Avoid doing chest x rays in infants with typical bronchiolitis
BMJ 2021; 375 doi: https://doi.org/10.1136/bmj-2021-064132 (Published 22 October 2021) Cite this as: BMJ 2021;375:e064132Linked Editorial
Sustainable practice: what can I do?
- Jeremy N Friedman, associate paediatrician-in-chief1,
- Tessa Davis, consultant in paediatric emergency medicine2,
- Aarani Somaskanthan, paediatric emergency medicine trainee3,
- Amy Ma, co-chair Family Advisory Forum4
- 1Paediatrics, Hospital for Sick Children, Toronto, Ontario M3B 3E8, Canada
- 2Paediatric Emergency Department, Royal London Hospital, London, UK
- 3Sydney Children’s Hospital Network, Australia
- 4Family Advisory Forum, Montreal Children's Hospital, Montreal, Quebec, Canada
- Correspondence to: J N Friedman jeremy.friedman{at}sickkids.ca
What you need to know
The diagnosis of bronchiolitis is based on history and physical examination findings and does not require any confirmatory testing
Performance of a chest x ray in cases of typical bronchiolitis increases the rate of incorrect diagnosis of bacterial pneumonia and unnecessary use of antibiotics
Abnormal chest x ray findings, such as peribronchial infiltrates and atelectasis, are common on imaging in typical bronchiolitis, but abnormalities leading to a new diagnosis are uncommon and likely seen in <1% of cases
Bronchiolitis is a viral lower respiratory tract infection occurring mainly in the winter months, most commonly caused by respiratory syncytial virus (RSV). It is seen primarily in infancy but occurs up to 2 years of age and is the most common indication for hospitalisation in this age group. Ninety percent of children are infected with RSV in their first 2 years, and up to 40% will experience bronchiolitis during the initial infection.1
Bronchiolitis usually begins with a viral upper respiratory tract prodrome (rhinorrhoea and cough) followed by increasing respiratory effort (tachypnoea and/or accessory muscle use) with wheezing and/or crackles heard on chest auscultation. Diagnosis and assessment of disease severity is based on history and physical examination findings and does not require any confirmatory testing (box 1).1
Guidance on optimal assessment of infants with bronchiolitis12
Typical features include coryzal prodrome followed by persistent cough, tachypnoea and/or chest recession, and wheeze and/or crackles on auscultation. If these are not present consider alternative diagnoses
Immediate referral for emergency hospital care if any apnoea, infant looks seriously unwell, severe respiratory distress (such as grunting, marked chest recession, or respiratory rate >70/min, cyanosis, or persistent low oxygen saturations <92%)
Consideration for referral to secondary care includes concerns over dehydration or difficulty with adequate oral intake (<75% of usual), or a persistent elevated respiratory rate >60/min
Risk factors for more severe illness include chronic lung disease, haemodynamically significant congenital heart disease, age <3 months, premature birth (especially <32 weeks), neuromuscular disorders, immunodeficiency
Scoring systems have not achieved widespread acceptance as few have demonstrated predictive validity. Assessment may require serial observations over time
International guidelines1234 recommend against the use of chest x rays in typical presentations (box 2). Some guidelines14 recommend imaging only if respiratory effort is severe enough to require intensive care, if infants may be at increased risk for developing complications,7 or if the history and examination findings suggest an alternative diagnosis (such as undiagnosed cardiac disease).
