limitation still were on inhaled medications after almost 1 year and, thus, inappropriately treated. So, in addition to misdiagnosis, overweight and obese subjects are at increased risk for overtreatment with respiratory medications. Not only is this ineffective, potentially harmful, and unnecessarily expensive, it also leaves a large proportion of the population with respiratory symptoms neglected. By treating respiratory symptoms with inhaled medications in the absence of airways disease, health-care professionals are currently missing the opportunity to establish alternative diagnoses and correctly manage respiratory symptoms in overweight and obese people. Importantly, this does not only apply to those professionals dealing with respiratory disease; in subjects with suspected heart failure and preserved left ventricular systolic function, obesity is a common cause of misdiagnosis.16 In the face of the global trend of overweight and obesity, knowledge among health-care professionals about the respiratory consequences of high BMI in both healthy and diseased populations should be increased. First, health-care professions should be aware that high BMI affects respiratory symptoms and function per se.17 Second, they should be trained in diagnosing respiratory disease in populations with increased BMI. Finally, treatments should be adjusted accordingly, and alternative causes of respiratory symptoms should be recognized and managed. For now, based on the results of the study by Collins and colleagues,15 misdiagnosis and overtreatment of COPD should be added to the long list of risk factors associated with overweight and obesity.
References 1. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766-781. 2. Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859): 2224-2260. 3. Beuther DA, Sutherland ER. Overweight, obesity, and incident asthma: a meta-analysis of prospective epidemiologic studies. Am J Respir Crit Care Med. 2007;175(7):661-666. 4. Peters-Golden M, Swern A, Bird SS, Hustad CM, Grant E, Edelman JM. Influence of body mass index on the response to asthma controller agents. Eur Respir J. 2006;27(3):495-503. 5. Crummy F, Piper AJ, Naughton MT. Obesity and the lung: 2. Obesity and sleep-disordered breathing. Thorax. 2008;63(8): 738-746. 6. O’Donnell DE, Deesomchok A, Lam YM, et al. Effects of BMI on static lung volumes in patients with airway obstruction. Chest. 2011;140(2):461-468. 7. Ora J, Laveneziana P, Ofir D, Deesomchok A, Webb KA, O’Donnell DE. Combined effects of obesity and chronic obstructive pulmonary disease on dyspnea and exercise tolerance. Am J Respir Crit Care Med. 2009;180(10):964-971.
1428 Editorials
8. Bautista J, Ehsan M, Normandin E, Zuwallack R, Lahiri B. Physiologic responses during the six minute walk test in obese and non-obese COPD patients. Respir Med. 2011;105(8):1189-1194. 9. Landbo C, Prescott E, Lange P, Vestbo J, Almdal TP. Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999;160(6):1856-1861. 10. Cecere LM, Littman AJ, Slatore CG, et al. Obesity and COPD: associated symptoms, health-related quality of life, and medication use. COPD. 2011;8(4):275-284. 11. Sin DD, Jones RL, Man SF. Obesity is a risk factor for dyspnea but not for airflow obstruction. Arch Intern Med. 2002;162(13): 1477-1481. 12. Ofir D, Laveneziana P, Webb KA, O’Donnell DE. Ventilatory and perceptual responses to cycle exercise in obese women. J Appl Physiol (1985). 2007;102(6):2217-2226. 13. Zutler M, Singer JP, Omachi TA, et al. Relationship of obesity with respiratory symptoms and decreased functional capacity in adults without established COPD. Prim Care Respir J. 2012;21(2):194-201. 14. Vanfleteren LE, Franssen FM, Wesseling G, Wouters EF. The prevalence of chronic obstructive pulmonary disease in Maastricht, the Netherlands. Respir Med. 2012;106(6):871-874. 15. Collins BF, Ramenofsky D, Au DH, Ma J, Uman JE, Feemster LC. The association of weight with the detection of airflow obstruction and inhaled treatment among patients with a clinical diagnosis of COPD. Chest. 2014;146(6):1513-1520. 16. Caruana L, Petrie MC, Davie AP, McMurray JJ. Do patients with suspected heart failure and preserved left ventricular systolic function suffer from “diastolic heart failure” or from misdiagnosis? A prospective descriptive study. BMJ. 2000;321(7255):215-218. 17. Salome CM, King GG, Berend N. Physiology of obesity and effects on lung function. J Appl Physiol (1985). 2010;108(1):206-211.
