bronchiolitis guidelines for kids

The American Academy of Pediatrics updated their 2006 guidelines on diagnosis and treatment of bronchiolitis (see bronchiolitis practice guideline Peds 2014 or go to http://pediatrics.aappublications.org/content/early/2014/10/21/peds.2014-2742.full.pdf+html). in brief:

--for diagnosis: it's all in the history and physical for both diagnosis and assessing disease severity -- assess risk factors for severity (<12 weeks old, history of prematurity, underlying cardiopulmonary disease or immunodeficiency). not routinely need xray or labs if clear diagnosis
--for treatment: NOT USE albuterol (new recommendation), epinephrine, nebulized hypertonic saline except if hospitalized (data suggest only useful in kids on this for 3 days for severe cases, and at least 24 hours in mild to moderate disease), steroids, supplemental oxygen if O2 sat>90%, chest PT, antibiotics (unless concomitant bacterial infection or strong suspicion). use nasogastric or IV fluids if infant cannot maintain hydration orally. use pulse oximetry if clinically indicated. 
--give palivizumab in first year of life if hemodynamically significant heart disease or chronic lung disease of prematurity (eg <32 weeks gestation, require oxygen>21% for at least the first 28 days of life). give 5 monthly doses during RSV season.
--all people should disinfect hands before and after direct patient contact, use alcohol-based rubs for hand decontamination when taking care of kids with bronchiolitis, check on smoking exposure and counsel to avoid exposing the infant/child, encourage exclusive breast-feeding for first six months to decrease morbidity of respiratory infections.

so, the biggest change is to not use b-agonists/albuterol. their recommendation is (it seems to me) a bit stronger than the data they reviewed -- several meta-analyses found some improvement in symptom score (though this is noted by them to be observer dependent and may not be reliable). a few studies have looked at pulmonary function tests as an objective measure, and a couple of studies did not find any objective difference in infants in tidal breathing responses to albuterol​ -- however, on looking further i found a recent Cochrane review on the subject of bronchodilators in infants with bronchiolitis (see bronchiolitis and bronchodilators cochrane review 2014, or DOI: 10.1002/14651858.CD001266.pub4.​10.1002/14651858.CD001266.pub4). i tried to look at the 3 specific PFT studies they cited from which they concluded there was no utility of albuterol , could only find 2, which had only 20 and 22 infants, one of which did find a statistically significant, but small and questionably clinically important improvement with albuterol, and one did not -- the other study i could not find in PubMed or even the journal itself in the Harvard on-line library). in general, studies of albuterol have not found that they affect disease resolution, need for hospitalization,  or length-of-stay in hospitals. and the guideline writers are concerned about cost and adverse effects (tachycardia, tremors). so, it seems that albuterol is unlikely to help most infants. but this does raise some questions. for example, we know that the correlation between PFTs and function in COPD and asthma is not great, so should we really consider this the objective gold standard in bronchiolitis (esp when several meta-analyses have found some clinical improvement)? what about in kids with mild-to-moderate bronchiolitis? effectively sending a very small infant away from the clinic and giving the parents nothing to treat them with may have some significant consequences: eg, increased parental anxiety and increased likelihood of going to the emergency room. and, again, per the clinical guidelines: "several meta-analyses and systematic reviews [they cite 6] have shown that bronchodilators may improve clinical symptom scores".​ Since the diagnosis of bronchiolitis is a clinical one, it is also likely that some of the kids have bronchospasm/reactive airway disease from a viral infection which in fact may respond to b-agonists. All-in-all, in kids with mild to moderate bronchiolitis/wheezing, it seems that one could make a cogent argument to try albuterol and stop it if it is not working. so, I'm not so sure about this recommendation.....