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Heterogeneity in Bronchodilator Use for Bronchiolitis Across Pediatric Emergency Departments: A Multicenter PEDSnet
Andrea Rivera-Sepulveda1, Timothy Maul2, Cara Reedy3
1Department of Pediatrics, Division of Emergency Medicine and Urgent Care, Nemours Children's Health, Orlando, FL.
Insights
Bronchodilator use for infant bronchiolitis varies widely in pediatric emergency departments, influenced by patient and site factors. Current prediction models show high accuracy but low sensitivity for identifying patients unlikely to receive treatment.
Area of Science:
- Pediatric Emergency Medicine
- Respiratory Illness Research
- Clinical Practice Guidelines
Background:
- Despite 2014 guidelines advising against routine bronchodilator use for bronchiolitis, significant practice variations persist in pediatric emergency departments.
- This variability highlights a gap between evidence-based recommendations and clinical implementation.
Purpose of the Study:
- To investigate demographic, clinical, and institutional factors linked to bronchodilator administration in pediatric bronchiolitis cases.
- To develop a predictive model for identifying key correlates of bronchodilator use.
Main Methods:
- A multicenter, retrospective study analyzed data from 14,213 children aged 3-24 months with bronchiolitis across nine PEDSnet institutions in 2019.
- Exclusion criteria included prematurity, comorbidities, and prior reactive airway disease. A random forest model was employed to identify predictors of bronchodilator administration.
Main Results:
- Bronchodilators were administered in 29% of cases, with significant variation observed based on geographic site, patient age, concurrent steroid use, respiratory rate, and prior diagnoses.
- The predictive model achieved 85% accuracy, 25% sensitivity, and 98% specificity, with steroid use, geographic site, and age identified as key correlates.
Conclusions:
- Bronchodilator administration for bronchiolitis is highly variable and associated with multiple patient and site-specific factors.
- While the developed model can identify patients unlikely to receive bronchodilators, its low sensitivity limits practical clinical application.
- Further research into phenotype-driven bronchiolitis care is recommended, with caution against assuming therapeutic benefit from observed associations.
Background:
Despite 2014 guidelines discouraging routine bronchodilator use for bronchiolitis, substantial practice variation persists across pediatric emergency departments (EDs).
Objective:
To examine demographic, clinical, and institutional factors associated with bronchodilator use and to develop a model identifying predictors of its administration.
Methods:
We conducted a multicenter, retrospective study of children 3 to 24 months old with bronchiolitis seen in EDs from nine PEDSnet institutions (2019). Exclusions included prematurity, comorbidities, and prior asthma or reactive airway disease. Associations between patient characteristics and bronchodilator use were examined. A random forest model was trained and tested to identify correlates of bronchodilator administration.
Results:
Among 14,213 visits, bronchodilators were administered in 29%. Use varied by site, age, steroid administration, respiratory rate, and prior diagnoses. The model achieved 85% accuracy (p < 0.001), 25% sensitivity, and 98% specificity. Key correlates included steroid use, geographic site, and age.
Conclusion:
Bronchodilator administration for bronchiolitis remains highly variable and is associated with demographic, clinical, and geographic factors. While our model demonstrates the ability to identify patients unlikely to receive bronchodilators, its low sensitivity limits clinical utility. Findings underscore the need for future prospective studies exploring phenotype-driven bronchiolitis care, while cautioning against overinterpreting associations as evidence of therapeutic benefit.
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