evidence based management of bronchiolitis.pdf

7/30/2019 evidence based management of bronchiolitis.pdf

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Evidence Based Management

of Bronchiolitis

Celeste A. Tarantino, M.D.

Childrens Mercy Hospital and Clinics


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Objectives

To review the etiology, epidemiology andpathophysiology of bronchiolitis

To define and review the clinicalpresentation of bronchiolitis

To review the evidence in the

management of bronchiolitis Infection control, prevention and

prophylaxis will not be covered


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Infant AHistory

A 9 wk old female presents with a CC ofcongestion. She has a 2 day history of cold,congestion, runny nose, tactile temperature and

decreased breastfeeding. No V/D. Good UO.

PMH-full term infant, P/L/D non-complicated,SVVD. Birth Wt 7#.

FH/SH-lives with both parents & 2 siblings in anon-smoking home; no daycare; both siblingsare ill with same sxs; neg asthma.


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Infant APhysical Exam

VS-Temp 38.3, HR 140, RR 48

Alert, vigorous, nonill, mild IC & SC retractions

Copious clear nasal secretions Diffuse coarse BS with UAC and expiratory

wheezes

Oxygen saturation > 95% on room air

RSV screen positive


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Infant AClinical Course

Infant had her nostrils suctioned with saline using a bulbsuction

She breast fed well & was observed for 1 hr

She had no increase in respiratory difficulty She did not develop an oxygen need

She was discharged with a diagnosis of bronchiolitis andfever

The parents were instructed to continue to bulb suctionwith saline, return for poor feeding, poor color or difficultybreathing and to see their PCP the next day


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Infant BHistory

A 4 wk old male infant & his twin brother present with aCC of spitting up. Parents report a 2 day history ofdecrease po intake & spitting up with feeds. Mom

reports an episode where the infant stopped breathing &had brief duskiness after a feed. She denies anyrespiratory difficulty & says the baby began breathingafter 10-15 secs. Sleeping more than usual. Deniesrunny nose, cough or fever. Twin has a cough.

PMH-Twin A, born @ 37 wks via repeat c-section, P/L/Dnoncomplicated. B Wt 5# 13oz.

FH/SH-lives with both parents, twin & 2 older siblings ina nonsmoking home; older sibling has cold symptoms


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Infant BPhysical Exam

VS-T 37.0, HR 178, RR 44, Wt. 3.29

Pink, good tone, a little sleepy

BS clear, good aeration, no increased WOB,rare cough

Oxygen saturation 100% on room air

RSV screen positive


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Infant BClinical Course

After a long discussion with the parents both infantswere admitted due to age, poor feeding & parentalconcern

Shortly after arrival to the floor the patient developedwitnessed episodes of apnea with bradycardia andcyanosis that responded well to stimulation

Infant placed on L O2 via NC and transferred to thePICU

CXR showed hyperinflation vs. viral process He had no further events and was discharged to home

after 2 day LOS


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Definition

Bronchiolitis is a common disease ininfants and young children due to

inflammatory obstruction of thebronchioles resulting from a viral lowerrespiratory tract infection (LRTI)


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Definition

Bronchiolitis is a constellation of clinicalsymptoms and signs including a viral

upper respiratory prodrome followed byincreased respiratory effort and wheezingin children less than 2 years of age

AAP, Subcommittee on Diagnosis and Management of Bronchiolitis. Pediatrics. 2006;

118 (4): 1774-1793


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Etiology

Respiratory Syncytial Virus (RSV) accounts for > 50% ofinfections

RSV is an enveloped RNA paramyxovirus

Other viral pathogens include parainfluenza,metapneumovirus, influenza & adenovirus

No evidence of a bacterial cause for bronchiolitis


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Epidemiology

Most common LRTI in the 1st 2 years of life

Approximately 100,000 hospitalizations annually in U.S.

