Bronchiolitis: The journey towards evidence -based care.

1. Bronchiolitis: The journey towards evidence -based care. Presenters: Jeanann P. Pardue, MD, FAAP Shawn Ralston, MD, FAAP \ B-QIP Learning Session Webinar August 20, 2013

2. Roll Call and Introductions • Those of you serving as the Local Lead Physicians for ABP MOC Part 4: • Please note that you are attending via the “Question” chat box. You do not need to share your hospital code. Thank you! • Jeanann Pardue, MD, FAAPEast Tennessee Children’s Hospital • Shawn Ralston, MD, FAAPDartmouth Hitchcock Medical Center The Quality Collaborative for Improving Hospitalist Compliance with the AAP Bronchiolitis Guideline (B-QIP) is funded by the AAP Quality Improvement Innovation Networks (QuIIN)

3. Agenda

4. Learning Objectives • Gain a clear understanding the evidence supporting the AAP guidelines • Evaluate potential roadblocks to the implementation of an evidence based pathway of care • Gain an understanding of the evidence supporting evidence based guideline implementation.

7. “Since acute viral bronchiolitis is thus a self-limited disease of relatively good prognosis, the principle of primum non nocereshould temper frustrated anxiety to do something-anything-to relieve severe dyspnea. Simple physical exhaustion may determine the fate of an infant laboring to meet his metabolic requirements for oxygen. His energies should not be frittered away by the annoyance of unnecessary or futile medications and procedures. Rest should be treasured.” Pediatrics, 1965

8. FRITTERING

10. The Question How do I provide evidence –based high value care for bronchiolitis?

11. The Answer What works?

15. Basic Elements of Evidence –based care for Bronchiolitis. • Airway clearance: suction first, last, and as needed • Nutritional Support: Often overlooked • Oxygen: recommendations for its use and clear guidelines for its discontinuation. • Eliminate the utilization of unnecessary resources with the implementation of an objective scoring tool to validate the effectiveness and the need for continuation of an intervention.

16. 1.Bronchiodilators 2. Steroids CPT Pulse oximetry

17. AAP Bronchiolitis Practice Guideline

18. AAP practice guideline: Diagnosis and management of bronchiolitis. Pediatrics 2006;118(4):1774-93. • The diagnosis should be made clinically • Bronchodilators are not recommended • Corticosteroids are not recommended • Ribavirin is not recommended • Antibiotics are not recommended • Chest physiotherapy is not recommended, oral rehydration is preferred • Oxygen saturation threshold is 90% and continuous monitoring not necessary • Prophylaxis is recommended for particular subsets of patients • Hand hygiene with alcohol hand gel is preferred • Secondhand smoke exposure is bad and should be addressed • Ask about use of alternative medicine

19. Bronchodilators are not recommended

22. New meta-analyses since last guideline • Beta-agonists:GadomskiAM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010;(12):CD001266. • Epinephrine: Hartling L, Bialy LM, Vandermeer B. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2011;(6):CD003123.

23. Hospitalization rates: 9 studies over 600 patients… RCT placebo vs bronchodilators Changes in Clinical Score: 8 inpatient studies with over 300 patients 11 outpatient studies with over 500 patients… RCT LOS: 6 studies over 300 patients… RCT No significant clinical difference

24. Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010; (12):CD001266. Authors’ conclusions: • Bronchodilators do not improve oxygen saturation, do not reduce hospital admission after outpatient treatment, do not shorten the duration of hospitalization and do not reduce the time to resolution of illness at home. • The small improvements in clinical scores for outpatients must be weighed against the costs and adverse effects of bronchodilators.

25. Hartling L, Bialy LM, Vandermeer B. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2011;(6):CD003123. Author’s Conclusions: • This review demonstrates the superiority of epinephrine compared to placebo for short-term outcomes for outpatients, particularly in the first 24 hours of care. • Exploratory evidence from a single study suggests benefits of epinephrine and steroid combined for later time points. More research is required to confirm the benefits of combined epinephrine and steroids among outpatients. • There is no evidence of effectiveness for repeated dose or prolonged use of epinephrine or epinephrine and dexamethasone combined among inpatients.

