Surveillance decision

Surveillance decision

We will update the guideline on bronchiolitis in children: diagnosis and management (NICE guideline NG9). The update will focus on safe and effective levels of oxygen saturation when discharging patients.

Reasons for the decision

Topic expert feedback, stakeholder feedback and several studies highlighted areas where there had been amendments to other national guidelines, alterations in clinical practice or new evidence that has an impact on recommendation 1.5.1.

Three topic experts and 1 stakeholder suggested that minimum oxygen saturation levels could be safely lowered from 92% to 90% in children with bronchiolitis. New evidence was found from 1 study that suggested oxygen saturation levels of 90% prior to discharge had no adverse effects. The American Paediatric Guidelines (2019) on bronchiolitis in children have amended their recommendation to state that oxygen levels can be lowered to 90% during treatment. The original surveillance proposal noted that, in the interests of patient safety, more evidence was needed in order to consider lowering the discharge threshold in the guideline. The population covered by the new evidence was only from 6 weeks to 12 months old, whereas the guideline covers patients from birth to 18 years old. However, having considered the consultation comments from stakeholders, reviewed the full text of the evidence, and reviewed the low-level evidence that the original recommendation was based on, it has been decided that there is a need to update the guideline in this area. The new evidence also included an economic evaluation, which suggested cost saving implications for the NHS and the wider healthcare setting.

No new evidence was identified through this surveillance review to suggest that a child could not be referred for emergency care and remain safe if their oxygen levels were lower than 92%, or that a child does not need oxygen supplementation if their levels are above 90%. Therefore, no impact on these recommendations within the guideline is expected.

Other areas that were raised by topic expert feedback but that will not be updated in the guideline included:

  • the measurement of oxygen saturation using pulse oximetry

    • The American Paediatric Guidelines (2019) on bronchiolitis in children suggests that pulse oximetry is prone to errors of measurement. One topic expert also suggested that pulse oximetry should be reconsidered for use in primary care due to issues around affordability and lack of availability. No new evidence was found through surveillance that suggests that pulse oximetry is ineffective at measuring oxygen levels and should not be recommended for use in primary care. Therefore, no impact on the guideline is expected.

  • the use of different methods of oxygen supplementation in the management of bronchiolitis

    • Two topic experts and 1 stakeholder suggested that high-flow oxygen therapy (HFOT) and nasal continuous positive airway pressure (CPAP) are being used more frequently in the UK. Evidence identified showed few significant differences between these methods of oxygen supplementation compared to standard care. Therefore, no impact on the guideline is expected.

  • risk factors for severe bronchiolitis including the possibility of failure to thrive

    • Two topic experts suggested that low birth weight and failure to thrive can be risk factors for more severe bronchiolitis. One topic expert contacted NICE in March 2019 to state that the wording in recommendations 1.2.3 and 1.3.3 may have been misinterpreted as being an exhaustive list of risk factors by clinicians potentially resulting in unsafe and unacceptable practice. Three studies suggested low birth weight as a risk factor, however it was unclear as to whether this was a specific risk factor for more severe bronchiolitis. Failure to thrive was not noted as a risk factor in the studies identified through surveillance. Due to the feedback received however, it is proposed that the wording of the current recommendations be amended to ensure it is not considered exhaustive. It is suggested that recommendations 1.2.3 and 1.3.3 should be amended to state clinicians 'take account of any known risk factors for more severe bronchiolitis, such as: chronic lung disease; hemodynamically significant congenital heart disease; age in young infants; premature birth; neuromuscular disorders; immunodeficiency'. This should help to confirm that the list of risk factors is not exclusive and may improve the safety of patients and their care.

  • the use of hypertonic saline for the management of bronchiolitis

    • Seven studies were identified that stated that hypertonic saline was safe and effective to use and showed positive results for improving clinical severity scores, reducing length of stay in hospital and reducing the risk of hospitalisation. The American Paediatric Guidelines (2019) recommends that hypertonic saline is safe and effective to use. However, 2 studies were found which suggested that hypertonic saline worsened episodes of cough and 6 studies indicated hypertonic saline did not make a difference to primary outcomes when the heterogeneity of the evidence was fully considered. It is proposed that there is not enough consistent high-quality evidence to suggest that nebulised hypertonic saline should be used in the management of bronchiolitis in infants and therefore no impact on the recommendation is expected.

  • diagnosing bronchiolitis

    • One topic expert and 1 stakeholder suggested there are 3 types of bronchiolitis that can be diagnosed at presentation and more effort should be made to appropriately diagnose the causing virus in order to treat this appropriately. No evidence was found regarding the diagnosis of bronchiolitis and therefore no impact on the guideline is expected.

  • considering sepsis at diagnosis

    • The Surveillance Team felt that clinicians should consider the possibility of sepsis when carrying out their assessments. It is proposed that NG9 cross-refers to sepsis: recognition, diagnosis and early management (NICE guideline NG51) to ensure that clinicians consider the possibility of sepsis as well as pneumonia when carrying out their assessments.

  • admittance avoidance and early support discharge

    • A placeholder statement in the bronchiolitis in children (NICE quality standard 122) was identified. No evidence was found regarding admittance avoidance or early support discharge and therefore no impact on the guideline is expected.

Overall, although an impact was found in 1 area, the majority of evidence identified through the surveillance was insufficient to impact on the recommendations within this guideline and needs to be substantiated by further longer-term studies.

For further details and a summary of all evidence identified in surveillance, see appendix A.

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