Viral bronchiolitis is a common and morbid condition and has been the subject of numerous investigations. Randomized clinical trials (RCTs) on pharmacologic interventions or advanced forms of respiratory support, such has high-flow nasal cannula, have had disappointing results, generally demonstrating that commonly administered therapies do not provide clear benefits to patients.Therefore, published recommendations mostly endorse supportive care, which for inpatients largely involves oxygen support, hydration, and nasal suctioning. 1 For outpatients, nasal suctioning is often offered.Although the practice of nasal suctioning has intuitive appeal and appears to be relatively safe and cheap, there has never been robust evidence to inform the practice. RCTs addressing the core components of supportive care for bronchiolitis, including suctioning, are scarce. Because RCTs are challenging to do well, especially in children, we have come to rely extensively on observational studies to try to better understand the efficacy of various practices. Unfortunately, the biases introduced by confounding make it challenging to establish causal links between associations described in these types of investigations.For example, one prior single-center retrospective study 2 demonstrated that hospitalized infants with bronchiolitis who had lapses in suctioning and infants who underwent deep suctioning appeared to have longer hospital length of stay. Although that investigation appropriately used propensity matching to adjust for covariates, confounding is still a reasonable explanation for one or both of these associations. A similar association between nasopharyngeal (ie, deep) suctioning and prolonged length of stay was noted in another single-center retrospective investigation. 3 Is scheduled suctioning actually beneficial? Is deep suctioning truly harmful, or are patients who undergo deep suctioning simply more ill in ways that are challenging to ascertain by medical record review? We need experimental designs to get trustworthy answers to these types of questions. One prior RCT 4 comparing bulb syringes and nasal-oral aspirators demonstrated no significant difference in return visits, although it was a single-center trial with premature termination. Schuh et al 5 at Sick Kids Toronto have once again stepped up to try to answer some of the most basic, yet important, questions surrounding the routine management of infants with bronchiolitis.They report on an RCT comparing 2 forms of suctioning for infants with bronchiolitis seen in an emergency department and subsequently discharged home.The authors enrolled 367 infants aged 1 to 11 months who were randomized to enhanced suctioning (a battery-operated suction device) or minimal suctioning (a bulb syringe). Parents were instructed to use the device prior to feeding over the ensuing 72 hours. Although there were no statistically significant differences between enhanced vs minimal suctioning in terms of unscheduled visits, overall parental satisfaction with care, normal sleeping, or ...
