PC1241: Which Patients with Bronchiolitis Receive Bronchodilator Trials? – a Chart Review Study to Identify Targets for Quality Improvement

Purpose/Objectives: In 2014, the American Academy of Pediatrics published updated clinical guidelines for bronchiolitis. Despite recommendation against bronchodilator trials, bronchodilator use continues with rates from 3.3% to 53.7% nationally. Our institution has relatively low rates of bronchodilator use in bronchiolitis patients at less than 10% since December 2015. Our primary objective was to describe characteristics of patients who receive bronchodilator trials to inform future Quality Improvement efforts. Our secondary objectives were to describe variability in bronchodilator trial composition, steroid administration, and ongoing albuterol administration after initial trial.

Design/Methods: This was a retrospective chart review study of 239 patients aged 30 days – 23 months with any diagnosis of bronchiolitis. Patients discharged from the Emergency Department (ED), Urgent Care (UC) or inpatient setting June 1, 2021 - March 6, 2022, who received bronchodilator during ED/UC or inpatient encounter were included. Following population identification, study variables were collected by chart review. Based on published asthma predictive index and expert consensus the following variables were collected as possible indicators of response to bronchodilators in the bronchiolitis population: 1) First degree relative with history of asthma, 2) > 2 prior wheeze episodes, 3) personal history of eczema requiring topical steroids, and 4) inhalant allergies. Bronchodilator trial composition categories included: albuterol x1, albuterol >2, albuterol/ipratropium x1, albuterol/ipratropium >2, and any racemic epinephrine. Following initial bronchodilator trial, patients were categorized as “responsive” by proxy if additional bronchodilators were ordered or prescribed, and/or received oral steroids. They were categorized as “nonresponsive” if neither. This definition was chosen given inconsistent documentation of responsiveness. Not all “responsive” inpatient subjects with albuterol ordered had additional bronchodilators administered and were evaluated for ongoing albuterol administration.

Results: We found 44.8% of subjects who received a bronchodilator trial were perceived “responsive” to the trial and 94.6% did not have >2 indicators of potential bronchodilator response. First degree relative with history of asthma was documented in 50% of patients who received bronchodilator trial (Figure 1.). Bronchodilator trial composition was variable (Figure 2.): albuterol x1 (57.8%, n=138), albuterol < 2 doses (1.7%, n=4), albuterol/ipratropium x1 (14.6%, n=35), albuterol/ipratropium >2 (25.1%, n=60), and racemic epinephrine (0.8%, n=2). Among “responsive” subjects who had bronchodilators ordered, 33.3% had additional bronchodilators administered or prescribed and 68.2% received oral steroids.

Conclusion/Discussion: Clinicians may be utilizing first degree relative with history of asthma as singular criteria for bronchodilator trials or other unmeasured criteria. Bronchodilator trial composition is variable. Many patients perceived to clinically respond to bronchodilator trial were administered steroids or required no additional bronchodilators during hospitalization. This highlights the challenge of determining bronchodilator responsiveness in this population, which is an opportunity for future de-implementation work.