Dear Kevin:

Without listing the number needed to treat and number needed to harm for
albuterol, racemic epi, and hypertonic saline, it is completely
irresponsible of the AAP subcommittee to state unequivocally that these
medications should NOT be used in the ED setting. That is not what the
evidence supports, and is not what clinical experience supports. This is
particularly true if one uses a broad definition of bronchiolitis up to 2
years of age.

Our ED Evidence Based Clinical Practice Guideline (CPG) lists 1) first
suctioning the upper airway, then 2)  a trial of one or two albuterols, or
one albuterol followed by one racemic epi in the Ed, then make a decision
about admission. This is safe and potentially effective.

I will not likely change my practice based on these new recommendations
since it would keep potentially beneficial treatments from children in the
ED, and is exceedingly unlikely to cause harm. If anything, I would like to
add a single trial of hypertonic saline to the protocol using the same

For those of us who have taken care of thousands of patients with
bronchiolitis over the past decades, it is not likely the AAP
recommendations will be followed. It would be much easier to swallow if the
recommendations were restricted to say children less than 4-6 months of age
where asthma is unlikely to be diagnosed.

Bob Flood
Cardinal Glennon
St. Louis, MO

On Fri, Oct 31, 2014 at 6:09 AM, Kevin Powell <[log in to unmask]> wrote:

> Jay,
> The revised guidelines reflect practices that have been in place for
> several
> years at many children's hospitals across the country. So I'm not sure what
> control group you are planning to use. Many of the changes were well known
> at the time the 2006 guideline was created. The revision just removes
> weasel
> words that permitted outmoded practices to persist.
> Marty,
> Every scientist knows about the risks of biased observations. Can you raise
> the bar from personal anecdote to Evidence based medicine?
> Everyone,
> A practice guideline is not THE ONLY standard of care. But it can and
> should
> be a starting point for reducing unnecessary variation between ER
> physicians
> in a given locality. Similarly, I suggest you discuss the ER practices with
> the pediatric hospitalists that provide inpatient care in your facility.
> Families get upset when they hear one thing in the ER and then repeatedly
> hear a different explanation over the next 2 days inpatient.
> A practice guideline can serve as a reference point. There will be reasons
> to deviate from it, but those events and rationales should be well
> documented. Be aware that parents these days are very tech savvy and they
> will find this guideline. I had a recent experience with a parent of a
> child
> who had HSP. There was only a 45 minute gap between hearing the diagnosis
> in
> the ER and my seeing the child with my residents. At that point, the father
> knew more about HSP than my senior resident. I was glad I had treated two
> cases in the previous 3 months (after going over 2 years without any) so I
> didn't feel foolish myself.
> Kevin Powell MD PhD FAAP
> Pediatric hospitalist
> Saint Louis, MO
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:

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