Sunday, November 9, 2014

The AAP's Don'ts and Don'ts of Bronchiolitis, Explained

A lot of clinicians are confused about the new American Academy of Pediatrics guidelines on treating bronchiolitis, released just in time for the wheezin’ season (see “wheezing” doesn’t really rhyme with “season,” but if you adopt a faux rural accent you can kind of make it work). To help, I’ve translated the technical language of the guidelines into plain English, using words like “wheezin’”. You’re welcome.


1a) Clinicians should definitely diagnose bronchiolitis. That way it looks like we know what we’re doing. This diagnosis should be made by taking a history, examining the child, then standing back and saying, “Looks like bronchiolitis.” Then go on to explain that this is not the same as the “bronchitis” that grandpa just got treated for with Zithromax at urgent care.

1b) Clinicians should get a worried look on their faces if the disease looks bad and say something like, “This looks pretty bad.”

1c) Whatever they do, clinicians should resist the urge to order chest x-rays or labs. You already know it’s bronchiolitis. What, are you going to act all surprised when the result comes back “Suspect bronchiolitis?”. Remember, no matter what you see in comic books, no amount of radiation will give the child superpowers.


2) Once you have diagnosed bronchiolitis, run and get your office’s nebulizer. Take it to the parking lot and dash it to the concrete until it’s irreparably broken. What were you thinking, considering giving that kid albuterol? Now you won’t be tempted.

3) Go back in the office, open your code cart, and find the epinephrine. Look at it sternly and say, “I’m saving you for croup and anaphylaxis.” Close the code cart, and give the key to someone you trust to hide it from you until the patient leaves.

4a) Break into the ED late at night and steal all their hypertonic saline nebs to use for brining turkeys (I recommend a minimum of 3 liters for a 16 lb bird). It does not help bronchiolitis, but if they have it, they’ll use it.

4b) If the child is admitted to the floor, and the hospitalist uses nebulized hypertonic saline, do not be insulting about it. The data are still unclear, and besides, you already have your turkey brine for this Thanksgiving.

5) Do not give steroids to children with bronchiolitis. They will grow unusually large muscles and be elected governor of California, where their unfortunate personal decisions will cloud their legacies.

6a) Don’t bother giving oxygen unless the patient’s oxygen saturation is under 90%. To do otherwise will make you look like a big wimp who’s frightened of a little old O2 monitor.

6b) Don’t use continuous pulse oximetry in the first place. You have eyes and a stethoscope, right? When children are really hypoxic, many of them will take on a bluish tint, like in the movie Avatar.

7) Do not use chest physiotherapy for infants with bronchiolitis. Do you really think that beating a kid like a drum with a cupped hand does something other than provide full employment for respiratory therapists? That said, sometimes the rhythm is pleasing and helps soothe you to sleep.

8) Step away from the antibiotics. Bronchiolitis is a virus, you know that, right? It causes a fever and rales, right? So dude, unless pus is streaming from the ear, why do you want to also invite diarrhea into this picture? 

9) If bronchiolitis is interfering with a child’s hydration, put in an IV or an NG tube and help the kid out. Congratulations, finally you have an intervention! Pat yourself on the back, you did good.


10a) Pavilizumab is a total racket, okay? We don’t care how many lunches the reps brought your staff, if the infant in question was born after 29 weeks gestation and didn’t have chronic lung disease or heart disease, leave it. Expect your local detail person to cry a little, but remember, he’s not thinking about the wellbeing of your patients. He’s remembering a puppy he lost when he was 7.

10b) For infants born before 32 weeks and who have lung and heart disease, go ahead and give the pavilizumab. That detail person has a family to feed.

10c) Give it 5 times in the first year of life. You can’t stand to see your drug rep cry, and he also has a boat payment to make.

11a) If you’ve touched a patient with bronchiolitis, wash your friggin’ hands! You were wearing gloves? So what? Is a little soap gonna kill you? Make sure you wash adequately by singing all of Wagner’s Ring Cycle.

11b) Alcohol hand sanitizer works, too, especially for those who can’t sing in German.

12a) Ask about tobacco smoke exposure when you see a kid with bronchiolitis. If you get a positive answer, gently shake your head from side to side and sigh heavily.

12b) Explain why you are so very disappointed about 12a.

13) Encourage moms to breastfeed exclusively for the first 6 months of an infant’s life by saying, “You wouldn’t want your baby to get bronchiolitis, now would you?” Nothing builds a therapeutic relationship like fear and guilt.

14) When diagnosing bronchiolitis, give parents and caregivers a handout to read. People love handouts, and they meet Meaningful Use guidelines. Make sure you get a new handout that explains why you’re doing nothing about the bronchiolitis. Then, get to the next room quickly. Remember, it’s the wheezin' season!


  1. I laughed so hard I needed a neb!

  2. As per usual, this was awesome. And have to say, also enjoyed the "Dr Hill-arious" comment….will have to remember that one for your next blog!

  3. Dr Hill, Can I get permission to use this in an upcoming grand rounds lecture (citation will be provided of course)? I think this will bring about a good-natured dialogue about how we can put the guidelines to work in our department. Thank you for your consideration and great humor!
    Jeff Bennett MD
    Associate Professor of Pediatrics
    University of Kentucky

  4. Dr. Bennett,
    I would be honored to be included in your grand rounds! Please consider this response my permission to reproduce the blog in part in or in whole!

  5. Well said. I would also add, "stop checking for RSV. Everybody knows what it looks like. That way, when we review the epidemiology, we can say that there are less cases than ever."
    The best way to eradicate a disease is to stop checking for it.

    1. 10. If you don't take a temperature, you can't find a fever. (I had the great honor of meeting Stephen Bergman early in my career.)

  6. Dr. Hill,

    With John Stephens, I will be giving a pediatric grand rounds at UNC in a few weeks entitled "Update in Pediatric Hospital Medicine." With your permission, I was hoping to incorporate this article into the slides.

    -Eric Edwards

  7. Eric,
    First, please tell both John and Ann hi for me! They are awesome! Second, I'd be honored for you to use this blog in your grand rounds. Good luck!

  8. Hi everyone here is some more information about bronchiolitis, hope this info helps someone. :)

  9. Thanks for sharing this with such in depth details about bronchitis. This is indeed a very informative post and really helpful for those suffering for bronchitis.