Guidelines on the use of chest x rays in assessment of infants with bronchiolitis
International guidelines1234
Australasia—Routine chest x ray is not recommended as it does not improve management in infants presenting with bronchiolitis and may lead to treatments of no benefit. [Strength of recommendation NHMRC D; GRADE conditional]
Canada—Bronchiolitis is a clinical diagnosis based on history and physical examination. Diagnostic studies, including chest radiograph, blood tests, and viral or bacterial cultures, are not recommended in typical cases. [Evidence quality: low]
UK—Do not routinely perform a chest x ray in children with bronchiolitis because changes on x ray may mimic pneumonia and should not be used to determine the need for antibiotics. Consider performing a chest x ray if intensive care is being proposed for a child. [Evidence quality: very low]
US—When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or laboratory studies should not be obtained routinely. [Evidence quality: B; recommendation strength: moderate recommendation]
Choosing Wisely recommendations
Do not order chest radiographs in children with uncomplicated asthma or bronchiolitis—National guidelines articulate a reliance on physical examination and patient history for diagnosis of asthma and bronchiolitis in the paediatric population. Multiple studies have established limited clinical utility of chest radiographs for patients with asthma or bronchiolitis. Omission of the use of chest radiography will reduce costs but not compromise diagnostic accuracy and care.5
Do not routinely undertake chest x rays for the diagnosis of bronchiolitis in children or routinely prescribe salbutamol or corticosteroids to treat bronchiolitis in children—Chest x rays for patients with acute lower respiratory tract infections rarely affect clinical treatments and outcomes. Chest radiographs do not discriminate well between bronchiolitis and other forms of lower respiratory tract infection, and in mild cases do not offer information that is likely to affect treatment. It is estimated that 133 children with typical bronchiolitis would have to undergo radiography to identify one radiograph that is suggestive of an alternate diagnosis.6
Contrary to international guidance, evidence suggests that chest x rays are overused in children with bronchiolitis and potentially result in unnecessary antibiotic use. A recent study of patients seen in 38 paediatric emergency departments across eight countries in North America, Europe, and Australasia found that chest x rays had been performed in 23% of previously healthy infants aged 2-12 months with bronchiolitis not requiring intensive care, and this was associated with antibiotic use irrespective of disease severity.8 The overuse of chest x rays and antibiotics in infants with typical bronchiolitis is even more common in general (non-paediatric) emergency departments.9
There is evidence of variability in chest x ray rates in bronchiolitis; a mean of 54.9%, ranging from 3.5% to 81%, of infants hospitalised for bronchiolitis in 42 hospitals in the US.10 It is unclear whether rates have decreased over time. Study results show some decline in children’s hospitals (from 58% to 27% over 10 years),11 but high rates of 46% with no decline in children discharged from emergency departments over a similar time period.9
The evidence for change
Radiological findings of peribronchial infiltrates, hyperinflation, and subsegmental atelectasis are typical in viral bronchiolitis (fig 1). However, atelectasis can be difficult to distinguish from a bacterial infiltrate or consolidation. There seems to be poor correlation between clinical findings and the presence of helpful findings on chest x ray.12 Other abnormal, unexpected findings on chest x ray, such as lobar consolidation, cardiomegaly, or other features suggestive of an alternate diagnosis, are uncommon in typical bronchiolitis cases.
Chest x ray showing typical changes seen in bronchiolitis: hyperinflation with flattened diaphragms, peribronchial thickening with subsegmental atelectasis
Imaging in infants with typical bronchiolitis has been shown in a prospective cohort study to lead to an incorrect diagnosis of bacterial pneumonia and contribute to increased unnecessary antibiotic use,8 from 2% to 15%.13 The study estimated that 133 children with typical bronchiolitis would have to undergo radiography to identify one x ray that is suggestive of an alternate diagnosis.13
The performance of unnecessary imaging in infants with typical bronchiolitis contributes to overdiagnosis of bacterial pneumonia with consequent antibiotic overuse,13 radiation exposure, inconvenience to the patient, and healthcare costs to the system.
Barriers to change
The care of patients with bronchiolitis spans multiple settings from primary care to general or paediatric-specific emergency departments to inpatient ward care. Because of the diverse settings and levels of experience of staff, there may be different degrees of familiarity with clinical practice guidelines in managing children with respiratory illnesses. This can result in the application of adult medicine practices to paediatric patients, including the use of medical imaging. Overall, there is a lack of a standardised unified message to families from physicians and nurses across multiple settings.14
There may also be provider discomfort with uncertainty around the “watch and wait” approach, with providers needing personal reassurance about the diagnosis. They may feel apprehensive about “doing nothing” with an unwell infant. Healthcare professionals may also struggle to manage the expectations or requests of carers.15
Reducing the ordering of chest x rays or de-implementation in general is often challenging for clinicians due to structural drivers of overuse such as order sets or organisational policies, as well as individual psychological barriers, including a fear of a malpractice lawsuit or missing a diagnosis associated with the discontinuation of existing practices.16
Finally, there is lack of consensus with regards to the appropriate overall rate of chest x rays for infants with bronchiolitis, as a chest x ray may indeed be appropriate in those with severe illness or in whom other diagnoses are being considered.
How should practice change?
Targeted quality improvement strategies—which include clinical champions, focused educational delivery, educational materials, and audit and feedback—are effective in de-implementing chest x rays in bronchiolitis.17 Examples of implementation of local clinical pathways based on national guidelines have achieved lower rates of unnecessary chest x rays, although which specific individual intervention is most effective is unclear.1819 Practice changes in the following key areas may reduce unnecessary radiographs, as well as other unnecessary testing and treatments, in children with typical bronchiolitis.
