Bronchiolitis (peds) - Revision history

Rossdonaldson1: /* Evaluation */

2024-04-24T21:27:24Z

Evaluation

← Older revision		Revision as of 21:27, 24 April 2024
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	==Evaluation==		==Evaluation==
	[[File:RSV.png\|thumb\|[[CXR]] of a child with RSV showing the typical bilateral perihilar fullness.]]		[[File:RSV.png\|thumb\|[[CXR]] of a child with RSV showing the typical bilateral perihilar fullness.]]
	[[File:Bronchiolitis chest X-ray.jpg\|thumb\|[[CXR]] demonstrating lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions in a 16-day-old infant. Note normal thymus.]]
	*Bronchiolitis is a clinical diagnosis		*Bronchiolitis is a clinical diagnosis
	*Consider rapid RSV testing		*Consider rapid RSV testing

Rossdonaldson1: /* Evaluation */

2024-04-24T21:26:58Z

Evaluation

← Older revision		Revision as of 21:26, 24 April 2024
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	==Evaluation==		==Evaluation==
	[[File:RSV.png\|thumb\|[[CXR]] of a child with RSV showing the typical bilateral perihilar fullness.]]		[[File:RSV.png\|thumb\|[[CXR]] of a child with RSV showing the typical bilateral perihilar fullness.]]
			[[File:Bronchiolitis chest X-ray.jpg\|thumb\|[[CXR]] demonstrating lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions in a 16-day-old infant. Note normal thymus.]]
	*Bronchiolitis is a clinical diagnosis		*Bronchiolitis is a clinical diagnosis
	*Consider rapid RSV testing		*Consider rapid RSV testing

Rossdonaldson1: /* Evaluation */

2024-04-24T21:24:36Z

Evaluation

← Older revision		Revision as of 21:24, 24 April 2024
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	==Evaluation==		==Evaluation==
			[[File:RSV.png\|thumb\|[[CXR]] of a child with RSV showing the typical bilateral perihilar fullness.]]
	*Bronchiolitis is a clinical diagnosis		*Bronchiolitis is a clinical diagnosis
	*Consider rapid RSV testing		*Consider rapid RSV testing

Rossdonaldson1: /* Background */

2024-04-24T20:47:58Z

Background

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 ==Background==
 *Most common reason for infant hospitalizations in the US<ref>Suh M, Movva N, Jiang X, Bylsma LC, Reichert H, Fryzek JP, Nelson CB. Respiratory Syncytial Virus Is the Leading Cause of United States Infant Hospitalizations, 2009-2019: A Study of the National (Nationwide) Inpatient Sample. J Infect Dis. 2022 Aug 15;226(Suppl 2):S154-S163. doi: 10.1093/infdis/jiac120. PMID: 35968878; PMCID: PMC9377046.</ref>
 *[[Respiratory syncytial virus]] (RSV) causes ~70% of cases of bronchiolitis<ref>Papadopoulos NG; Moustaki M; Tsolia M; Bossios A; Astra E; Prezerakou A (2002). Am J Respir Crit Care Med.</ref>

Patricklin at 02:40, 7 November 2023

2023-11-07T02:40:39Z

← Older revision		Revision as of 02:40, 7 November 2023
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	==Background==		==Background==
			*Most common reason for infant hospitalizations in the US<ref>Suh M, Movva N, Jiang X, Bylsma LC, Reichert H, Fryzek JP, Nelson CB. Respiratory Syncytial Virus Is the Leading Cause of United States Infant Hospitalizations, 2009-2019: A Study of the National (Nationwide) Inpatient Sample. J Infect Dis. 2022 Aug 15;226(Suppl 2):S154-S163. doi: 10.1093/infdis/jiac120. PMID: 35968878; PMCID: PMC9377046.</ref>
			*[[Respiratory syncytial virus]] (RSV) causes ~70% of cases of bronchiolitis<ref>Papadopoulos NG; Moustaki M; Tsolia M; Bossios A; Astra E; Prezerakou A (2002). Am J Respir Crit Care Med.</ref>
	*<2yr old (peak 2-6mo age)		*<2yr old (peak 2-6mo age)
	*[[Respiratory syncytial virus]] (RSV) causes ~70% of cases<ref>Papadopoulos NG; Moustaki M; Tsolia M; Bossios A; Astra E; Prezerakou A (2002). Am J Respir Crit Care Med.</ref>
	*Preemies, neonates, [[congenital heart disease]] are at risk for serious disease		*Preemies, neonates, [[congenital heart disease]] are at risk for serious disease
	*Peaks in winter		*Peaks in winter (November to March)
	*Duration = 7-14d (worst during days 3-5)		*Duration = 7-14d (worst during days 3-5)
	*Inflammation, edema, and epithelial necrosis of bronchioles		*Inflammation, edema, mucus production, and epithelial necrosis of bronchioles lead to lower airway obstruction
			**Hypoxemia due to V/Q mismatch of poorly ventilated alveolar units