Highest rate of infection occurs between Dec-March

90% of children become infected with RSV by age 2 40% of children infected with RSV will have LRTI

Infection with RSV does not give life-long immunity

Infection in older children & adults presents as URI


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Epidemiology

Humans are the only source of infection

Transmission occurs by direct or close contact withcontaminated secretions

RSV is unstable in the environment, surviving only a fewhrs

RSV may persist for > 30mins on hands; readilyinactivated with soap & water and disinfectants

Spread among household & child care contacts iscommon

Incubation period averages 4-6 days (range 2-8)

Viral shedding lasts 3-8 days, may be as long as 3-4 wks


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Pathophysiology

Not all infected infants develop LRTI

Bronchiolar obstruction with edema,

mucous & cellular debris Minor bronchiolar wall thickening may

significantly affect airflow (R=1/r4)


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Signs and Symptoms

URI Rhinorrhea Congestion Sneezing Cough Poor appetite Fever Respiratory difficulty

Tachypnea Wheezing Crackles Apnea


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Physical Exam Findings

Rhinorrhea

Congestion

Cough Tachypnea (RR > 60)

Respiratory distress-retractions, nasal flaringand grunting

Crackles Wheezes

Poor aeration


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Differential Diagnosis for aWheezing Infant

Viral bronchiolitis Other pulmonary infections (eg, pneumonia, Mycoplasma,

Chlamydia, tuberculosis) Laryngotracheomalacia

Foreign body, esophageal or aspirated Gastroesophageal reflux Congestive heart failure Vascular ring Allergic reaction Cystic fibrosis Mediastinal mass Bronchogenic cyst Tracheoesophageal fistula


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Goals in Assessment

Differentiation of infants with probablebronchiolitis from those with other disorders

Estimation of the severity of illness


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Diagnosis of Bronchiolitis

AAP Clinical Practice Guidelines Clinicians should diagnose bronchiolitis & assess

disease severity on the basis of HX & PE. Clinicians

should not routinely order laboratory & radiographicstudies for diagnosis

Clinicians should assess risk factors for severedisease such as age < 12 weeks, a hx of prematurity,underlying cardiopulmonary disease, orimmunodeficiency when making decisions aboutevaluation & management of children withbronchiolitis


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Risk Factors for Severe Disease

Several studies have identified prematurity (< 37wks EGA) & young age (< 6-12 wks) withincreased risk of severe disease

Young infants may develop apnea

Increased risk of severe disease or mortality

Congenital heart disease

Chronic lung disease (BPD, CF, congenitalanomaly)

Immunocompromised state


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What About Apnea?

Retrospective study of 691 hospitalizedinfants < 6 mos age

Apnea in 19 (2.7%) Identified risk criteria

History of apneic episode

Young age < 1 month age for term infants

< 48 wks postconceptional age for prematureinfants


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Factors Associated with SevereIllness

Ill or toxic appearance

Oxygen saturation < 95%

Gestational age < 34 weeks RR > 70 breaths/min

Age < 3 months

Co morbidities

Rapid progression of symptoms


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Chicken or Egg?

Unclear whether severe viral illness earlyin life predisposes children to develop

recurrent wheezing or if infants whoexperience severe bronchiolitis have anunderlying predisposition to recurrentwheezing


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Treatments to Consider

Is laboratory testing necessary to diagnose infants withbronchiolitis?

Is a chest x-ray necessary for infants with bronchiolitis? Should bronchodilators be used routinely in the treatment of

bronchiolitis? Should racemic epineprhine be used routinely in the treatment

of bronchiolitis? Is nasal suctioning beneficial in the treatment of bronchiolitis? Should antibiotics be used routinely in the treatment of

bronchiolitis? Is there a role for hypertonic saline?


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What does the evidence sayabout lab testing?

