Current Practices of PICU Practitioners in the Treatment of Bronchiolitis

Bronchiolitis remains one of the leading causes of pediatric intensive care unit (PICU) admission. Management is primarily supportive care. Some frequently administered therapies are not evidence based. In 2014, the American Academy of Pediatrics (AAP) published guidelines for the management of bronchiolitis recommending against administering β-agonists, hypertonic saline, antibiotics, or steroids to children with a bronchiolitis diagnosis.¹ These recommendations applied to all children with bronchiolitis, not just to those who are critically ill. Although the evidence for these recommendations was relatively strong (Grade A or B), the recommendation strength of the guidelines ranged from strong to weak.

In 2023, the French Society of Pediatric Intensive Care and Emergency Medicine (GFRUP) published guidelines for the management of infants younger than 12 months with severe bronchiolitis, which again suggested that β-agonists (IV or inhaled), corticosteroids, hypertonic saline, antibiotics, and the mucolytic agent DNAse should probably not be used.² Although there was strong agreement for all of these recommendations, the evidence for them was moderate, low, or very low.

Flaherty et al sought to examine the patterns of use for some of these therapies in PICUs.³ Their primary aim was to describe the use of medications for bronchiolitis, hypothesizing that β2-agonists, steroids, and hypertonic saline would still be commonly used despite these guidelines and that the use of mucolytics―dornase alfa (DA) and N-acetylcysteine (NAC)―would be infrequent. The authors sought to determine whether patterns of medications used for inpatient bronchiolitis had changed at all based on the AAP guidelines. Additionally, the authors sought to report on factors associated with medication use and the association between their use and PICU length of stay.

The authors used de-identified data from the Pediatric Health Information System (PHIS) database to examine billing and diagnostic codes of patients younger than 24 months who were admitted to a PICU with a bronchiolitis diagnosis (children with cystic fibrosis were excluded). The primary outcome was the rate of medication use (anyone billed for 2 or more doses of β-agonists, steroids, nebulized hypertonic saline, inhaled NAC, and/or inhaled DA) between 2018 and 2022. Secondary analyses examined demographic and clinical factors associated with the use of these medications, the association between their use and PICU length of stay, and any changes over time in the rate of their use between 2009 and 2022.

Overall, 47,520 hospitalizations for bronchiolitis were identified from 52 hospitals. β-agonists and steroids were used the most (52.6% and 33.4%, respectively) and were used in every hospital reviewed; nebulized 3% saline, NAC, and DA were used less often (14.8%, 0.8%, and 1.4%, respectively). Factors associated with medication use included an asthma diagnosis for the β-agonists and steroids and a diagnosis of pneumonia for all the medications. All were associated with increases in length of PICU stay.

Interestingly, there was no association between PICU length of stay and asthma diagnosis with use of β-agonists and steroids, suggesting that these medications may not be beneficial in children believed to have reactive airways. The authors found no significant change in the use of β-agonists before and after the AAP guidelines were published, although steroid use declined initially before rebounding. The rate of nebulized 3% saline use rose before the guidelines were published but then declined afterward.

The absence of recommendations for critically ill children in the 2014 AAP guidelines may be responsible for the continued use of β-agonists and steroids in U.S. PICUs, as was found in this study. In the 2014 guidelines, no recommendations were made regarding the use of mucolytics, and they continue to be used only to a small extent. Along with the GFRUP’s 2023 recommendations, a case can be made that the routine use of these medications, as well as mucolytics, in the management of critically ill children with bronchiolitis should also be avoided.

References
1.    Ralston SL, Lieberthal AS, Meissner HC, et al; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014 Nov;134(5):e1474-e1502. Erratum in Pediatrics. 2015 Oct;136(4):782.
2.    Milési C, Baudin F, Durand P, et al; French Speaking Group for Pediatric Intensive and Emergency Care. Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit. Intensive Care Med. 2023 Jan;49(1):5-25.
3.    Flaherty BF, Olsen CS, Coon ER, Srivastava R, Cook LJ, Keenan HT. Patterns of use of β-2 agonists, steroids, and mucoactive medications to treat bronchiolitis in the PICU: U.S. pediatric health information system 2009-2022 database study. Pediatr Crit Care Med. 2024 Dec 18. Online ahead of print.