Improving the Management of Children With Bronchiolitis The Updated American Academy of Pediatrics Clinical Practice Guideline Siew C. Su, MBBS Anne B. Chang, MBBS, PhD Brisbane, QLD, Australia
Bronchiolitis is the most common cause of hospitalization of very young children.1 Although the mortality associated with bronchiolitis is low in affluent countries, the related cost and morbidity are high,2 especially in AFFILIATIONS:
From the Queensland Children’s Respiratory Centre (Dr Su and Prof Chang), Queensland Children’s Medical Research Institute, Royal Children’s Hospital Brisbane, Queensland University of Technology; and Child Health Division (Prof Chang), Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia. CORRESPONDENCE TO: Anne B. Chang, MBBS, PhD, Queensland Children’s Respiratory Centre, Royal Children’s Hospital Brisbane, Herston Rd, Herston, QLD, 4029, Australia; e-mail: [email protected] © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-2024
[
146#6 CHEST DECEMBER 2014
]
some minority groups, such as indigenous children.3 Despite the burden of illness, there is a relative paucity of evidence-based guidelines on the management of bronchiolitis in and out of hospitals. Prior to the updated bronchiolitis guideline from the American Academy of Pediatrics (AAP),1 the latest most comprehensive collation of evidence for the management of bronchiolitis was that from the Scottish Intercollegiate Guidelines Network (SIGN) guideline from the United Kingdom,2 where the latest search date was 2005. Thus, the updated AAP bronchiolitis guideline,1 which has incorporated relevant data from the past 10 years, should be a welcomed document by clinicians worldwide.
What Are the Changes? The updated guideline contains many new and clinically important changes1; of the 14 recommendations, only four (1, 7, 8, and 11) have minimal or no changes from the 2006 guideline.4 The rest of the recommendations are new or amended, reflecting the evidence obtained from newer studies. Statements referring to the use of ribavirin and complementary and alternative medicines, present in the previous guideline,4 have been omitted in the updated guideline.1 All but four recommendations (6, 9, 12b, and 14) have B-rated evidence (studies with minor limitations; consistent findings from multiple observational studies) or higher.1 The most important cost-saving change is arguably the recommendation (10a) against the use of palivizumab prophylaxis for all healthy children born prematurely (ⱖ 29 weeks gestation).1,5 Not surprisingly, this was followed by “big pharma” remonstration.6 Other important changes in the updated guideline1 include when to consider the use of hypertonic saline (recommendation 4), the definitive statement not to use short-acting b2-agonists (recommendation 2) or epinephrine (recommendation 3), and the alternate use of nasogastric fluids to IV fluids (recommendation 9). The technical report is currently in preparation1 and will contain further information not reflected in the recommendations, such as data on nasal suctioning and the use of high-flow nasal and home therapy oxygen. Like the 2006 AAP bronchiolitis guideline,4 important dissimilarities between the updated 2014 guideline1 and SIGN guideline2 are the following: when supplementary oxygen should be considered (AAP, oxygen saturation as measured by pulse oximetry [Spo2] , 90%1,4; SIGN, Spo2 ⱕ 92%2), the use of continuous Spo2 monitoring (AAP, not routinely recommended1,4; SIGN, recommended for 8-12 h after cessation of oxygen2), and virology testing
journal.publications.chestnet.org
(AAP recommends that laboratory testing should not be obtained1,4; SIGN recommends rapid virologic testing for cohorting children2).
