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Melanie Cole, MS (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. And joining me today is Dr. Michele Lossius. She's the Chief of Pediatric Hospital Medicine and a Professor in the Department of Pediatrics at the University of Florida College of Medicine. And she's here today to highlight bronchiolitis for us. Dr. Lossius, it's a pleasure to have you with us. So, I'd like you to review bronchiolitis. Tell us a little bit about it, how it differs from other respiratory conditions in infants and young children.

Dr Michele Lossius: Thank you for this opportunity to share about a very common illness in pediatrics. So at its core, bronchiolitis is defined as an acute disorder of the lower respiratory tract, and it's characterized by inflammation and obstruction of the bronchioles. It is the most common lower respiratory tract infection for children two years and younger. And in fact, if you were to remove routine births and exclude those, it would actually be about 20%. So, this is a very common disease process for us. And it's different in that it often causes difficulty breathing and sometimes difficulty eating, because of all the congestion for the infant. As you get older, you're able to manage that a little bit better. So, we really see this affecting the ends of the age spectrum, so the very young and the very old.

Melanie Cole, MS: Well, thank you for that overview. So are there risk factors associated with it? How has the epidemiology of this disease evolved in recent years? Because it wasn't something we knew a lot about a few decades ago.

Dr Michele Lossius: So for us in pediatrics, it's been around, but I think it's one of those things that we've continued to try to find ways to ameliorate it. And it's very hard for us to stand bedside and tell a family that we're doing supportive care. Sometimes they perceive that as not doing anything, and it's really hard to watch our child breathe really fast or struggle to breathe and feel like there's no specific intervention, medication, those kind of things that we can do. And so, we are starting to have a new vaccine on the horizon. But in past years, it really had a seasonal aspect to it. And that differs from parts of the country. And even sometimes in the state of Florida, it tends to peak in the winter, but in Florida, because we're subtropical, you really do see it all year long, though you still have a peak in the winter.

And again, that ranges from September to March in some places, to October to February in other places. And then when we had the pandemic, and all the children were kept home for some period of time. We didn't see it during the winter time. And then, all of a sudden we had a peak in about April of the following year. So again, it does have a seasonality to it. We are getting back to the traditional seasonality, now that we're kind of through the acute part of the pandemic. And so, that's some of the epidemiology that we see with it.

Melanie Cole, MS: So, you are seeing an uptick in this type of respiratory virus and how is it similar or different from RSV?

Dr Michele Lossius: So, bronchiolitis is the disease process, and it's the diagnosis. RSV is one of the viruses that can cause bronchiolitis to occur. And so, RSV is the most common virus associated with bronchiolitis, but really we can see it with any virus. So, other common etiologies would be adenovirus, even influenza, parainfluenza. So, we see it again with any virus. It's just that RSV is the most common association.

Melanie Cole, MS: So, can you summarize for us, Dr. Lossius, the key recommendations and findings of the 2014 clinical guidelines on it? And have there been any updates or changes to these since 2014? How have they impacted clinical practice if there have been?

Dr Michele Lossius: So in 2014, we had updated the guidelines, and much stayed the same. And as I mentioned before, this really is a supportive process. And so, there aren't known interventions like medications that change the course of the disease process. And so, there is no antibiotic that's recommended. And oftentimes, people will hear wheezing with bronchiolitis. And so in the past, steroids were tried, bronchodilators like albuterol were tried, because we're very familiar with those interventions related to asthma, and we hear wheezing in asthma. But the reason you wheeze in bronchiolitis isn't the same reason that you wheeze in asthma. And so, those interventions that we do for asthma don't work for bronchiolitis. So, there's been many studies over time that show that steroids are not effective, they don't change anything. Albuterol is not effective. And that's hard because, again, you want to do something. You want to feel like you're offering something that looks like an intervention. But again, those haven't been shown to be effective. And with all interventions, there's possible side effects. So, we really don't want to do anything or offer anything that doesn't have evidence-based medicine behind it. So, no albuterol, no steroids.

You really don't need to know what virus is causing it. It doesn't change anything, so we don't necessarily need to test. You really don't need a chest x-ray unless something completely changes. And part of that's because bronchiolitis causes what we call atelectasis. So when you take a chest x-ray of an infant and there's atelectasis, it can look like pneumonia. And then, you offer antibiotics and then you have the potential side effects of those. And so, chest x-rays are not routinely recommended because they kind of just send you down a process that may not be warranted.

And then, over the years, people have tried different things. We've tried something called hypertonic saline. We've offered high-flow nasal cannula intervention. And as more time has gone on we've started to see caveats to whether that really works and in what groups it could or could not work. And so with high-flow nasal cannula, this is a supportive measure that you can add oxygen to where you can just essentially be supporting with increased pressure air, if you will. And while that can be helpful, it also has been overutilized at times.

