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Official American Thoracic Society Clinical Practice Guidelines: Diagnostic Evaluation of Infants with Recurrent or
Insights
Guidelines for diagnosing persistent infantile wheezing are lacking due to limited evidence. Conditional recommendations suggest airway evaluation and swallowing studies, but more research is needed.
Area of Science:
- Pediatric Pulmonology
- Clinical Guidelines
- Diagnostic Evaluation
Background:
- Infantile wheezing is a frequent clinical issue.
- Lack of established guidelines for evaluating persistent or recurrent wheezing unresponsive to standard treatments.
Purpose of the Study:
- To address uncertainties in the diagnostic evaluation of infants with recurrent or persistent wheezing.
- To develop evidence-based recommendations for clinical practice.
Main Methods:
- American Thoracic Society-endorsed guideline development committee.
- Pragmatic evidence syntheses using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.
- Formulation and grading of recommendations based on synthesized evidence.
Main Results:
- Identified a scarcity of high-quality studies for diagnostic evaluation of infantile wheezing.
- Evidence quality was very low, primarily from case series with significant biases.
- Conditional recommendations for bronchoscopic airway survey, bronchoalveolar lavage, esophageal pH monitoring, and swallowing studies.
- Conditional recommendations against empiric food avoidance, upper gastrointestinal radiography, and gastrointestinal scintigraphy.
- Recommended further research on infant pulmonary function testing and allergy-based dietary changes.
Conclusions:
- Paucity of evidence complicates diagnostic test selection for infantile wheezing.
- Conditional recommendations are provided, but require further research.
- Additional research focusing on clinical outcomes is crucial to enhance diagnostic intervention confidence.
Background:
Infantile wheezing is a common problem, but there are no guidelines for the evaluation of infants with recurrent or persistent wheezing that is not relieved or prevented by standard therapies.
Methods:
An American Thoracic Society-sanctioned guideline development committee selected clinical questions related to uncertainties or controversies in the diagnostic evaluation of wheezing infants. Members of the committee conducted pragmatic evidence syntheses, which followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The evidence syntheses were used to inform the formulation and grading of recommendations.
Results:
The pragmatic evidence syntheses identified few studies that addressed the clinical questions. The studies that were identified constituted very low-quality evidence, consisting almost exclusively of case series with risk of selection bias, indirect patient populations, and imprecise estimates. The committee made conditional recommendations to perform bronchoscopic airway survey, bronchoalveolar lavage, esophageal pH monitoring, and a swallowing study. It also made conditional recommendations against empiric food avoidance, upper gastrointestinal radiography, and gastrointestinal scintigraphy. Finally, the committee recommended additional research about the roles of infant pulmonary function testing and food avoidance or dietary changes, based on allergy testing.
Conclusions:
Although infantile wheezing is common, there is a paucity of evidence to guide clinicians in selecting diagnostic tests for recurrent or persistent wheezing. Our committee made several conditional recommendations to guide clinicians; however, additional research that measures clinical outcomes is needed to improve our confidence in the effects of various diagnostic interventions and to allow advice to be provided with greater confidence.