Why Use Guidelines? Why should clinicians take note of or use clinical practice guidelines? The previous AAP bronchiolitis guideline4 has been credited with a significant reduction in the use of diagnostic and therapeutic resources7 in the United States, although variation in bronchiolitis management persists even after almost 8 years of implementation.8 High-quality and well-implemented guidelines can reduce variance in clinical care, reduce cost,7 and, most importantly, improve clinical outcomes.9 However, the quality of guidelines are highly variable,9 including those endorsed by academic societies,10 and perhaps unsurprisingly, guidelines are not universally popular. Furthermore, poorly developed guidelines, such as those overseen by panel members with close relationships with big pharma, propagate discontent about guidelines,10 create management dilemmas for physicians, and are possibly harmful to patients.9,10 Good clinical guidelines are transparent, derived from a rigorous process, and reviewed externally, and they disseminate “the most scientifically sound healthcare practice”9 undertaken by a multidisciplinary panel whose members are free of financial conflicts.9,11 The updated AAP guideline1 has a multidisciplinary panel (including a methodologist, a parent/consumer, a family physician, a neonatologist, general pediatricians, pediatric pulmonologists, pediatric hospitalists, emergency physicians, intensivists, and infectious disease physicians) that has no financial ties to pharmaceutical companies and that underwent an extensive peer review process (including review by the American Academy of Family Physicians, American College of Chest Physicians, American Thoracic Society, and American College of Emergency Physicians). The panel of the updated AAP guideline1 thus responds to the eight items of guideline panel review outlined by Lenzer and colleagues.9
The Future The updated AAP guideline1 lists ideas for future research, highlighting the incompleteness of the guideline related to insufficient existing data. Other important clinical questions include issues reflecting the differences in the AAP1,4 and SIGN guidelines2 described previously; the diagnosis and management of possible coexisting pneumonia in settings with a high incidence of pneumonia-related deaths; postdischarge monitoring,
1429
particularly for at-risk children; and postbronchiolitis syndrome and its management.12 Guidelines should never represent “cookbook medicine” and are not a substitute for individualized high-quality clinical care because patients, families, and settings are heterogenous, necessitating individualized nuances and deviations in selected circumstances. However, when implemented well, the contribution of untainted high-quality guidelines to improved clinical outcomes is undisputed.9,11 The field of guideline development and implementation has undergone substantial changes11 since defined in the 1990s as “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.”13 The high standard of the 2014 AAP guideline is important in our current era and advances the field of guidelines and the management of bronchiolitis as described previously. It is thus highly likely that the updated guideline1 along with its accompanying technical report and that on the guidance for the use of palivizumab5 will be welcomed by clinicians worldwide. The guideline’s value in improving clinical outcomes and the use of resources now depends on its implementation.
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Prof Chang has undertaken studies related to the management of bronchiolitis and is a panel member for several guidelines unrelated to bronchiolitis. Dr Su has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
1430 Editorials
References 1. Ralston S, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis and management of bronchiolitis. Pediatrics. In press. 2. Scottish Intercollegiate Guidelines Network. Bronchiolitis in children, 2006. SIGN website. http://www.sign.ac.uk/pdf/sign91. pdf. Accessed August 15, 2014. 3. Chang AB, Brown N, Toombs M, et al. Lung disease in indigenous children [published online ahead of print May 16, 2014]. Paediatr Respir Rev. doi:10.1016/j.prrv.2014.04.016. 4. American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118(4):1774-1793. 5. Committee on Infectious Diseases and Bronchiolitis Guidelines Committee. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics. 2014;134(2): 415-420. 6. Tanner L. Virus drugmaker fights pediatricians’ new advice. Associated Press website. http://bigstory.ap.org/article/virus-drugmaker-fightspediatricians-new-advice. Accessed August 26, 2014. 7. Parikh K, Hall M, Teach SJ. Bronchiolitis management before and after the AAP guidelines. Pediatrics. 2014;133(1):e1-e7. 8. Florin TA, Byczkowski T, Ruddy RM, Zorc JJ, Test M, Shah SS. Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics Bronchiolitis Guidelines [published online ahead of print July 8, 2014]. J Pediatr. doi:10.1016/j.jpeds.2014.05.057. 9. Lenzer J, Hoffman JR, Furberg CD, Ioannidis JP; Guideline Panel Review Working Group. Ensuring the integrity of clinical practice guidelines: a tool for protecting patients. BMJ. 2013;347:f5535. 10. Lenzer J. Why we can’t trust clinical guidelines. BMJ. 2013;346: f3830. 11. Woolf S, Schünemann HJ, Eccles MP, Grimshaw JM, Shekelle P. Developing clinical practice guidelines: types of evidence and outcomes; values and economics, synthesis, grading, and presentation and deriving recommendations. Implement Sci. 2012;7:61. 12. McCallum GB, Morris PS, Chang AB. Antibiotics for persistent cough or wheeze following acute bronchiolitis in children. Cochrane Database Syst Rev. 2012;12:CD009834. 13. Field MJ, Lohr KN, eds. Clinical Practice Guidelines: Directions for a New Program. Institute of Medicine. Washington, DC: National Academy Press; 1990.
