LONDON – Primary care and emergency physicians face significant difficulties in the diagnosis and treatment of bronchiolitis, particularly during the winter months when the prevalence of the condition rises.
Part of the problem is making a differential diagnosis, compounded by the lack of available evidence-based treatments, experts said at the Excellence in Paediatrics annual meeting in London.
Primary care physicians and general practitioners (GPs) are often not comfortable making a diagnosis of bronchiolitis, said Dr. Mike Thomas, an Asthma UK senior research fellow at the University of Aberdeen (Scotland). "There isn’t a simple, gold-standard diagnostic test, which makes things rather difficult," he observed.
Bronchiolitis typically occurs in infants aged 3-6 months, and a diagnosis is often based on the presenting symptoms, which may include difficulty in breathing, wheeze, crackles on auscultation, cough, and even apnea in very young babies. General irritability and poor feeding may also be apparent.
These symptoms are shared with several other respiratory conditions, such as asthma, viral-induced wheeze, bacterial lower respiratory tract infection, pneumonia, and some rarer lung diseases such as cystic fibrosis.
Investigations – chest x-ray, hematology, and virology – are not routinely recommended, and even when a diagnosis is made, "we’re not 100% sure what to do," Dr. Thomas said.
Evidence-based treatments for the condition are lacking, Dr. Thomas said, with current practice guidelines set in 2006 in both the United Kingdom and United States tending to give advice on what not to do rather than what treatment to give.
"The bottom line is that there is no evidence-based specific treatment in prehospitalized infants ... and we’re left giving standard advice to children with viral illness on the use of fluids and antipyretics."
Dr. Joan L. Robinson, professor of pediatrics at Stollery Children’s Hospital in Edmonton, Alberta, noted that problems in diagnosing and treating bronchiolitis also exist in the ED.
Indeed, evidence shows that ED physicians and radiologists may interpret chest X-rays very differently, often misdiagnosing bronchiolitis as bacterial pneumonia (J. Pediatr. 2007;150:429-33; Pediatr. Pulmonol. 2009;44:122-7).
"Chest x-ray in a typical case of bronchiolitis leads to overdiagnosis of pneumonia and therefore overuse of antibiotics," Dr. Robinson cautioned.
Viral testing has its pros and cons, but it is probably not cost effective in the majority of non–high-risk outpatient cases, she added. "There is no clear correct answer as to whether hospitals should encourage routine testing for inpatients," Dr. Robinson observed.
Dr. Steve Cunningham, a consultant respiratory pediatrician at the Royal Hospital for Sick Children in Edinburgh, commented that treatments for bronchiolitis range from those that aim to improve airflow to those that reduce mucosal inflammation, lessen edema, or improve mucous movement.
Of all available treatments, however, only continuous positive airway pressure and nasal hypertonic saline had any, although still questionable, effect.
With the difficulties in diagnosis and treatment, it becomes all the more important for parents and other caregivers to be well informed about bronchiolitis and how to recognize the signs of a child’s possible deterioration.
"Most infants with bronchiolitis will have a mild illness that can be managed at home," Dr. Thomas said. Caregivers need to know, however, that there is "no cure," and that while symptoms may disappear at around 2 weeks in half of all affected infants, prolonged illness can result in others. It is unclear if there is a higher risk of developing asthma later in life.
Together with general advice on hygiene and regular hand-washing, physicians should remind caregivers that other factors, such as breast-feeding and passive smoking, can have an effect on the child’s health.
"There is also need for better education for GPs and a better evidence base for management," Dr. Thomas suggested. Primary care and general practitioners are uniquely placed to help monitor infants and young children, possibly preventing the need for emergency hospital admission.
Dr. Thomas, Dr. Robinson, and Dr. Cunningham said that they had no conflicts of interest.