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Three Part Question

In [infants with bronchiolitis who need maintenance or replacement fluid therapy] is [administration of fluid by NG tube compared to IV infusion] [cause more respiratory difficulty or electrolyte disturbance]

Clinical Scenario

It is mid-December. As a paediatric SHO working a busy evening shift in a district general hospital, you are called to re-site the iv cannula of an infant with bronchiolitis. This is the 5th time that day you have been asked to perform such a task, and you approach the distressed, chubby infant with a sense of dread. Of the 20 children on the ward, 15 have bronchiolitis and 10 are on iv fluids. You consider how much distress placement and regular replacement of the cannulae causes these infants, and wonder if fluids could be given safely by another route. Would rehydration using a nasogastric tube be appropriate?

Search Strategy

On line search of Pubmed / Cochrane library performed in March 2004
Cochrane Library: Nil relevant
PubMed: 3 searches
(i) "bronchiolitis" AND "nasogastric"
(ii) "nasogastric" AND "airway" OR "airway obstruction"
(iii) "Bronchiolitis" AND "fluid" OR "rehydration"
Limits: Birth – 18 years, human

Search Outcome

Search outcome: 72 papers, of which 5 were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Stocks J 1980 UK	7 preterm infants (1.6-2kg) measured with and without an NGT in-situ	Controlled physiological study (level 5)	Nasal resistance(Rn) (measured in 7) and total airway resistance (Raw) measured in 4	Increased Rn of 50-150% withNGT in situ. 30-50% increase in Raw with NGT	Study only of 'well' preterm infants. No comment on clinical effects. Small study. Considerable measurement difficulties
Martin et al 1988 USA	8 preterm infants (1220-1740g)	Controlled physiological study (level5)	Change in oral / nasal airflow (measured as % total Tidal Volume [Tv]) with and without NGT	Nasl Tv decreased from 54% to 39% with NGT in place. Total Tv remained constant despite NGT	Small study of 'well' neonates wihtout significant lung disease
Greenspan et al 1990 USA	14 neonates < 2kg, 10 neonates > 2 kg with either NG or orogastric tube (OGT)	Controlled physiological study (level 5)	Minute volume, pulmonary resistance	Reduced minute volume, increased pulmonary resistance in <2 Kg group wiht NGT. No effect vs OGT in babies > 2 Kg	Study only of 'well' neonates, up to 3 Kg without lung disease
Sammartino et al 2002 Australia	73 infants admitted with bronchiolitis, 55 needing fluids. 37 given fluid by NGT. Other 18 infants given fluid by iv route as < 4 months, or reduced level of consciousness or apnoea or GO reflux needing treatment	Uncontrolled Cohort (level 4)	1. Respiratory and heart rate, SaO2. 2.Number beginning with NGT fluids going on to iv.	1. NGT 'tolerated without incident' in all. 2. 2/37 deteriorated as illness progressed. Removal of NGT did not help	Uncontrolled case series. Excluded children < 4 months
Vogel et al 2003 New Zealand	409 infants in 5 New Zealand Hospitals	Uncontrolled cohort (level 5)	Percentage receiving i.v. or NGT fluids in each hospital	15-30% received i.v. fluids. 1-39% received NGT fluids	Uncontrolled series. No comparison of outcome of NGT vs i.v. routes. Large variations in practice

Comment(s)

Maintaining optimal hydration is an important component in the management of bronchiolitis. Practice varies between units as to the route of administration. There is some evidence (Stocks) that a NGT increases airway resistance in small preterm neonates, but not in older heavier ones (Greenspan et al). Total tidal volume in well neonates is not affected by an NGT (Martin et al) However it is difficult to extrapolate from these studies to the clinical significance of an NGT in older, larger children with bronchiolitis. Expert opinion varies. Nicholai and Pohl and Sporik argue from 'first principles' that the nasogastric route be avoided because of the theoretical risk of increased airway resistance. However, based on the same studies cited by Sporik, Milner came to the conclusion that the NG route is acceptable in infants over 2 kg. The case series reported by Sammartino et al and Vogel et al demonstrate that there is widespread use of the NG route in many units (Sammartino, Vogel). However, no conclusions can be drawn from their data regarding the safety of NG fluids vs the iv route. No studies were identified assessing the likelihood of electroltye disturbance in children with bronchiolitis given intravenous rather than nasogastric fluids. In infants with bronchiolitis, there is no good quality evidence that rehydration by the NG route is more or less safe than via the iv route. A randomised controlled trial is needed.

Clinical Bottom Line

There is no good quality evidence for or against the use of NG fluids in infants with bronchiolitis Physiological studies would suggest that use of a NGT be limited to infants > 2kg. Until good quality evidence is available, local guidelines should be followed.

References

1. Stocks J. Effect of nasogastric tubes on nasal resistance during infancy. Archives Disease Childhood 1980; 55: 17-21.
2. Martin RJ, Siner B, Waldemar A, Lough M, Miller M. Effect of head position on distribution of nasal airflow in preterm infants. Journal of Pediatrics 1988; 112: 99-103.
3. Greenspan JS, Wolfson MR, Holt WJ, Shaffer TH. Neonatal gastric intubation: differential respiratory effects between nasogastric and orogastric tubes. Pediatric Pulmonology 1990: 8: 254-8.
4. Nicholai T, Pohl A. Acute viral bronchiolitis in infancy: epidemiology and management. Lung 1990 (suppl): 396-405.
5. Sporik R (Commentary by Milner AD). Why block a small hole? The adverse effects of nasogastric tubes. Archives of Disease in Childhood 1994; 71: 393-4.
6. Sammartino L, James D, Goutzamanis J, Lines D. Nasogastric rehydration does have a role in acute paediatric bronchiolitis. Journal Paediatric and Child Health 2002; 38: 321-323.
7. Vogel AM, Lennon DR, Pinnock RE, Graham DA, Grimwood K, Pattemore PK. Variations in bronchiolitis management between 5 N Zealand hospitals: can we do better? Journal of Paediatric and Child Health 2003; 39: 40-5.