[
146#6 CHEST DECEMBER 2014
]
References 1. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766-781. 2. Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859): 2224-2260. 3. Beuther DA, Sutherland ER. Overweight, obesity, and incident asthma: a meta-analysis of prospective epidemiologic studies. Am J Respir Crit Care Med. 2007;175(7):661-666. 4. Peters-Golden M, Swern A, Bird SS, Hustad CM, Grant E, Edelman JM. Influence of body mass index on the response to asthma controller agents. Eur Respir J. 2006;27(3):495-503. 5. Crummy F, Piper AJ, Naughton MT. Obesity and the lung: 2. Obesity and sleep-disordered breathing. Thorax. 2008;63(8): 738-746. 6. O’Donnell DE, Deesomchok A, Lam YM, et al. Effects of BMI on static lung volumes in patients with airway obstruction. Chest. 2011;140(2):461-468. 7. Ora J, Laveneziana P, Ofir D, Deesomchok A, Webb KA, O’Donnell DE. Combined effects of obesity and chronic obstructive pulmonary disease on dyspnea and exercise tolerance. Am J Respir Crit Care Med. 2009;180(10):964-971.
1428 Editorials
8. Bautista J, Ehsan M, Normandin E, Zuwallack R, Lahiri B. Physiologic responses during the six minute walk test in obese and non-obese COPD patients. Respir Med. 2011;105(8):1189-1194. 9. Landbo C, Prescott E, Lange P, Vestbo J, Almdal TP. Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999;160(6):1856-1861. 10. Cecere LM, Littman AJ, Slatore CG, et al. Obesity and COPD: associated symptoms, health-related quality of life, and medication use. COPD. 2011;8(4):275-284. 11. Sin DD, Jones RL, Man SF. Obesity is a risk factor for dyspnea but not for airflow obstruction. Arch Intern Med. 2002;162(13): 1477-1481. 12. Ofir D, Laveneziana P, Webb KA, O’Donnell DE. Ventilatory and perceptual responses to cycle exercise in obese women. J Appl Physiol (1985). 2007;102(6):2217-2226. 13. Zutler M, Singer JP, Omachi TA, et al. Relationship of obesity with respiratory symptoms and decreased functional capacity in adults without established COPD. Prim Care Respir J. 2012;21(2):194-201. 14. Vanfleteren LE, Franssen FM, Wesseling G, Wouters EF. The prevalence of chronic obstructive pulmonary disease in Maastricht, the Netherlands. Respir Med. 2012;106(6):871-874. 15. Collins BF, Ramenofsky D, Au DH, Ma J, Uman JE, Feemster LC. The association of weight with the detection of airflow obstruction and inhaled treatment among patients with a clinical diagnosis of COPD. Chest. 2014;146(6):1513-1520. 16. Caruana L, Petrie MC, Davie AP, McMurray JJ. Do patients with suspected heart failure and preserved left ventricular systolic function suffer from “diastolic heart failure” or from misdiagnosis? A prospective descriptive study. BMJ. 2000;321(7255):215-218. 17. Salome CM, King GG, Berend N. Physiology of obesity and effects on lung function. J Appl Physiol (1985). 2010;108(1):206-211.
