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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 intravenous cannula of an infant with bronchiolitis. This is the fifth 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 intravenous 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 (NGT) be appropriate?
Structured clinical question
In infants with bronchiolitis who need maintenance or replacement fluid therapy [subject], does administration by the nasogastric route [intervention] cause more respiratory difficulty or electrolyte disturbance [outcome] than intravenous infusion [comparison]?
Search strategy and outcome
Cochrane Library: Nil relevant
PubMed: three searches:
“bronchiolitis” AND “nasogastric”
“nasogastric” AND “airway” OR “airway obstruction”
“bronchiolitis” AND “fluid” OR “rehydration” Limits: birth–18 years, human.
Search date: March 2004.
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 evidence1 that a NGT increases airway resistance in small preterm neonates, but not in older heavier ones.2 Total tidal volume in well neonates is not affected by an NGT.3 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. Nicolai and Pohl4 and Sporik5 argue “from first principles” that the nasogastric (NG) 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 show that there is widespread use of the NG route in many units.6,7 However, no conclusions can be drawn from their data regarding the safety of NG fluids versus the intravenous route.
No studies were identified assessing the likelihood of electrolyte 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 intravenous route. A randomised controlled trial is needed.
CLINICAL BOTTOM LINE
There is no good quality evidence for or against the use of nasogastric fluids in infants with bronchiolitis. (Grade D)
Physiological studies would suggest that use of a nasogastric tube be limited to infants >2 kg. (Grade D)
Until good quality evidence is available, local guidelines should be followed. (Grade D)