Okay, Laura. So as you see, we have from the Journal of Pediatrics, which is the official journal of the American Academy of Pediatrics, we have some guidelines for bronchiolitis. Since this is something that we see so commonly, of course they would have guidelines for something like this. So the title being Clinical Practice Guidelines: the Diagnosis, Management and Prevention of Bronchiolitis. And our question is about whether or not we need a chest X-ray, so that falls within this in the diagnosis category. >> Okay. Great. >> One of the first steps, since you haven't seen a guideline before, is to look to see whether or not your patient population actually fits this guideline. >> Okay, let's look. >> So as you see- >> Okay, so it's an evidence-based approach to the diagnosis of bronchiolitis in children from one month through 23 months of age. So our patient's three months old, so that would fit. >> Absolutely. And if we go to the next page here, we can see what patients were excluded. So it looks like right here, they've excluded HIV patients and patients with solid organ or stem cell transplants, and our patient doesn't have either one of these. >> Right. >> It also says right here though that they've excluded children with underlying respiratory illness, such as recurrent wheezing, chronic lung disease, cystic fibrosis, neuromuscular disorders, or congenital heart disease. But as you see, that's only excluding in sections that have to deal with management. >> I see. So we're not really thinking about that, or wondering about that right now. >> No we're not, but our patient doesn't have any of these problems anyway. >> That's true. >> Which makes it much easier. So the next, and we don't have to spend a ton of time because of course there's a propensity to kind of get right to the results and try to find out what you want to do. But I think it's a good idea to look over the methods a little bit so that you know what they actually did so that you know the evidence is strong when you're actually making clinical decisions. So as you see right here, this was looked at in June of 2013, and they sort of updated the 2006 bronchiolitis guidelines. So there was already a guideline in place, and they put a team of experts together that included general pediatricians, family doctors, pediatric specialists, including hospice and neonatologists and pediatric infectious disease doctors. So you have a big group of experts in the room to sort of take a look at the guidelines in the primary literature to update things. It looks like they've also done an evidence search. So looking here, where have they done the evidence search? >> Looks like they did an evidence search through electronic databases such as the Cochran library, Medline via Ovid, also on PubMed. >> Yeah, so they looked at recent related article searches that were conducted in PubMed. One of the things you can do here is it says if you look at the appendix which is in the back it talks about which search terms they used. So when you look here under diagnosis, it shows you what search terms they used in the different databases. >> Okay, great. >> Okay, so the next step is to look to see how they grade evidence. Now, have you ever looked at evidence that was graded before? >> I don't think so. >> Okay, well there different levels. There's level A, there's level B, there's level C, and there's level D. And they have a nice chart right here that we can take a look at after we look at what our evidence is actually rated as. So, if we go to the diagnosis section, it looks like they have a couple action statements on the diagnosis. But it looks like, from skimming this, that this is the one that we're interested in. So what does this have to say? >> So this says when clinicians diagnose bronchiolitis on the basis of history and physical exam, radiographic or laboratory studies should not be obtained routinely. And that's evidence quality B with a recommendation strength of moderate. >> Exactly. So now what I would do is I would see that this evidence quality B and go back to this chart that we talked about. And what does evidence level B say? >> So level B says trials or diagnostic studies with mild limitations fall under level B. And level B also means that there are consistent findings from multiple observational studies. >> Exactly, and as you can see It goes with the moderate recommendation. >> Right, okay. >> So then if we go over here in this table that they've made so nice for us about moderate recommendations, it says that the definition is a particular action is favored because anticipated benefits clearly exceed harms or vice versa, and the quality of evidence is good but not excellent, okay? >> Okay. >> And then the implication is that clinicians would be prudent to follow a moderate recommendation, but should remain alert to new information and sensitive to patient preferences. So, now that we know what that key action statement actually falls under, I think the thing to do now is read through these paragraphs to try to find the paragraph on chest x-ray. And as you can see, that's on the next page. So right here, it talks about current evidence not supporting routine chest x-ray in children with bronchiolitis. Why don't you read right here? That kind of shows us the primary literature incorporated. >> Sure. So further studies, including one randomized trial, suggest that children with a suspected lower respiratory tract infection who had radiography performed were more likely to receive antibiotics without any difference in outcomes. >> That's really interesting. And as you see that they have articles cited here that we could actually look at if we wanted to know about the primary literature. >> Right, okay. >> So now that we have a recommendation, we know that it's a moderate recommendation, and if the American Academy of Pediatrics feels that it's not necessarily necessary to get a chest X-ray, now,we get to figure out what we're going to do with our patient. So how does this apply to our patient? >> Well, so our patient is a three-month-old previously healthy infant, so definitely fits into these recommendations. I mean, we really diagnosed bronchiolitis based on the history and the physical alone. >> We did. >> And so I don't think that we need to obtain a chest x-ray at this point. >> I completely agree. So we will just continue to watch this baby and make sure that things go okay. >> Great, thank you. >> Thank you so much for looking at the literature and trying to learn how to use evidence based medicine. >> Thank you, Dr. Stogen. >> You're welcome.
