COMMENTARY
Bronchiolitis: More Evidence, Fewer
InterventionsShifting Paradigms With
Evidence-based Diagnostics
Y oung, nonverbal children presenting to the emer-
gency department (ED) with nonspecific com-
plaints pose a significant diagnostic challenge to the
emergency physician (EP). Given the paucity of pedi-
atric research and clinical decision rules (CDR)1 for
many common conditions that present to the ED, this
can lead to overinvestigation, which can have negative
consequences for the patient and families.2 Tradition-
ally, rigorous evidence requires derivation of a rule,
testing and validating the rule in small contexts, and
externally validating the CDR in multiple settings.3
This has been done successfully in various contexts,
including the traumatic head injury rules in children
and management of low-risk ankle fractures.45 In the
era of Choosing Wisely, and the recognition that
more testing does not equate to better care, it is
important to have CDRs that can both minimize
unnecessary testing and give a clinician confidence in
ordering specific tests.2,6
The American Academy of Pediatrics published evi-
dence-based guidelines for the management of bronchi-
olitis in 20067 and updated them in 2015.8 One study
examining the effect of the 2006 guidelines on the
investigation and treatment of children with bronchioli-
tis noted a significant reduction in investigations (labs
35% vs. 29%, respiratory syncytial virus testing 61%
vs. 41%, chest X-ray [CXR] 61% vs. 52%) and treat-
ment (bronchodilator 65% vs. 58%, steroids 25% vs.
16%).9 Antibiotic administration rates were unchanged
(34% vs. 33%).9 The study showed that although
releasing national guidelines had an impact in decreas-
ing unnecessary tests and interventions, there is room
to improve.10 The guidelines do not provide an ED
CDR or an algorithmic pathway that could aid EPs in
their approach to a child with suspected bronchiolitis.
ISSN 1069-6563
114 PII ISSN 1069-6563583
In Volume 23 Issue 10 Academic Emergency Medi-
cine (AEM), Chao et al.11 present a systematic review
and meta-analysis of the clinical predictors of air-
space disease in pediatric patients presenting to the
ED with bronchiolitis. The authors literature search
and article selection were clearly outlined. In addi-
tion, they used the quality assessment of studies diag-
nostic accuracy tool to assess level of evidence from
the five articles included. The authors conducted a
pooled analysis of the 15 studies and 1,139 patients
under the age of 2 years and found a weighted
prevalence of 17% for a positive CXR with airspace
disease. The only predictor was an oxygen saturation
of <95%, with a likelihood ratio12 of 2.3. Fever,
tachypnea, crackles, retractions, or breath sound
asymmetry did not significantly change the post-test
probability of a positive CXR.
Low oxygen saturations did not necessitate the need
for a CXR to rule out an infiltrate. However, in a
novel approach, the authors created a mathematical
diagnostic calculator based on the Pauker and Kas-
sirer13 decision threshold model. Their model takes
into account all important determinants like operating
characteristics of a CXR in identifying superimposed
bacterial infection, the risk of exposure to ionizing
radiation, the risk of overtreatment with antibiotics,
and anticipated benefit of treatment. The authors were
clear that benefit from treatment of bacterial pneumo-
nia with antibiotics has never been measured against
placebo; therefore, using the best possible evidence
they quantified and assigned reasonable conservative
estimates of risk/benefit for every category. Based on
their calculations, a CXR is only justifiable in patients
with bronchiolitis and respiratory failure or severe
bronchiolitis requiring admission. In patients with
2016 by the Society for Academic Emergency Medicine
doi: 10.1111/acem.13109
ACADEMIC EMERGENCY MEDICINE January 2017, Vol. 24, No. 1 www.aemj.org
mild bronchiolitis who are eligible for discharge from
the ED, the treatment benefit is estimated only at 5%,
indicating that even when oxygen saturation is less
than 95%, the harm will outweigh the benefit of find-
ing airspace disease or treating it. Based on those find-
ings, the authors suggest children with mild
bronchiolitis should not be X-rayed, which is
consistent with the national guidelines in North
America.8,14
Given that the findings focus primarily on oxygen
saturation, it is worth discussing previous studies
examining oxygen saturations in bronchiolitis diagno-
sis and management. In a double-blinded random-
ized controlled trial, Schuh and colleagues15
examined the outcome of children with mild to
moderate bronchiolitis with initial oxygen saturation
of 88%, with one group having their oxygen satura-
tion artificially elevated by 3%. The group that had
elevated oxygen saturation had almost half the admis-
sion rate when compared to the true saturation
(25% vs. 41%), despite no physiologic difference in
oxygen delivery. In another study, Principi et al.16
attached a blinded oxygen saturation probe to infants
diagnosed with bronchiolitis who were discharged
home. They found that 64% of children had desatu-
ration events at home, with some having saturations
as low as 70% for 1 minute or longer. The majority
of desaturations took place during feeding or sleep-
ing, and children with or without desaturations had
comparable rates of return visits. This study helped
build the evidence base that oxygen desaturations
alone do not necessarily predict severe outcomes.
With the increasing use of percutaneous oxygen satu-
ration measurements for bronchiolitis, admission
rates for children less than 6 months increased by
239% from 1980 to 1996 without any change in
mortality.17,18 Children with spot saturations > 89%
while awake can be safely discharged. Oxygen satura-
tion should only be used in conjunction with
infants risk factors, respiratory distress, and ability
to feed safely to make a decision regarding further
workup and disposition.
This systematic review reinforces existing guidelines
and supports it with pooled data. Unfortunately,
there were no clear predictors for positive CXR from
the study, and thus no significant clinical decision
tools were put forward from the aggregated data. It
is interesting that there were only five diagnostic
studies with just over 1000 patients with high risk
of bias. For good reasons, researchers were focused
115
on therapeutics in randomized controlled trials for
bronchiolitis that showed little benefit. We are now
starting to understand that bronchiolitis is a hetero-
geneous illness that could be subtyped into groups.19
Future studies need to be more selective of their
bronchiolitis patients when designing clinical risk
scoring systems.20
After decades of research we still need a reliable,
easy-to-apply, and validated clinical scoring system that
takes into account risk factors, history, and respiratory
assessment for infants presenting with wheezing to
the ED. This coupled with diagnostic research and
incorporating cutting-edge rapid microbiologic testing
will allow us to diagnostically cluster infants with
wheezing more accurately. A well-developed CDR
would need to be designed and rigorously evaluated
in a prospective randomized fashion in a multicenter
trial against usual care. Until a breakthrough in
therapeutics occurs, we should now focus on decreas-
ing morbidity from overinvestigating and overtreating
children with mild to moderate bronchiolitis.
This review marks the first of AEMs Evidence-
Based Diagnostic series focusing on pediatric issues.
There are a myriad of other topics in pediatrics that
should be reviewed, given their clinical frequency and
practice variations. For example, investigating and
reviewing diagnostics in children with a limp, renal
stones or appendicitis are topics that should be
reviewed and discussed. We hope that this review
stimulated interest in this topic, and AEM looks for-
ward to future submissions relevant directly to the EP
who sees children.
Mohamed Eltorki, MBchB1
(mohamed.eltorki@gmail.com)
Daniel Rosenfield, MD2
1
Division of Pediatric Emergency Medicine, McMaster
Childrens Hospital, McMaster University, Hamilton,
Ontario and 2Division of Paediatric Emergency Medi-
cine, The Hospital for Sick Children & University of
Toronto, Toronto, Ontario, Canada
Supervising Editor: John H. Burton, MD
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