Improving the Management of Children With Bronchiolitis The Updated American Academy of Pediatrics Clinical Practice Guideline Siew C. Su, MBBS Anne B. Chang, MBBS, PhD Brisbane, QLD, Australia
Bronchiolitis is the most common cause of hospitalization of very young children.1 Although the mortality associated with bronchiolitis is low in affluent countries, the related cost and morbidity are high,2 especially in AFFILIATIONS:
From the Queensland Children’s Respiratory Centre (Dr Su and Prof Chang), Queensland Children’s Medical Research Institute, Royal Children’s Hospital Brisbane, Queensland University of Technology; and Child Health Division (Prof Chang), Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia. CORRESPONDENCE TO: Anne B. Chang, MBBS, PhD, Queensland Children’s Respiratory Centre, Royal Children’s Hospital Brisbane, Herston Rd, Herston, QLD, 4029, Australia; e-mail: [email protected] © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-2024
[
146#6 CHEST DECEMBER 2014
]
some minority groups, such as indigenous children.3 Despite the burden of illness, there is a relative paucity of evidence-based guidelines on the management of bronchiolitis in and out of hospitals. Prior to the updated bronchiolitis guideline from the American Academy of Pediatrics (AAP),1 the latest most comprehensive collation of evidence for the management of bronchiolitis was that from the Scottish Intercollegiate Guidelines Network (SIGN) guideline from the United Kingdom,2 where the latest search date was 2005. Thus, the updated AAP bronchiolitis guideline,1 which has incorporated relevant data from the past 10 years, should be a welcomed document by clinicians worldwide.
What Are the Changes? The updated guideline contains many new and clinically important changes1; of the 14 recommendations, only four (1, 7, 8, and 11) have minimal or no changes from the 2006 guideline.4 The rest of the recommendations are new or amended, reflecting the evidence obtained from newer studies. Statements referring to the use of ribavirin and complementary and alternative medicines, present in the previous guideline,4 have been omitted in the updated guideline.1 All but four recommendations (6, 9, 12b, and 14) have B-rated evidence (studies with minor limitations; consistent findings from multiple observational studies) or higher.1 The most important cost-saving change is arguably the recommendation (10a) against the use of palivizumab prophylaxis for all healthy children born prematurely (ⱖ 29 weeks gestation).1,5 Not surprisingly, this was followed by “big pharma” remonstration.6 Other important changes in the updated guideline1 include when to consider the use of hypertonic saline (recommendation 4), the definitive statement not to use short-acting b2-agonists (recommendation 2) or epinephrine (recommendation 3), and the alternate use of nasogastric fluids to IV fluids (recommendation 9). The technical report is currently in preparation1 and will contain further information not reflected in the recommendations, such as data on nasal suctioning and the use of high-flow nasal and home therapy oxygen. Like the 2006 AAP bronchiolitis guideline,4 important dissimilarities between the updated 2014 guideline1 and SIGN guideline2 are the following: when supplementary oxygen should be considered (AAP, oxygen saturation as measured by pulse oximetry [Spo2] , 90%1,4; SIGN, Spo2 ⱕ 92%2), the use of continuous Spo2 monitoring (AAP, not routinely recommended1,4; SIGN, recommended for 8-12 h after cessation of oxygen2), and virology testing
journal.publications.chestnet.org
(AAP recommends that laboratory testing should not be obtained1,4; SIGN recommends rapid virologic testing for cohorting children2).
