A systematic review of clinical practice guidelines for the diagnosis and management of bronchiolitis

Introduction: Bronchiolitis is the leading cause of respiratory admission to hospital in infants less than one year. Clinical practice guidelines can benefit patients by reducing unnecessary tests, hospital admissions and treatments with lack of a supportive evidence base. This review aimed to identify current clinical practice guidelines worldwide, appraise their methodological quality and discuss variability across guidelines for the diagnosis and management of bronchiolitis. Methods: A systematic literature review of electronic databases EMBASE, Global Health and Medline was performed. Manual searches of grey literature, national paediatric society websites and guideline focused databases were carried out and selected international experts were contacted to identify additional guidelines. The Appraisal of Guidelines for Research & Evaluation (AGREE II) assessment tool was used to appraise each guideline by two independent reviewers. Results: Thirty two clinical practice guidelines met the selection criteria. Quality assessment revealed significant shortcomings in a number of guidelines including lack of systematic processes in formulating guidelines, failure to state conflicts of interest and lack of consultation with families of affected children. There was widespread agreement over a number of aspects such as avoidance of the use of unnecessary diagnostic tests, risk factors for severe disease, indicators for hospital admission, discharge criteria and nosocomial infection control. However, there was variability even within areas of consensus over specific recommendations such as variable thresholds for oxygen therapy. Guidelines showed significant variability in recommendations for the pharmacological management of bronchiolitis with conflicting recommendations over whether nebulised epinephrine, hypertonic saline or bronchodilators should be trialled. Conclusions: Future guidelines should aim to be compliant with international standards for clinical guidelines to improve their quality, clarity and promote their adoption into practice. Variable recommendations between guidelines may reflect the evolving evidence base for bronchiolitis management and platforms should be created to understand this variability and promote evidence-based recommendations.