No evidence to support routine CBC & Diff w/platelets

No evidence to support routine BMP

RSV routine testing is generally not indicated

Numerous studies demonstrate rapid RSVtesting with high sensitivity & specificity

No evidence to support routine RSV testingaffects clinical outcomes in typical disease


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RSV Testing

Rapid Ag

Rapid results

Sensitivity 70-90%, specificity > 95% Resp Viral Panel PCR

Results within 1 day

Detects both live & dead virus High sensitivity & specificity

Reserve for use inpatient testing if highlysuspicious and other testing neg


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RSV Testing

Resp Viral Cx

Gold standard to detect viral infection

Includes tube and shell vial culture

Isolation affected by specimen collection or transport Positive results in 1-2 days, final in 10 days

Common respiratory viruses grow in shell vial

Reserve tube cx for immunocompromised & severly ill

Resp Shell Vial Cx RSV grows readily in shell vial cx

Best choice for resp viruses (RSV, Flu A & B, Adenovirus,Parainfluenza 1, 2 & 3, hMPV)

Positive results in 2 days


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RSV Testing CO$T

RSV rapid Ag=$144

RSV PCR=$667

Respiratory viral Cx=$686 If positive, add $188 for identification

Respiratory shell vial=$188

If positive, add $188 for identification


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Evidence on use of routinechest x-rays

Swingler et al-RCT of 522 infants &children aged 2-59 months, CXR + vs.CXR -

CXR+: more likely to be diagnosed withpneumonia or URI & receive antibiotics

CXR-: more likely to be dxed bronchiolitis Median time to recovery 7 days both

groups


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Evidence of use of routine

CXR

Prospective study of pts 2-23 months inED showed low yield of routine CXR

In 2 of 265 uncomplicated pts, routineCXR identified findings inconsistent withbronchiolitis

Findings did not change acutemanagement


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CXR Findings

Approximately 25% of hospitalized infants withbronchiolitis have radiographic evidence ofatelectasis or infiltrates often misinterpreted as

possible bacterial pneumonia Bacterial pneumonia in infants with bronchiolitis

without consolidation is unusual


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Reviewing the evidence:bronchodilators

RCTs failed to demonstrate consistent benefit

Cochrane systematic review found 8 RCTsinvolving 394 children

Some studies included children with priorwheezing

Some studies used ipratropium &

metaproterenol other than albuterol &epinephrine

1 in 4 demonstrated transient response


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What about Albuterol specifically?

Studies have demonstrated improvement in O2saturation and/or clinical scores 2 studies show improvement in O2 saturation & clinical

scores shortly after completion of treatment. No

measurements over time Klassen et al. evaluated clinical score & O2 saturation

30 & 60 mins after a single treatment. Improvement inclinical score but not O2 sat at 30 minutes but nochange after 60 mins

Gadomski et al.-no difference between albuterol &placebo after 2 nebulized treatements given 30 minsapart


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Albuterol in the hospital

Dobson et al. conducted a RCT in infantshospitalized with viral bronchiolitis failed todemonstrate clinical improvement

Two meta-analyses could not directly compareinpatient studies of abuterol because of widelydiffering methodology. Overall, the studiesreviewed did not show the use of albuterol in

infants with bronchiolitis to be beneficial inshortening duration of illness or length ofhospital stay


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What about Epinephrine?

Multicenter study by Wainwright et al. concludedepinephrine did not impact the overall course of illnessmeasured by hospital length of stay

Several studies compared epinephrine to albuterol or

epinephrine to placebo. Racemic epinephrine hasdemonstrated slightly better clinical effect than albuterol. Meta-analysis by Hartling et al suggests epineprhine

may be favorable to albuterol Cochrane review There is insufficient evidence to

support the use of epineprine for the treatement ofbronchiolitis among inpatients. There is some evidenceto suggest that epinephrine may be favorable to albuteroland placebo among outpatients.


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The Role of Bronchodilators

AAP Clinical Practice Guidelines

Bronchodilators should not be used routinelyin the management of bronchiolitis

A carefully monitored trial of-adreneric & -adrenergic medication is an option. Inhaledbronchodilators should be continued only if

there is a documented positive clinicalresponse to the trial using an objective meansof evaluation.


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What does the evidence show forsteroids?