27. Why do you need an objective clinical score? • Albuterol continued despite poor response to therapy. Chart review of 90 infants. Pharmocotherapy 18: 198. 1998 Lugo RA, et all Effects of Practice Variation on Resource Utilization in infants Hospitalized for a Viral Lower Resp Infection. Pediatrics 2001. 108: 851-855

28. Corticosteroids are not recommended

29. Randomized, double-blind, placebo controlled trial 5 day course of prednisolone or placebo 700 enrolled , ages 10 months- 60months Primary outcome: LOS Secondary outcomes: Score on Preschool Respiratory Assessment Measure ; Albuterol use; 7 day symptom score

31. Fernandes RM, Bialy LM, Vandermeer B. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2010;(10):CD004878. Author’s Conclusions: • Current evidence does not support a clinically relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalization. • Combined dexamethasone and epinephrine may reduce outpatient admissions, but results are exploratory and safety data limited.

33. Chest physiotherapy is not recommended, oral rehydration is preferred

35. Oxygen saturation threshold is 90% and continuous monitoring not necessary

36. Shay et al, JAMA, 1999

37. Why have hospitalization rates increased? • ? Increased survival of children with comorbidities • ? Virulence • ? Increase in daycare • Changes in hospitalization criteria

38. ED physician survey Mallory, Pediatrics, 2003

39. Effect on LOS • Prolonged in 26% - 57% of hospitalized patients [Schroeder, Archives 2004; Unger, Pediatrics 2008] • Ongoing RCT of continuous vs intermittent pulse oximetry showing no differences in outcomes

41. Secondhand smoke exposure should be addressed

42. Tobacco Smoke Exposure & Bronchiolitis A series of meta-analyses by Strachan and Cook1 concluded Tobacco Smoke Exposure (TSE) caused a range of diseases, including acute lower respiratory infections • Strachan DP, Cook DG: Health effects of passive smoking 1.Parental smoking and lower respiratory illness in infancy and early childhood. Thorax 1997, 52: 905-914. Meta-analysis of TSE on acute lower respiratory infections in 20112 demonstrated TSE increases risk for LRI, most significantly bronchiolitis (OR 2.51 95% CI 1.96 to 3.21) • Jones LL, Hashim A, McKeever T, Cook DG, Britton J, Leonardi-Bee J. Parental and household smoking and the increased risk of bronchitis, bronchiolitis, and other lower respiratory infections in infancy: systematic review and meta-analysis. Respiratory Research 2011, 12 (5).

44. Studies included in Meta-analysis 1. Al-Shehri MA, Sadeq A, Quli K: Bronchiolitis in Abha, Southwest Saudi Arabia: viral etiology and predictors for hospital admission. West Afr J Med2005, 24:299-304 2. Anderson LJ, Parker RA, Strikas RA, Farrar JA, Gangarosa EJ, Keyserling HL, Sikes RK: Day-care center attendance and hospitalization for lower respiratory tract illness. Pediatrics 1988, 82:300-308 3. Breese Hall C, Hall WJ, Gala CL, MaGill FB, Leddy JP: Long-term prospective study in children after respiratory syncytial virus infection. J Pediatr 1984, 105:358-364 4. Gurkan F, Kiral A, Dagli E, Karakoc F: The effect of passive smoking on the development of respiratory syncytial virus bronchiolitis. Eur J Epidemiol 2000, 16:465-468. 5. Hayes EB, Hurwitz ES, Schonberger LB, Anderson LJ: Respiratory syncytial virus outbreak on American Samoa. Evaluation of risk factors. Am J Dis Child 1989, 143:316-321 6. McConnochie KM, Roghmann KJ: Parental smoking, presence of older siblings, and family history of asthma increase risk of bronchiolitis. Am J Dis Child 1986, 140:806-812 7. Sims DG, Downham MA, Gardner PS, Webb JK, Weightman D: Study of 8-year-old children with a history of respiratory syncytial virus bronchiolitis in infancy. BMJ 1978, 1:11-14 8.Chatzimichael A, Tsalkidis A, Cassimos D, Gardikis S, Tripsianis G, Deftereos S, Ktenidou-Kartali S, Tsanakas I: The role of breastfeeding and passive smoking on the development of severe bronchiolitis in infants. Minerva Pediatr 2007, 59:199-206 9. Reese AC, James IR, Landau LI, Lesouef PN: Relationship between urinary cotinine level and diagnosis in children admitted to hospital. Am Rev Respir Dis 1992, 146:66-70

