Information about current guideline

Bronchiolitis is a lower respiratory tract infection commonly seen in children less than 1 year of age.1 ,2 Predominantly occurring in winter months, bronchiolitis is in the majority managed in the primary care setting, but it contributes to a significant proportion of the admissions to paediatric wards with a small number requiring intensive care. The National Institute for Health and Care Excellence (NICE) guideline ‘Bronchiolitis in Children’ was published in June 2015.1 It aims to direct management of bronchiolitis in both primary and secondary care. The guideline was developed by the National Collaborating Centre for Women's and Children's Health.

Previous guideline

This is the first NICE guideline that covers bronchiolitis. The Scottish Intercollegiate College Network published a guideline in 2006 detailing diagnosis, management and prevention of bronchiolitis.3 The American Association of Paediatrics published a guideline with a similar scope in October 2014.2 Traditionally, there is discrepancy in terminology between the UK and the USA, with clinical conditions described in the UK as virus-induced wheeze or infantile asthma termed bronchiolitis in USA. This makes it difficult to compare studies and guidelines (see table 1 and box 1).

Key issues of the guideline recommends

Underlying evidence base/methodology

This, like all NICE recommendations, is based on systematic reviews of research evidence. Where no substantive clinical research evidence is found, the recommendation will be based on other evidence-based guidelines or the collective experience of the Guideline Development Group (see box 1).

What do I need to know

Unresolved controversies

Nebulised HS (usually 3%) became part of UK paediatric practice for the management of bronchiolitis, following the publication of several studies and a Cochrane review from 2013, which stated that ‘current evidence suggests nebulised 3% saline may significantly reduce the length of hospital stay among infants hospitalised with non-severe acute viral bronchiolitis and improve the clinical severity score in both outpatient and inpatient populations’.4 The AAP bronchiolitis guideline recommends its use in infants with bronchiolitis requiring hospital admission.2 However, further studies have not shown such benefit. The UK SABRE study,5 a randomised open trial, did not show HS to be of any benefit over conventional secondary care management, and similar conclusions were drawn from a further meta-analysis.5 ,6 The current NICE guidelines do not advise use of HS. Four editorials address this controversy.7–10

No evidence exists as to the optimal target SpO₂ for supplemental oxygen therapy for bronchiolitis. A recent double-blind randomised equivalence trial compared SpO₂ 90% versus SpO₂ 94% as thresholds for supplementary oxygen. The study concluded that a target SpO₂ of 90% is as safe and clinically effective as 94%.11

While supplementary oxygen is currently recommended for infants whose SpO₂ is <92% in air, the type of administration is not specified. There is currently insufficient evidence to show any benefit for use of heated humidified high-flow nasal cannula oxygen.12 ,13 This is despite the widespread use in paediatric practice, including general paediatric wards. Studies are urgently needed to assess the potential benefits, for example, length of stay, prevention of HDU and paediatric intensive care unit admissions and prevention of need for CPAP respiratory support. Evidence-based weaning schedules are also needed to ensure that the additional equipment and consumables, together with potential staffing issues, are cost effective.