used—and the question is—has the frequency of their use decreased in the setting of these AAP published guidelines?
To answer that question, Ralston et al (10.1542/peds.2021-050710) evaluated Achievable Benchmarks of Care (ABCs) for bronchiolitis had improved over time (the sought after benchmarks being performance level metrics achieved by the top 10% of those emergency departments (EDs) or inpatient facilities being analyzed) between two time periods—2006-2014 and 2014-2019 (before and after the 2014 update of the 2006 AAP Bronchiolitis policy was released). The authors used independent free-standing children’s hospitals who submitted administrative data to a large data registry—the Pediatric Health Information System –and looked at bronchiolitis cases in 25 EDs and 35 hospitalized cohorts of patients. The authors also looked at performance gaps between the ideal defined benchmark and the median value for that benchmark in both the ED and inpatient hospitalized cohorts.
The good news is that there were improvements in ABCs, with reductions in bronchodilator use across the two time periods in the ED and in-patient settings, with reductions in chest radiography, viral testing, and antibiotic use. The not-so-good news is that while performance gaps declined in all 6 metrics between the two time periods, there are still large performance gaps remaining for viral testing and bronchodilator use in both cohorts.
What can we learn and do as a result of this study’s findings to further narrow the performance gap if not improve the defined ABCs? To answer these questions, we asked pediatric hospitalists Drs. Jennifer Treasure, Michelle Parker, and Samir Shah from Cincinnati Children’s Hospital to provide their insight with an accompanying commentary (10.1542/peds.2021-051697). They point out the strengths and limitations of the Ralston et al study, offer next steps for us to consider if we want to reduce the viral testing and use of bronchodilators still being used, and frame the results of this study in the context of coming out of the pandemic when we might even see an uptick in the use of these non-recommended quality indicators because of our being less familiar with a presentation of bronchiolitis in light of the few cases we experienced over the past year.
Before you feel the need to “do something” other than supportive care for a wheezing infant with respiratory distress from viral bronchiolitis, check out this study and commentary and remind yourself and others of the ABCs, where doing less means doing more of the right thing in helping children and their families get through this lower respiratory infection.