Bronchiolitis (peds): Difference between revisions
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#CA
#CA


==Treatment<ref>Cherry J. Clinical practice. Croup. NEJM. 2008; 358; 68:453-456</ref><ref>Zorc J. Bronchiolitis: recent evidence on diagnosis and management. Pediatrics. 2010: 125:343-349</ref>==
==Treatment==
#O2 (maintain SaO2 >90%)
;Randomized controlled trials of bronchodilater 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>
#Racemic epi neb
 
##Only repeat if initial beneficial response
===Oxygen===
#+/- albuterol
*The AAP guidelines also state that it is reasonable to not perform continuous oximetry on infants and children with bronchiolitis<ref name="AAP guides">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 [http://pediatrics.aappublications.org/content/early/2014/10/21/peds.2014-2742.full.pdf+html PDF]
 
*O2 (maintain SaO2 >90%)
**oxygen saturation alone should not dictate admission<ref>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>
===Albuterol===
*Do not administer bronchodilator therapy<ref name="AAP guides"></ref>([[Evidence_Based_Recommendation_Levels|Class B]])
 
===Epinephrine===
*Do not administer racemic epinephrine<ref name="AAP guides"></ref> ([[Evidence_Based_Recommendation_Levels|Class B]])
===Hypertonic Saline===
*Only administer to infants who require hospitalization<ref name="AAP guides"></ref> ([[Evidence_Based_Recommendation_Levels|Class B]]))
#Suction nares / nasal saline drops
#Suction nares / nasal saline drops
#Steroids
##Consider 0.6mg/kg of dexamethasone


;Randomized controlled trials of bronchodilater 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>
===Suctioning==-
*Nasopharyngeal suctioning may temporarily relieve symptoms
*Do not perform deep suctioning since it will increase length of stay with no added benefit<ref name="AAP guides"></ref>
 
====Steroids===
Do not administer 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>


==Disposition==
==Disposition==

Revision as of 15:56, 30 November 2014

Background

  • <2yr old (peak 2-6mo age)
  • Preemies, neonates, congenital heart dz are at risk for serious disease
  • Peaks in winter
  • Duration = 7-14d (worst during days 3-5)
  • Inflammation, edema, and epithelial necrosis of bronchioles

Diagnosis

  • 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)

Work-Up

  • Rapid RSV
    • Obtain if <1mo old
    • If positive then admit pt
  • CXR
    • Not routinely necessary
      • May lead to unnecessary use of abx (atelectais mimics infiltrate)
    • Consider if
      • Diagnosis unclear
      • Critically ill
  • Infants <60 days with RSV bronchiolitis and fever
    • Concern is for SBI with RSV
    • UTI 5.4% in RSV+, 10.1% RSV-
    • Bacteremia 1.1% RSV+, 2.3% RSV-
    • Meningitis 0% RSV+, 0.9% RSV-
    • CONCLUSION-Low risk of bacteremia and meningitis in RSV+, still appreciable UTI risk

DDx

  1. Asthma
  2. PNA
  3. Foreign Body
  4. Pertusis
  5. CHF
  6. Cystic fibrosis
  7. Vascular ring
  8. CA

Treatment

Randomized controlled trials of bronchodilater or corticosteroid therapy have shown mixed results. Bronchodilators could aggravate the symptoms.[1][2][3]

Oxygen

  • The AAP guidelines also state that it is reasonable to not perform continuous oximetry on infants and children with bronchiolitisCite error: Closing </ref> missing for <ref> tag

Albuterol

  • Do not administer bronchodilator therapy[4](Class B)

Epinephrine

  • Do not administer racemic epinephrine[4] (Class B)

Hypertonic Saline

  • Only administer to infants who require hospitalization[4] (Class B))
  1. Suction nares / nasal saline drops

===Suctioning==-

  • Nasopharyngeal suctioning may temporarily relieve symptoms
  • Do not perform deep suctioning since it will increase length of stay with no added benefit[4]

=Steroids

Do not administer steroids[4][5]

Disposition

Consider admission for:

  1. Age <3months
  2. Preterm (<34wks)
  3. Underlying heart/lung disease
  4. Initial SaO2 <92%
  5. Unable to tolerate PO

See Also

Croup

Source

  • Rosen's, Tintinalli
  • Pediatrics.2004 Jun;113(6):1728-34
  1. ↑ Bjornson CL. et al. A randomized trial of a single dose of oral dexamethasone for mild croup. NEJM. 2004;351:1306-1313.
  2. ↑ 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
  3. ↑ 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
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Cite error: Invalid <ref> tag; no text was provided for refs named AAP guides
  5. ↑ 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
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