Available evidence suggests that corticosteroid therapyis not of benefit in this patient group

Cochrane data base review included 13 studies & 1198patients Decrease LOS of 0.38 days-not statistically significant No benefits in LOS or clinical score in infants & young children

treated with steroids vs placebo 2 available studies evaluated inhaled corticosteroids showed no

benefit in the course of acute disease

3 studies evaluated hospital admission rates No difference in respiratory rate No difference in O2 saturation No difference in hospital revisit rate No difference in readmission rate


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The Role of Corticosteroids

AAP Clinical Practice Guidelines

Corticosteroid medications should not beused routinely in the management ofbronchiolitis


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Cochran Review of HypertonicSaline

Hypertonic saline=concentration > 3%

4 RCT, 254 infants: 189 inpatients & 65outpatients

Infants < 24 mos age with acute bronchiolitis

Confirmation of viral etiology not necessary

Excluded pts with recurrent wheezing


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Nebulized hypertonic saline alone vs. nebulized0.9% saline

Nebulized hypertonic saline + bronchodilator vs.

nebulized 0.9% saline

Nebulized hypertonic saline + bronchodilator vs.nebulized 0.9% saline + same bronchodilator

Nebulized hypertonic saline + bronchodilator vs.no intervention


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Nebulized hypertonic saline produces a 25.9%reduction (0.94 days) in mean length of hospitalstay vs. nebulized normal saline in hospitalizedinfants

No adverse side affects

Nebulized hypertonic saline + bronchodilators

should be considered effective & safe treatmentfor infants with viral bronchiolitis


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What is Ribavirin?

Guanosine analogue with broad spectrumantiviral activity

Approved by FDA in 1985

Approved for use in nebulized form in infants &children with RSV

VERY expensive

Potentially teratogenic in pregnant caregivers


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Reviewing the Evidence:Ribavirin

A recent Cochrane review of RCT comparingRibavirin to placebo

Decrease in mortality rate was not statistically

significant Decrease in risk of respiratory deterioration was not

statistically significant

Decrease in hospital days was not statistically

significant Decrease in ventilator days was not statistically

significant


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What does the evidence show forantibiotics?

Several retrospective studies indentifiedlow rates of SBI (0-3.7%) in patients withbronchiolitis and/or infections with RSV

More likely to be UTI than bacteremia ormeningitis

2396 infants with RSV bronchiolitis,

39 patients with SBI (1.6 %)

69% of the 39 patients with SBI had a UTI


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What does the evidence show forantibiotics?

Prospective studies of SBI in bronchiolitisand/or RSV infections also show low rates(1-12%)

Infants < 28 days, risk of SBI 10.1% in RSV +vs 14.2% in RSV

Infants 29-60 days RSV +, all SBIs were UTIs

Infants 29-60 days, rate of UTI 5.5% in RSV+vs 11.7% in RSV -


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The Role of Antibiotics

AAP Clinical Practice Guideline

Antibiotics medications should be used only inchildren with bronchiolitis who have specificindications of the coexistence of a bacterialinfection. When present, bacterial infectionshould be treated in the same manner as in

the absence of bronchiolitis

Th R l f S l t l


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The Role of SupplementalO2


Supplemental oxygen is indicated if oxyhemoglobinsaturation (SpO2) falls persistently < 90% in

previously healthy infants. As the childs clinical course improves, continuous

measurement of SpO2 is not routinely needed.

Infants with a known history of hemodynamically

significant heart of lung disease and prematureinfants require close monitoring as the oxygen isweaned.


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Hydration Status


Clinicians should assess hydration & ability totake fluids orally

Th R l f Ch t


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The Role of ChestPhysiotherapy


Chest physiotherapy should not be usedroutinely in the management of bronchiolitis


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The Role of Suctioning

Common practice at CMH

No evidence to support the benefit of

suctioning


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Reasons to Suction

Inability to cougheffectively WITH oneof the following:

Oxygen requirement Increased RR

Increased WOB(retractions, head

bobbing, nasal flaring)

Retention ofsecretions WITH oneof the following:

Oxygen requirement Increased RR

Increased WOB(retractions, head

bobbing, nasal flaring)


