The Choosing Wisely® campaign is an initiative that promotes collaborative conversations between clinicians and families to safely avoid unnecessary and potentially harmful tests.
The American Academy of Paediatrics Section on Emergency Medicine (AAP SOEM) created a list of five key recommendations for Paediatric Emergency Medicine after a structured review process and expert consensus opinion.
This series of DFTB articles aims to increase awareness of the Choosing Wisely® recommendations. Each article will take a deep dive into each recommendation’s supporting evidence and practical implications.
Do not obtain comprehensive viral panel testing for patients who have suspected respiratory viral illnesses.
The parents of two-year-old, previously healthy, Jamie bring him to the Emergency Department with coryzal symptoms, wheezing and difficulty breathing.
SpO2 is 88%. Jamie does not improve after receiving nebulized salbutamol and low-flow O2 via mask.
Jamie is admitted to the Paediatric Ward, and the paediatric trainee calls the ED to ask if a viral respiratory panel was obtained.
What do the guidelines say?
They are generally not routinely recommended in the UK, USA, Canadian and Australian guidelines for bronchiolitis and community-acquired pneumonia.
What is the evidence for avoiding respiratory viral panels (RVP)?
We cannot think about using RVPs without this quote from Archie Cochrane, “Before ordering a test, decide what you will do if it is positive or negative. If both answers are the same, don’t take the test.”
In a world where we want information now, it is easy to see why respiratory virus panels are so popular. Before RVPs, viral cultures were the gold standard. Unfortunately, this method is slow. Respiratory swabs give much faster results by detecting genetic material but are expensive. They may tell you what virus(es) a child has, but often, you can’t do anything about it anyway. There are some exceptions like Bordetella pertussis or influenza (although oseltamivir use is questionable, and if your index of suspicion for pertussis is high enough, you should start treatment before test results) that are on certain RVPs. But if you have clinical suspicion, why not just order the more specific test?
What are the limitations of respiratory viral panels?
Before discussing the technical and clinical limitations, we must acknowledge the discomfort and stress these tests may add to children and their families.
- Lingering positivity – a test may be positive even if the virus is not manifesting clinically. During this time, the patient may still be shedding the virus. Children under five seem to have a longer duration of positive RVP tests despite being asymptomatic. A positive RVP does not tell you whether the virus is still causing symptoms.
- Concurrent infection – a positive result on an RVP can feel reassuring, but should it? Unfortunately, a positive RVP does not eliminate the possibility of another infection. For example, the child with a fever for five days, red eyes, and a positive adenovirus result on RVP can still have Kawasaki disease or the child with a fever and positive influenza result can still have a bacterial pneumonia or otitis media.
- What to do with a negative RVP – Not all RVPs are created equal. Different RVPs detect different pathogens. A negative result on RVP could mean that an inadequate sample was collected (not surprising given that I have yet to meet a child who enjoys getting a nasal swab) or that the child has another virus that the RVP does not detect. Do not forget that a major pathogen that most RVPs do not detect is Streptococcus pneumoniae – the most common bacterial cause of pneumonia.
Which children need a respiratory viral panel?
There may be a role in viral respiratory panels for children admitted to the hospital or intensive care unit. In addition, RVPs are valuable in immunocompromised paediatric patients and children with chronic medical problems (e.g., cystic fibrosis). One study found that a respiratory virus panel had no significant impact on the length of stay but was associated with a shorter duration of intravenous antibiotics in some patient groups. However, this finding does not seem to apply in all settings. Respiratory viral panel testing did not reduce antibiotic use in the emergency department. The role of RVPs in decreasing antibiotic use is still contested.
Of note, during COVID-19, some hospitals used RVPs to differentiate patients who had been infected with SARS-CoV-2 from other viral infections. Some facilities may also use the results from RVPs to cohort patients in the hospital. Finally, viral testing may also play a role in disease tracking during outbreaks.
How can we reduce the respiratory viral panel ordering?
One cross-sectional study using the Paediatric Health Information System database established achievable benchmarks for care as a starting point for quality improvement (QI) activities to reduce the use of RVP. One institution decreased the use of respiratory viral panels by an impressive 53% by addressing knowledge gaps with educational interventions, flyers, and more targeted testing. Another QI project in Canada performed a multifaceted improvement strategy that included modifications on how RVPs were ordered, education of healthcare workers, audits, and feedback. There was a significant reduction of RVP ordering both in the ED and paediatric wards without impacting ED returns.
What should we say to parents and caregivers?
We should tell families their child likely has a virus causing respiratory symptoms. While there is testing that may be able to identify the virus, there are important limitations. More importantly, we have no treatments for most viruses. We recommend supportive care, which includes antipyretics as needed for fever and encouraging hydration in addition to closely monitoring the child’s breathing.
We strive to provide high-quality, high-value care based on the best available evidence. So, the next time you plan to order a respiratory viral panel, ask yourself, “Will this change my management?” If the answer is “no,” it is a useless test.
Take home points
References
Byington CL, Ampofo K, Stockmann C, et al. Community surveillance of respiratory viruses among families in the Utah better identification of germs-longitudinal viral epidemiology (Big-love) study. Clin Infect Dis. 2015;61(8):1217-1224.
https://www.rch.org.au/clinicalguide/guideline_index/Community_acquired_pneumonia/
Innis K, Hasson D, Bodilly L, Sveen W, Stalets EL, Dewan M. Do I need proof of the culprit? Decreasing respiratory viral testing in critically ill patients. Hosp Pediatr. 2021;11(1):e1-e5.
Making Sense of Respiratory Viral Panel Results. Brennan-Krohn, Thea. American Society for Microbiology. https://asm.org/Articles/2020/March/Making-Sense-of-Respiratory-Viral-Panel-Results. Accessed July 17, 2023.
Mattila S, Paalanne N, Honkila M, Pokka T, Tapiainen T. Effect of point-of-care testing for respiratory pathogens on antibiotic use in children. JAMA Netw Open. 2022;5(6):e2216162.
Ostrow O, Savlov D, Richardson SE, et al. Reducing Unnecessary Respiratory Viral Testing to Promote High-Value Care. Pediatrics. 2022;149(2):e2020042366
Ouafi M, Dubos F, Engelman I, Lazrek M, Guigon A, Bocket L, Hober D, Alidjinou EK. Rapid syndromic testing for respiratory viral infections in children attending the emergency department during COVID-19 pandemic in Lille, France, 2021-2022. J Clin Virol. 2022 Aug;153:105221. doi: 10.1016/j.jcv.2022.105221.
Parikh K, Hall M, Mittal V, Montalbano A, Mussman GM, Morse RB, Hain P, Wilson KM, Shah SS. Establishing benchmarks for the hospitalized care of children with asthma, bronchiolitis, and pneumonia. Pediatrics. 2014 Sep;134(3):555-62. doi: 10.1542/peds.2014-1052.
Power M, Fell G, Wright M. Principles for high-quality, high-value testing. Evid Based Med. 2013 Feb;18(1):5-10. doi: 10.1136/eb-2012-100645.
Rao S, Lamb MM, Moss A, et al. Effect of Rapid Respiratory Virus Testing on Antibiotic Prescribing Among Children Presenting to the Emergency Department With Acute Respiratory Illness: A Randomized Clinical Trial. JAMA Netw Open. 2021;4(6):e2111836. doi:10.1001/jamanetworkopen.2021.11836
Schulert GS, Lu Z, Wingo T, Tang YW, Saville BR, Hain PD. Role of a respiratory viral panel in the clinical management of pediatric inpatients. Pediatr Infect Dis J. 2013;32(5):467-472.