Clinician education
Develop and implement local, evidence based guidelines or pathways for bronchiolitis (or operationalise national guidelines)18 that are standardised across all settings (urgent care clinic, emergency department, inpatient)20 and focused especially on general (non-paediatric) emergency departments staffed by clinicians involved mainly in adult care. Removing chest x ray as a selectable option from order sets has been successful in various quality improvement projects, as has providing a list of indications for which the ordering of a chest x ray may be appropriate (see below).21 A focused intervention, including education sessions for physicians and nurses and posting of this guidance in clear view of clinicians, has been shown to decrease chest x ray rates.22 Evidence suggests involving individual clinicians (sharing provider-level feedback and audit data) as well as institutional-level work (updating clinical practice guidelines and order sets) helps create lasting change.23 Some success has been achieved by working as a “collaborative” of hospitals, which may help to establish a new normative behaviour among peer groups and overcome the inertia of an established clinical practice.24
Family engagement
Communicate effectively with families regarding the diagnosis and natural course of the illness (box 3). Deliver information early and aim for it to be standardised (such as videos, posters, and patient information materials in multiple languages).2526 This may help to reassure carers, alleviating concerns and setting expectations. Input from families in developing standardised information can ensure that these communication materials address family members’ concerns and information needs.
What families need to know
Most cases of bronchiolitis settle without the need for tests or medications
A chest x ray is unlikely to change the diagnosis, and may lead to unnecessary use of antibiotics and radiation exposure
Bronchiolitis is a common infection of the lungs in young children, caused by a virus. The infection causes inflammation and mucus to build up in the tiny airways (bronchioles) making it harder to breathe. At first, your child may have symptoms of a cold including a runny or blocked nose and a cough. After a few days, the dry cough may progress to a more wet cough with increased mucous. This may be accompanied by fast, shallow, noisy breathing with sucking in of the chest below the rib cage and flaring of the nostrils. The child may also be irritable, tired, and less interested in eating and drinking. Symptoms are usually worst on the second or third day, and your child may be sick for 7-10 days, although the cough can continue for weeks.
Most cases can be managed at home by letting your baby have plenty of rest and continuing to feed as usual. If your baby is not feeding well, try to give smaller feedings more often. If your baby’s nose is congested then saline nose drops or sprays may help to clear it, as may the use of a device to suction mucous from the nostrils. This may help your baby’s breathing and feeding. Keep your baby away from any irritants such as cigarette smoke and do not use cough medicines, as they do not help and can result in side effects.
Children who have trouble breathing need to be assessed by a healthcare professional. This would include if your child is breathing very fast, having trouble breathing which may include skin retraction in the chest or neck, or flaring of the nostrils. Assessment may also be required if your child isn’t drinking enough and their eyes are dry or sunken, they are peeing less than usual, or just much sleepier and more lethargic, suggesting possible dehydration.
Identification of when to consider ordering a chest x ray
In addition to clear guidance against the routine use of chest x rays, provide specific direction as to when a chest x ray may be indicated (for example, severe respiratory distress requiring admission to intensive care, concern about underlying cardiac or chronic lung disease related to risk factors elicited on history or physical examination, high suspicion for bacterial pneumonia or other alternate diagnosis).
Education into practice
Do you know how many of your patients with typical bronchiolitis have received a chest x ray?
If you order x rays for patients with typical presentations of bronchiolitis, what are you expecting to find?
Do you offer an information sheet to families of children with bronchiolitis outlining what to expect, how best to manage symptoms, and when to return for reassessment?
How patients and families were involved in the creation of this article
Amy Ma is a patient advisor with Choosing Wisely Canada and has been involved in numerous activities relating to reducing unnecessary tests and procedures. She is also a member of the family advisory group at her local children's hospital. She reviewed a range of publicly facing patient materials. While she does not have a child with bronchiolitis, she reviewed and commented on all versions of the manuscript and in particular was responsible for the development of material for “Family engagement.”
Search methods
We searched Medline and the Cochrane Library using three broad concepts: (1) bronchiolitis terms, (2) infant terms, (3) chest x ray terms. References were captured by the search if they had at least one term in each of the three concepts. Searches were limited to English language and publication years from 2010 to present. We also reviewed the reference lists of all relevant articles identified by the search as well as those included in the major international guidelines.
Acknowledgments
Advisers to the “Change” series are Sera Tort, David Tovey, Win Sen Kuan, Paula Riganti, and Juan Franco.
This article is part of a series of Education articles based on recommendations from international Choosing Wisely campaigns. The BMJ thanks Wendy Levinson and Karen Born at Choosing Wisely for valuable advice and supporting the selection of topics. Choosing Wisely had no input into the peer review process or editorial decision.
Footnotes
“Change” aim to alert clinicians to the immediate need for a change in practice to make it consistent with current evidence. We welcome any suggestions for future articles (email us at practice@bmj.com).
Contributors: All authors participated in the conception of the article, writing the original draft, and reviewing the content. JF was responsible for project administration and is guarantor for the study.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned, based on an idea from the authors; externally peer reviewed
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