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Suctioning Quick Tips

Nasal Aspiration

First line of defense, try this beforenasopharyngeal suctioning

Common practice at CMH is to use saline

No evidence to support or disprove the use ofsaline in nasal suctioning


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Adverse Effects of Suctioning

Mucosal trauma

Hypoxia

Emotional distress toparent or child

Atelectasis

Discomfort

Tachycardia

Apnea

Increasedbronchospasm

Vagal stimulation

Increased bloodpressure

Pneumothorax

Increased Intracranialpressure


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Summary of the Evidence

Bronchiolitis is primarily a clinical diagnosis Treatment is primarily supportive care & includes oxygen, suctioning

and if necessary intubation and mechanical ventilation Clinicians should not routinely order labs & x-rays

X-rays may be useful when the hospitalized patient does not improve asexpected

Bronchodilators should not be used routinely in the treatment ofbronchiolitis It may be reasonable to administer a nebulized bronchodilator &

evaluate clinical response Racemic epinephrine may be beneficial

Evidence does not support the use of steroids Antibiotics should only be used to treat coexisting bacterial

infections

Shortfalls in Care:


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Shortfalls in Care:Variation in Care

Significant practice variation & resource over-utilizationexits

Antibiotic use in US ED estimated 37-53%

Resistant bacteria Unnecessary cost

Short acting B-agonist use 53%

Systemic steroids use 13%

Use of ineffective therapies: anticholinergics,theophylline & OTC decongestants

CXR use 46-72%


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References

American Academy of Pediatrics. Bronchiolitis. In: Pickering LK,Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report ofthe Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL:

American Academy of Pediatrics; 2006; 560-566. American Academy of Pediatrics, Subcommittee on Diagnosis and

Management of Bronchiolitis. Diagnosis and Management ofBronchiolitis. Pediatrics. 2006; 118:1774-1793.

Bordley WC, Viswanathan M, King V, et al. Diagnosis and testing inbronchiolitis: A systematic review. Arch Pediatr Adolesc Med.2004; 158:119-126.

Childrens Mercy Hospital & Clinics Clinical Practice Guidelines forBronchiolitis.


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References

Center for Disease Control & Prevention website @ www.cdc.gov,National Center for Infectious Diseases, Respiratory and EntericViruses Branch.

The Cochrane Collaboration, Cochrane Reviews @www.cochrane.org.

Colditz PB, Henry RL, DeSilva LM. Apnoea and bronchiolitis due torespiratory syncytial virus.Aust Paediatr J1982; 18:53-54. Corneli HM, Mahajan P, Shaw KN, Zorc JJ, Kuppermann N. Oral

Dexamethasone in Bronchiolitis: A Multicenter RandomizedControlled Trial. Abstract in Pediatr Emerg Care. 2006; 22:683.

Goodman D. In: Behrman RE, Kliegman RM, Jenson HB, eds.

Nelson Text Book of Pediatrics. 17th

ed. Philadelphia, PA: Saunders;2004; 1415-1417.
http://www.cdc.gov/http://www.cochrane.org/http://www.cochrane.org/http://www.cdc.gov/


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References

Kneyber MC, Brandenburg AH, de Groot R, Joosten KF, RothbarthPH, Ott A, Moll HA. Risk factors for respiratory synctial virusassociated apnoea. Eur J Pediatr. 1998. 157:331-5.

Kupperman N, Bank DE, Walton EA, Senac MO, McCaslin I. Risksfor bacteremia and urinary tract infections in young febrile childrenwith bronchiolitis.Arch Pediatr Adolesc Med. 1997. 151:1207-1214.

Levine DA, Platt SL, Dayan PS, et. al. Risk of serious bacterialinfection in young febrile infants with respiratory synctial virusinfections. Pediatrics. 2004. 113:1728-1734.

Willwerth BM, Harper MB, Greenes DS. Identifying hospitalizedinfants who have bronchiolitis and are at high risk for apnea.AnnEmerg Med. 2006. 48:441-7.

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evidence based management of bronchiolitis.pdf