UPDATE - 2022 Italian guidelines on the management of bronchiolitis in infants

Based on the evidence obtained for each question, the recommendations were formulated. All questions answered on the management of bronchiolitis were summarized in Table 2.

Table 2 Questions answered in regards to the management of bronchiolitisHow is bronchiolitis diagnosed?

Recommendations: The diagnosis of bronchiolitis is based on the clinical history and physical examination (Evidence Quality: B; Recommendation Strength: Strong Recommendation).

The collection of data on clinical history must investigate the presence of the following: exposure to individuals presenting with upper respiratory tract viral infections during the epidemic season, underlying conditions that may be associated with an increased risk of progression to severe morbidity or mortality, e.g., in utero smoke exposure, prematurity, congenital anomalies, genetic abnormalities, haemodynamically significant congenital heart disease, chronic lung disease (bronchopulmonary dysplasia (BPD)), and the presence of an immunocompromising state [1, 20,21,22,23,24,25,26,27,28,29,30,31,32].

Combined with the collection of clinical history, the physician should look for a wide range of suggestive but not specific clinical symptoms such as rhinorrhea and/or upper respiratory tract infections; first episode of respiratory distress associated with cough; crackles and/or wheezing; dyspnea; polypnea; increased respiratory effort manifested as nasal flaring, grunting, use of accessory muscles or intercostal and/or subcostal chest wall retractions; low oxygen (O2) saturation levels, apnea; skin colour changes; feeding difficulties; lethargy; and fever [1, 20,21,22,23,24,25,26,27,28,29,30,31,32].

The peak severity of the disease occurs around 3-5 days from the disease onset, and improvement occurs in 7-14 days, with 90% of infants having a resolution of cough within 2-3 weeks [1, 20,21,22,23,24,25,26,27,28,29,30,31,32].

Several clinical scores have been proposed to guide treatment and resource allocation in acute bronchiolitis [33,34,35]. However, due to the weak relationship between changes in scores and the clinical picture and the high inter-rater variability among the physicians [1, 20,21,22,23,24,25,26,27,28,29,30,31,32], clinical scores should be used in conjunction with careful clinical evaluation to improve and individualize the decision-making process.

What is the role of primary care paediatricians in managing a child with bronchiolitis?

Recommendations: Primary care paediatricians should educate family members on evidence-based prevention, diagnosis, and management of bronchiolitis (Evidence Quality: C; Recommendation Strength; Moderate Recommendation).

Most children with acute bronchiolitis may be adequately managed in the outpatient setting by primary care paediatricians, parents or caregivers able to provide assistance and monitoring. After having ascertained the parents compliance and the presence of any risk factors (Table 3), the clinician must educate the parents or caregivers on the following:

1)

how to assess the child’s general clinical conditions;

2)

which supportive therapies to administer (see the chapter “Treatment”); and

3)

when to ask for primary care paediatricians or when to access the Emergency Room.

Table 3 Risk factors for severe bronchiolitis

The following signs of a worsening condition should be promptly recognized: reduced feeding; increased respiratory rate; onset of laboured breathing suggested by flared nostrils; use of accessory muscles, retractions, cyanosis, apnea, fewer wet diapers, or a generally toxic appearance [1, 20,21,22,23,24,25,26,27,28,29,30,31,32].

Initiatives to reduce non-evidence-based treatments in bronchiolitis, such as using common electronic medical records with quality control of treatments, can contribute to avoiding the prescription of ineffective medicines.

In addition, the creation and diffusion of parents' educational materials (information leaflet) on the evidence-based management of bronchiolitis can inform parents who often expect and demand medications for their sick infants and avoid the "doctor-shopping" for treating bronchiolitis. In parallel, the diffusion of information leaflets about environmental prophylaxis of RSV and other viruses can be helpful in protecting infants from these infections [36, 37].

Are laboratory (blood an/or urine) tests and radiological exams supported in managing bronchiolitis?

Recommendations: Neither laboratory tests nor radiological exams are usually indicated for the routine work-up of infants with bronchiolitis (Evidence Quality: B; Recommendation Strength: Moderate Recommendation).

Laboratory tests are not usually indicated for the routine work-up of infants with bronchiolitis [1, 20,21,22,23,24,25,26,27,28,29,30,31,32, 38]. Complete blood counts, serum electrolytes, blood gas analysis, urinalysis and urine culture should not be routinely performed [1, 20,21,22,23,24,25,26,27,28,29,30,31,32, 38]. A bacterial co-infection is rarely associated with bronchiolitis; thus, guidelines [1, 20,21,22,23,24,25,26,27,28,29,

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