Bronchiolitis (peds)

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Background

  • <2yr old (peak 2-6mo age)
  • Respiratory Syncytial Virus (RSV) causes ~70% of cases[1]
  • Preemies, neonates, congenital heart disease are at risk for serious disease
  • Peaks in winter
  • Duration = 7-14d (worst during days 3-5)
  • Inflammation, edema, and epithelial necrosis of bronchioles

Clinical Features

  • Symptoms
    • Rhinorrhea, cough, irritability, apnea (neonates)
  • Signs
    • Tachypnea, cyanosis, wheezing, retractions
    • Fever is usually low-grade or absent
  • Assess for dehydration (tachypnea may interfere with feeding)

Differential Diagnosis

Evaluation

  • Rapid RSV
    • Obtain if <1mo old
    • If positive then admit
  • CXR
    • Not routinely necessary
      • May lead to unnecessary use of antibiotics (atelectais mimics infiltrate)
    • Consider if
      • Diagnosis unclear
      • Critically ill

Concurrent infection risk

Infants <60 days with RSV bronchiolitis and fever

  • Low risk of bacteremia and meningitis in RSV+, still appreciable UTI risk
    • UTI 5.4% in RSV+, 10.1% RSV-
    • Bacteremia 1.1% RSV+, 2.3% RSV-
    • Meningitis 0% RSV+, 0.9% RSV-

Management

Oxygen

  • The AAP guidelines also state that it is reasonable to not perform continuous oximetry on infants and children with bronchiolitis[2]
  • O2 (maintain SaO2 >90%)
    • oxygen saturation alone should not dictate admission[3]

Suctioning

  • Nasopharyngeal suctioning may temporarily relieve symptoms
  • The use of routine “deep” suctioning may lead to increased length of stay based on one small study [2]

There is insufficient data to make a recommendation about suctioning.

Hypertonic Saline

AAP recommends as a possible intervention, but SABRE trial found no change in discharge or adverse events with nebulised HS.[4]

  • Only consider administer to infants who require hospitalization[2] (Class B))
    • Suction nares / nasal saline drops

Not Indicated

Randomized controlled trials of bronchodilater or corticosteroid therapy have shown mixed results. Bronchodilators could aggravate the symptoms.[5][6][7]

Disposition

Consider Admission

  • Age <3months
  • Preterm (<34wks)
  • Underlying heart/lung disease
  • Initial SaO2 <90%
    • Sa02 alone should not be used as the only factor for admission[9]
  • Unable to tolerate PO

Consider Discharge

  • Conventional treatment used (epinephrine, dex) and no rebound stridor in 2h[10][11]

See Also

External Links

References

  1. Papadopoulos NG; Moustaki M; Tsolia M; Bossios A; Astra E; Prezerakou A (2002). Am J Respir Crit Care Med.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Ralston S. et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics 134(5) Nov. 2014. 1474 -e150 doi: 10.1542/peds.2014-2742 PDF
  3. Schuh S. et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014 Aug 20;312(7):712-8. doi: 10.1001/jama.2014.8637
  4. Everard ML, Hind D, Ugonna K, et al. SABRE: a multicentre randomised control trial of nebulised hypertonic saline in infants hospitalised with acute bronchiolitis. Thorax. 2014;69(12):1105–1112. doi:10.1136/thoraxjnl-2014-205953.
  5. Bjornson CL. et al. A randomized trial of a single dose of oral dexamethasone for mild croup. NEJM. 2004;351:1306-1313.
  6. Geelhoed GC. et al. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. BMJ. 1996;313:140-142
  7. Ralston S. et al. Randomized, placebo-controlled trial of albuterol and epinephrine at equipotent beta-2 agonist doses in acute bronchiolitis. Pediatr Pulmonol. 2005;40:292-299
  8. Corneli HM, Zorc JJ, Mahajan P, et al; Bronchiolitis Study Group of the Pediatric Emergency Care Applied Research Net- work (PECARN). A multicenter, random- ized, controlled trial of dexamethasone for bronchiolitis [published correction appears in N Engl J Med 2008;359(18): 1972]. N Engl J Med. 2007;357(4):331–339
  9. Schuh S, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014; 312(7):712-718.
  10. Ross JD, et al. The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department. J Emerg Med. 1998; 16:535-539.
  11. Kelley PB, et al. Racemic epinephrine use in croup and disposition. J Emerg Med. 1992; 10:181-183.