Why Use Guidelines? Why should clinicians take note of or use clinical practice guidelines? The previous AAP bronchiolitis guideline4 has been credited with a significant reduction in the use of diagnostic and therapeutic resources7 in the United States, although variation in bronchiolitis management persists even after almost 8 years of implementation.8 High-quality and well-implemented guidelines can reduce variance in clinical care, reduce cost,7 and, most importantly, improve clinical outcomes.9 However, the quality of guidelines are highly variable,9 including those endorsed by academic societies,10 and perhaps unsurprisingly, guidelines are not universally popular. Furthermore, poorly developed guidelines, such as those overseen by panel members with close relationships with big pharma, propagate discontent about guidelines,10 create management dilemmas for physicians, and are possibly harmful to patients.9,10 Good clinical guidelines are transparent, derived from a rigorous process, and reviewed externally, and they disseminate “the most scientifically sound healthcare practice”9 undertaken by a multidisciplinary panel whose members are free of financial conflicts.9,11 The updated AAP guideline1 has a multidisciplinary panel (including a methodologist, a parent/consumer, a family physician, a neonatologist, general pediatricians, pediatric pulmonologists, pediatric hospitalists, emergency physicians, intensivists, and infectious disease physicians) that has no financial ties to pharmaceutical companies and that underwent an extensive peer review process (including review by the American Academy of Family Physicians, American College of Chest Physicians, American Thoracic Society, and American College of Emergency Physicians). The panel of the updated AAP guideline1 thus responds to the eight items of guideline panel review outlined by Lenzer and colleagues.9
The Future The updated AAP guideline1 lists ideas for future research, highlighting the incompleteness of the guideline related to insufficient existing data. Other important clinical questions include issues reflecting the differences in the AAP1,4 and SIGN guidelines2 described previously; the diagnosis and management of possible coexisting pneumonia in settings with a high incidence of pneumonia-related deaths; postdischarge monitoring,
1429
particularly for at-risk children; and postbronchiolitis syndrome and its management.12 Guidelines should never represent “cookbook medicine” and are not a substitute for individualized high-quality clinical care because patients, families, and settings are heterogenous, necessitating individualized nuances and deviations in selected circumstances. However, when implemented well, the contribution of untainted high-quality guidelines to improved clinical outcomes is undisputed.9,11 The field of guideline development and implementation has undergone substantial changes11 since defined in the 1990s as “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.”13 The high standard of the 2014 AAP guideline is important in our current era and advances the field of guidelines and the management of bronchiolitis as described previously. It is thus highly likely that the updated guideline1 along with its accompanying technical report and that on the guidance for the use of palivizumab5 will be welcomed by clinicians worldwide. The guideline’s value in improving clinical outcomes and the use of resources now depends on its implementation.
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Prof Chang has undertaken studies related to the management of bronchiolitis and is a panel member for several guidelines unrelated to bronchiolitis. Dr Su has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
1430 Editorials
References 1. Ralston S, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis and management of bronchiolitis. Pediatrics. In press. 2. Scottish Intercollegiate Guidelines Network. Bronchiolitis in children, 2006. SIGN website. http://www.sign.ac.uk/pdf/sign91. pdf. Accessed August 15, 2014. 3. Chang AB, Brown N, Toombs M, et al. Lung disease in indigenous children [published online ahead of print May 16, 2014]. Paediatr Respir Rev. doi:10.1016/j.prrv.2014.04.016. 4. American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118(4):1774-1793. 5. Committee on Infectious Diseases and Bronchiolitis Guidelines Committee. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics. 2014;134(2): 415-420. 6. Tanner L. Virus drugmaker fights pediatricians’ new advice. Associated Press website. http://bigstory.ap.org/article/virus-drugmaker-fightspediatricians-new-advice. Accessed August 26, 2014. 7. Parikh K, Hall M, Teach SJ. Bronchiolitis management before and after the AAP guidelines. Pediatrics. 2014;133(1):e1-e7. 8. Florin TA, Byczkowski T, Ruddy RM, Zorc JJ, Test M, Shah SS. Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics Bronchiolitis Guidelines [published online ahead of print July 8, 2014]. J Pediatr. doi:10.1016/j.jpeds.2014.05.057. 9. Lenzer J, Hoffman JR, Furberg CD, Ioannidis JP; Guideline Panel Review Working Group. Ensuring the integrity of clinical practice guidelines: a tool for protecting patients. BMJ. 2013;347:f5535. 10. Lenzer J. Why we can’t trust clinical guidelines. BMJ. 2013;346: f3830. 11. Woolf S, Schünemann HJ, Eccles MP, Grimshaw JM, Shekelle P. Developing clinical practice guidelines: types of evidence and outcomes; values and economics, synthesis, grading, and presentation and deriving recommendations. Implement Sci. 2012;7:61. 12. McCallum GB, Morris PS, Chang AB. Antibiotics for persistent cough or wheeze following acute bronchiolitis in children. Cochrane Database Syst Rev. 2012;12:CD009834. 13. Field MJ, Lohr KN, eds. Clinical Practice Guidelines: Directions for a New Program. Institute of Medicine. Washington, DC: National Academy Press; 1990.
[
146#6 CHEST DECEMBER 2014
]
