Inpatient Management of Bronchiolitis Before and After the COVID-19 Pandemic

Introduction Bronchiolitis is the most common cause of respiratory-related hospital admissions in children under two years. It is typically caused by viral infections, most commonly respiratory syncytial virus (RSV). Despite the availability of various international guidelines, Malta lacks local protocols, leading clinicians to rely on international recommendations for management. Objectives The primary aim of this audit was to compare epidemiological and management trends in bronchiolitis among children under one year admitted to Mater Dei Hospital between 2019 (pre-COVID) and 2024 (post-COVID). Secondary objectives included assessing adherence to the National Institute for Health and Care Excellence (NICE) guidelines on bronchiolitis management and evaluating the impact of the 2021 NICE guideline update. Methodology A retrospective audit was conducted using data from October to February of 2018-2019 and 2023-2024. Infants under 12 months diagnosed with bronchiolitis were included. Data was anonymised and extracted from medical records and the local portal for patient lab results. Statistical analysis was performed using Z-tests for proportions and Chi-squared test. Results A total of 196 patients were included - 90 in 2019 and 106 in 2024. Admissions increased post-COVID (p = 0.008), with a higher proportion of male patients in 2024. Typical bronchiolitis symptoms were more common in 2024, including coryza (p = 0.0214), spluttery cough (p < 0.001), and wheeze/crackles (p = 0.0085). Fluid intake <50% of usual amount became a more frequent reason for admission (p = 0.014). Investigations increased significantly post-pandemic, with more chest X-rays, blood tests, and viral PCR screens performed (all p < 0.001), despite guideline recommendations to limit these. Non-evidence-based treatments were commonly used, with salbutamol prescribed in over 60% of cases in both years. There was also increased use of hypertonic saline (p = 0.0464), antibiotics (p < 0.001), and corticosteroids (prednisolone p < 0.001; hydrocortisone p = 0.0355) in 2024. More patients required fluid support in 2024 (p = 0.0008), though intravenous fluids were favoured over nasogastric hydration, contrary to best practice. Oxygen requirement significantly increased post-COVID (p = 0.0001). Despite improvements in documentation, reflected by more admission plans and treatment charts including oxygen (p = 0.001 and p = 0.0084, respectively), 69% of oxygen-dependent patients in 2024 still did not have a formal oxygen prescription. Conclusion The audit identified suboptimal adherence to NICE guidelines in the management of bronchiolitis. Post-COVID, there was a notable increase in admissions, investigations, and non-guideline-supported treatments, suggesting a drift from evidence-based care. Improved documentation and the development of local protocols are essential to standardise care and reduce unnecessary interventions.