Melanie Cole, MS: Well, thank you for telling us about some of the challenges related to implementing these guidelines, because I imagine, as you said, supportive care being what's offered and the families getting frustrated and thinking it's not really enough, tests and interventions and such. I'd like you to speak about de-implementation strategies and projects that are related to bronchiolitis management and how you're managing this and how you're mitigating some of these.

Dr Michele Lossius: Thanks for that question, Melanie. Over the last few years, I think what's really been important is to be collaborative with your partners along the spectrum of care. And what I mean by that is outpatient pediatricians or family docs, the ER docs, the ICU docs, because if we all do something a little bit different, it not only causes confusion for the family, but it may look like we ourselves don't know what we're really doing.

And so, we want to make sure that along that spectrum of our continuum of care, we're all saying the same thing and doing the same thing for the most part. So many years ago, there was an opportunity to do a QI project around evidence-based medicine and bronchiolitis. And at that time, those de-implementation strategies were not offering albuterol, not offering steroids, and not doing those things that we knew had evidence-based medicine behind it.

Over the years, there have been opportunities to engage in national QI projects as well, which we have availed ourselves of. And that has allowed us to educate ourselves, the ancillary staff, to partner with nursing and respiratory, partner with our colleagues in the ER and the PICU. And so, the first round of that was quite a few years ago, where we worked to not offer interventions that we, again, we knew were not evidence-based.

So, the first round of these QI projects, we partnered with the respiratory therapists. And I remember I was told by a mentor, you want to collaborate with someone who's as frustrated as you are around the issue. And it turned out for us that was respiratory therapy, because they had been standing at bedside doing therapies and interventions that they recognized were not changing the patient's clinical status. And so, we partnered with the respiratory therapist and created a protocol that was really driven by them at bedside, although nursing and physicians also could participate in that evaluation of the patients. There was inter rater reliability, if you will.

And then, we also worked to create family education so that families understood the disease process, why we were doing or not doing certain things, and what they could expect. And that was really successful. But when we did that project, we just did it within the group that we had ability to affect. And at that time, it was the hospitalist group. And then, we had such great data. And we had decreased length of say without increasing readmissions. The patients didn't get worse. More of them didn't go to the ICU apart from your typical expected disease progression in a few of them. And so, we went back to our ER colleagues and shared the data and asked, "Are you willing to consider this QI collaborative? Can we start this down in the ED?" And at that point, they said, "Yes", they said, "We see what you're saying. We're looking at the data." And so, we implemented this across that continuum of ER to the floor. And that was another round of QI interventions.

And then over the years, other interventions that people wanted to evaluate such as high-flow nasal cannula. This is an Intervention that is supportive for the patient's respiratory efforts. And it really became in vogue. But as often happens with these kind of things, there's also a downside and sometimes there's overutilization, which there was in this case. And so again, a national opportunity came to us from a quality improvement project with the American Academy of Pediatrics. And that time, there were two arms. And so, we chose to partner with the ICU on this particular intervention since we had partnered with the ER before. And so, that It was around decreasing the time on which patients were on high-flow nasal cannula. And we were successful in doing that. We trialed patients off sooner than we had in the past, once they were transitioning from the ICU to the floor. And we were able to decrease the time of that intervention, which allowed patients to go home sooner and just be more aware of the overutilization of this modality. And again, to do that, we create a protocol, put it in the hands of a respiratory therapist with the physicians and the nurses also participating. We didn't see, again, any negative effects. We didn't see rapid deterioration in patient conditions and patients going back to the PICU. It was really a quite successful de-implementation project.

Melanie Cole, MS: This is so interesting, Dr. Lossius. And as we wrap up in your experience, speak to other providers, the key factors that are contributing to the success of initiatives in bronchiolitis management when you feel it's important that they refer and what you'd like the key takeaways to be from this podcast today.

Dr Michele Lossius: I think the first thing I would say is we all recognize the challenge of de-implementation and we recognize the challenge of meeting the expectations of families and supporting them through this challenging time and concerning time for them and their child.

And so, I think I would say what we've proven over time, again and again is that with evidence-based medicine and through QI projects. The recommendations and the guidelines are indeed there for a reason. And we don't need to do all the things that maybe make us feel better, but don't necessarily impact clinical care. So, we don't need to do chest x-rays routinely. We don't need to do steroids or albuterol. And maybe we can do the high-flow nasal cannula a little less than we have over the years. Certainly, a role for the high-flow nasal cannula. But I certainly think that in doing high value healthcare, we can be a little bit more judicious about how often we do it, or at least, how long we use it for patients.

So, I think I would say is if you have an opportunity to partner with your team, other physicians, respiratory therapy, nursing staff, across that continuum of care for patients, it really is an incredible opportunity and ultimately it impacts patient care in a really positive way.

Melanie Cole, MS: Thank you so much, Dr. Lossius, for joining us today. And to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters. That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today.