45. Other pertinent studies • Bradley JP, Bacharier LB, Bonfiglio J, Schechtman KB, Strunk R, Storch G, Castro M. Severity of respiratory syncytial virus bronchiolitis is affected by cigarette smoke exposure and atopy. Pediatrics. 2005; 115(1):e7-14. • Al-Shawwa B, Al-Huniti N, Weinberger M, Abu-Hasan M. Clinical and therapeutic variables influencing hospitalisation for bronchiolitis in a community-based paediatric group practice. Primary Care Respiratory Journal. 2007; 16 (2): 93-97. • Law BJ, Carbonell-Estrany X, Simoes EA. An update on respiratory syncytial virus epidemiology: a developed country perspective. Respi Med 2002; 96 (Suppl B): S1-7. • Carroll KN, Gebretsadik T, Griffin MR, et al. Maternal asthma and maternal smoking are associated with increased risk of bronchiolitis during infancy. Pediatrics. 2007;119:1104-12. • Semple MG, Taylor-Robinson DC, Lane S, Smyth RL. Household Tobacco Smoke and Admission Weight Predict Severe Bronchiolitis in Infants Independent of Deprivation: Prospective Cohort Study. 2011; PLoS ONE 6(7): e22425.

46. Epidemiology • Inpatient admission screening (nurseor physician) identified 24% children with TSE compared to 46% children with TSE by cotinine level. • 55% children in an urban outpatient setting had evidence of TSE by testing cotinine levels, a biomarker of tobacco exposure, in comparison to 13% TSE by parental report. • In an urban pediatric ER study, 41% parents of children with asthma/bronchiolitis were self-reported smokers. • Study in the UK of infants admitted with bronchiolitis demonstrated 53-84% infants had a self-reported household tobacco smoker. • Wilson K, Wesgate S, Best D, Blumkin A, Klein J. Admission Screening for Secondhand Tobacco Smoke Exposure. Hospital Pediatrics 2012; 2 (1): 26-33. • Dempsey DA, Meyers MJ, Benowiz NL et al. Determination of Tobacco Smoke Exposure by Plasma Cotinine Levels in Infants and Children Attending Urban Public Hospital Clinics. Arch PediatrAdolesc Med 2012; 166(9): 851-856. • Mahabee-Gittens M. Smoking in Parents of Children with Asthma and Bronchiolitis in a Pediatric Emergency Department. Pediatric Emergency Care. 2002; 18 (1): 4-7.

47. Literature on Interventions • One time clinical interventions for reduction of TSE appear marginally effective with repeated minimal interventions showing some positive outcomes. • Meta-analysis by Rosen on parental smoking cessation concluded interventions targeted to parents can be successful • Rosen LJ, Noach MB, Winickoff JP, Hovell MF. Parental Cessation to Protect Young Children: A Systemic Review and Meta-analysis. Pediatrics. 2012;129(1):141-52. • Limited intervention studies have been performed on addressing parental smoking during acute illness visits: • Mahabee-GittensEM, Gordon JS, Krugh ME, Henry B, Leonard AC. A smoking cessation intervention plus proactive quitline referral in the pediatric emergency department: a pilot study. Nicotine Tob Res 2008; 10: 1745-51. • Ralston S, Roohi M. A randomized, controlled trial of smoking cessation counseling provided during child hospitalization for respiratory illness. PediatrPulmonol 2008; 43: 561-6. • Winickoff JP, Hillis VJ, Palfrey JS, Perrin JM, Rigotti NA. A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program. Pediatrics 2003; 111(1): 140-5. • Chan SS, Lam TH, Salili F, et al. A randomized controlled trial of an individualized motivational intervention on smoking cessation for parents of sick children: a pilot study. ApplNurs Res 2005; 18: 178-81.

48. Does quality improvement work in bronchiolitis? How to improve outcomes and eliminate waste.

49. Waste in US Healthcare Berwick, D. M. et al. JAMA doi:10.1001/jama.2012.362