American Academy of Pediatrics 2014 Bronchiolitis Guidelines: Bonfire of the Evidence

The American Academy of Pediatrics (AAP) 2014 Bronchiolitis guidelines (the guidelines) were recently published in the official journal of the AAP, Pediatrics. 1 The committee that wrote the guidelines anticipates that these will form the basis of bronchiolitis treatment throughout the house of medicine, not just in pediatricians' offices.Emergency physicians may well encounter pressure to follow these guidelines from their pediatric colleagues who, not unreasonably, rely on guidelines from their professional organization.However, two key recommendations in these guidelines could substantially change pediatric emergency medicine practice.These recommendations are (1) to not use even a trial of bronchodilators and (2) to regard oxygen saturations of 90% rather than 92%-94% as the degree of hypoxia at which oxygen should be administered. 1Neither of these recommendations is sufficiently justified by the evidence and both are potentially harmful.We deal first with the new guideline to not use bronchodilators.The committee bases its recommendation to not attempt even a trial of bronchodilators on the following:(1) The committee's interpretation of a meta-analysis that reported a decrease in hospital admissions when epinephrine rather than placebo was given in the emergency department (ED). 1 (2) A meta-analysis contained in a Cochrane review, which did not show decreased hospital admissions from the ED when albuterol rather than placebo was given. 2 (3) Albuterol non-responders cannot be distinguished from responders, and clinicians' ability to observe a clinically relevant response to bronchodilators is limited. 1 (4) Albuterol's risks and expense outweigh its benefits. 1We deal with each of these in turn.Bronchiolitis