	==Clinical Features==		==Clinical Features==
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	**[[Rhinorrhea]], [[cough]], irritability, apnea (neonates)		**[[Rhinorrhea]], [[cough]], irritability, apnea (neonates)
	*Signs		*Signs
	**[[shortness of breath (peds)\|Tachypnea]], cyanosis, [[wheezing]], retractions		**[[shortness of breath (peds)\|Tachypnea]], cyanosis, [[wheezing]], respiratory distress (retractions, nasal flaring)
	**[[Fever (Peds)\|Fever]] is usually low-grade or absent		**[[Fever (Peds)\|Fever]] is usually low-grade or absent
	***If high-grade fever consider [[otitis media]], [[UTI (peds)\|UTI]]		***If high-grade fever consider [[otitis media]], [[UTI (peds)\|UTI]], or other bacterial infections
	*Assess for [[dehydration (peds)\|dehydration]] (tachypnea may interfere with feeding)		*Assess for [[dehydration (peds)\|dehydration]] (tachypnea may interfere with feeding)
			**Sunken fontanelle, decreased PO intake, decreased wet diapers, and lethargy

	==Differential Diagnosis==		==Differential Diagnosis==
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	==Evaluation==		==Evaluation==
			*Bronchiolitis is a clinical diagnosis
	*Consider rapid RSV testing		*Consider rapid RSV testing
	**However, RSV is NOT linked to apnea or acute severity (compared to other causes of bronchiolitis)<ref>Well-appearing Young Infants with RSV Infection:		**However, RSV is NOT linked to apnea or acute severity (compared to other causes of bronchiolitis)<ref>Well-appearing Young Infants with RSV Infection:
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	**You should NOT use RSV status to drive admission decisions and admission locations (eg, ward, step-down unit, ICU)<ref>Well-appearing Young Infants with RSV Infection:		**You should NOT use RSV status to drive admission decisions and admission locations (eg, ward, step-down unit, ICU)<ref>Well-appearing Young Infants with RSV Infection:
	Guidance Related To Criteria for Admission. Harbor-UCLA Pediatric Infectious Diseases, October 2017</ref><ref>Schroeder AR, et al. Pediatrics 2013;132:e1194-201</ref>		Guidance Related To Criteria for Admission. Harbor-UCLA Pediatric Infectious Diseases, October 2017</ref><ref>Schroeder AR, et al. Pediatrics 2013;132:e1194-201</ref>
			*Consider CBC and CRP to assess the risk of superimposed bacterial infection

	*[[CXR]]		*[[CXR]]
	**Not routinely necessary : May lead to unnecessary use of [[antibiotics]] (atelectasis mimics infiltrate)		**Not routinely necessary : May lead to unnecessary use of [[antibiotics]] (atelectasis from airway plugging mimics infiltrate)
	**Consider if:		**Consider if patient is critically ill or diagnosis unclear
	***Diagnosis unclear
	***Critically ill

	===Concurrent infection risk===		===Concurrent infection risk===
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	==Management==		==Management==
			*Note that supportive care remains the mainstay of therapy
	*Hydration for all infants		*Hydration for all infants

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	***Initial flow rate: Based on age/weight. Can be started at 1-2 L/kg per min.		***Initial flow rate: Based on age/weight. Can be started at 1-2 L/kg per min.
	***Oxygen (FiO2): 21% to 100%, based on patient’s prior oxygenation; goal of 94% to 99%.		***Oxygen (FiO2): 21% to 100%, based on patient’s prior oxygenation; goal of 94% to 99%.

			*Nasal CPAP or intubation may be necessary for evolving respiratory failure

	===Suctioning===		===Suctioning===
	''There is insufficient data to make an evidence-based recommendation about suctioning.''		''There is insufficient data to make an evidence-based recommendation about suctioning.''
	*Nasopharyngeal suctioning may temporarily relieve symptoms		*Nasopharyngeal suctioning may temporarily relieve symptoms due to decrease in total airway resistance
	*The use of routine “deep” suctioning may lead to increased length of stay based on one small study <ref name="AAP guides"></ref>		*The use of routine “deep” suctioning may lead to increased length of stay based on one small study <ref name="AAP guides"></ref>

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	''Randomized controlled trials of bronchodilator or corticosteroid therapy have shown mixed results. Bronchodilators could aggravate the symptoms.''<ref>Bjornson CL. et al. A randomized trial of a single dose of oral dexamethasone for mild croup. NEJM. 2004;351:1306-1313.</ref><ref>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</ref><ref>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</ref>		''Randomized controlled trials of bronchodilator or corticosteroid therapy have shown mixed results. Bronchodilators could aggravate the symptoms.''<ref>Bjornson CL. et al. A randomized trial of a single dose of oral dexamethasone for mild croup. NEJM. 2004;351:1306-1313.</ref><ref>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</ref><ref>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</ref>
	*[[Albuterol]]/bronchodilator ([[Evidence_Based_Recommendation_Levels\|Class B]])<ref name="AAP guides"></ref>		*[[Albuterol]]/bronchodilator ([[Evidence_Based_Recommendation_Levels\|Class B]])<ref name="AAP guides"></ref>
	**May trial if strong family hx of asthma/atopy in older infants		**May trial if strong family hx of asthma/atopy in older infants, as this may present a greater reactive airway component
	*Racemic [[Epinephrine]] ([[Evidence_Based_Recommendation_Levels\|Class B]])<ref name="AAP guides"></ref>		*Racemic [[Epinephrine]] ([[Evidence_Based_Recommendation_Levels\|Class B]])<ref name="AAP guides"></ref>
	*Steroids<ref name="AAP guides"></ref><ref>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</ref>		*Steroids<ref name="AAP guides"></ref><ref>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</ref>
	**Consider [[dexamethasone]] 0.6-1mg/kg PO or IM x1 in severe cases		**Consider [[dexamethasone]] 0.6-1mg/kg PO or IM x1 in severe cases
			**Note that AAP recommends against systemic steroids in any settings<ref>Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics November 2014; 134 (5): e1474–e1502. 10.1542/peds.2014-2742</ref>
			*Antibiotics
			**Only indicated if there is strong suspicion of, or proven bacterial infection

	==Disposition==		==Disposition==
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	*Unable to tolerate PO		*Unable to tolerate PO
	*Tachypnea with accessory muscle use		*Tachypnea with accessory muscle use
			*Caregiver unreliable or otherwise unstable home situation

	==See Also==		==See Also==

Zbuchwald: /* Consider Admission */

2022-12-09T13:46:55Z

Consider Admission

← Older revision		Revision as of 13:46, 9 December 2022
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	*Underlying heart/lung disease		*Underlying heart/lung disease
	*Initial SaO2 <88% <ref name="Schuh"/>		*Initial SaO2 <88% <ref name="Schuh"/>
	**Sa02 alone should not be used as ~~the only~~ factor for admission		**Sa02 alone should not alone be used as a factor for admission
	*Unable to tolerate PO		*Unable to tolerate PO
	*Tachypnea with accessory muscle use		*Tachypnea with accessory muscle use

Zbuchwald: /* Consider Admission */

2022-12-09T13:46:15Z

Consider Admission

← Older revision		Revision as of 13:46, 9 December 2022
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	*Preterm (<34wks)		*Preterm (<34wks)
	*Underlying heart/lung disease		*Underlying heart/lung disease
	*Initial SaO2 <90%		*Initial SaO2 <88% <ref name="Schuh"/>
	**Sa02 alone should not be used as the only factor for admission~~<ref name="Schuh"/>~~		**Sa02 alone should not be used as the only factor for admission
	*Unable to tolerate PO		*Unable to tolerate PO
	*Tachypnea with accessory muscle use		*Tachypnea with accessory muscle use

Zbuchwald: /* Oxygen/High Flow */

2022-12-09T13:41:59Z

Oxygen/High Flow

← Older revision		Revision as of 13:41, 9 December 2022
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	*O2 (maintain SaO2 >90%)		*O2 (maintain SaO2 >90%)
	**~~oxygen~~ saturation alone should not dictate admission (for patients with O2 sat of 88% or above)<ref name="Schuh">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</ref>		**Oxygen saturation alone should not dictate admission (for patients with O2 sat of 88% or above)<ref name="Schuh">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</ref>

	*High flow nasal cannula		*High flow nasal cannula

Zbuchwald: /* Evaluation */

2022-12-09T13:41:11Z

Evaluation

← Older revision		Revision as of 13:41, 9 December 2022
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	*[[CXR]]		*[[CXR]]
	**Not routinely necessary		**Not routinely necessary : May lead to unnecessary use of [[antibiotics]] (atelectasis mimics infiltrate)
	~~***~~May lead to unnecessary use of [[antibiotics]] (atelectasis mimics infiltrate)		**Consider if:
	**Consider if
	***Diagnosis unclear		***Diagnosis unclear
	***Critically ill		***Critically ill

Zbuchwald: /* Evaluation */

2022-12-09T13:39:48Z

Evaluation

← Older revision		Revision as of 13:39, 9 December 2022
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	==Evaluation==		==Evaluation==
	*Consider rapid RSV testing		*Consider rapid RSV testing
	**However, RSV is NOT linked apnea or acute severity (compared to other causes of bronchiolitis)<ref>Well-appearing Young Infants with RSV Infection:		**However, RSV is NOT linked to apnea or acute severity (compared to other causes of bronchiolitis)<ref>Well-appearing Young Infants with RSV Infection:
	Guidance Related To Criteria for Admission. Harbor-UCLA Pediatric Infectious Diseases, October 2017</ref><ref>Schroeder AR, et al. Pediatrics 2013;132:e1194-201</ref>		Guidance Related To Criteria for Admission. Harbor-UCLA Pediatric Infectious Diseases, October 2017</ref><ref>Schroeder AR, et al. Pediatrics 2013;132:e1194-201</ref>
	**You should NOT use RSV status to drive admission decisions and admission locations (eg, ward, step-down unit, ICU)<ref>Well-appearing Young Infants with RSV Infection:		**You should NOT use RSV status to drive admission decisions and admission locations (eg, ward, step-down unit, ICU)<ref>Well-appearing Young Infants with RSV Infection: