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Department of Pediatrics : Academic Divisions : Emergency Medicine : Resident Manual : Pediatric ED Treatment Guidelines : Bronchiolitis

Introduction

  • Children 1 month-2 years
    • 90% of children have had bronchiolitis by age 2 years
  • Most commonly caused by viral lower respiratory tract infection
    • Many viral causes including RSV
  • Pathophysiology
    • Acute inflammation, edema & necrosis of respiratory epithelium in small airways
    • Increased mucous production
    • Bronchospasm
  • Signs & symptoms
    • Rhinitis
    • Tachypnea, cough
    • Wheezing, crackles
    • Increased work of breathing

Diagnosis

It's a clinical diagnosis!

Diagnose bronchiolitis and assess disease severity on the basis of history and physical examination. Laboratory and/or radiologic studies are not needed for diagnosis.1,2

Assess risk factors for severe disease such as age less than 12 weeks, a history of prematurity, underlying cardiopulmonary disease, or immunodeficiency when making decisions about evaluation and management of children with bronchiolitis.1

Specific indications for obtaining chest x-rays are lacking. Many infants with bronchiolitis have abnormalities on chest radiographs and it is difficult to distinguish atelectasis from infiltrate, bacterial disease from viral. Findings on CXR often lead to overuse of antibiotic.2

Antigen testing for RSV is not necessary. Management outcomes will not change if the causative virus is RSV or another virus. Although, hospital cohorting does require RSV testing.

Treatment

Bronchodilators:

Randomized, controlled trials failed to demonstrate consistent benefit.

Meta-analysis: at best, ¼ treated with bronchodilators have transient, unsustained improvement in clinical score of unclear clinical significance. They do not shorten duration of illness or inpatient length of stay.3

Clinical experience suggests there is an improvement in selected infants therefore, it may be reasonable to administer a trial dose of albuterol to patients, especially when there is a family history of atopy. The patient should be evaluated after the treatment. If there is no improvement in work of breathing, air exchange on exam or oxygen saturations, repeat nebulization treatments are not indicated.1

Racemic epi:

Trials have demonstrated some small improvement in clinical score, O2 sats, heart rate and respirtory rate. There is documentation that it performs better than albuterol in trials, most likely due to alpha effects which help decrease airway edema and secretions. Though epi preferred, albuterol may be the better trial agent because:

  • Lack of studies re: epi use at home
  • Short duration of action of epi
  • Potential side effects of epi

A carefully monitored trial of alpha-adrenergic or beta-adrenergic medication is an option. Inhaled bronchodilators should be continued only if there is a documented positive clinical response to the trial using an objective means of evaluation.1

Steroids:

Randomized, controlled trials showed insufficient evidence to support use of corticosteroids.

Meta-analysis of nearly 1200 patients showed no benefit of steroids vs. placebo in terms of hospital length of stay or clinical scores. Specific data on harm of steroids in this group are lacking.4

One study looking at dexamethasone showed no significant difference in rate of admission or respiratory improvement at 4 hours in moderate-to-severe bronchiolitics.5

Corticosteroids should not be used in the management of bronchiolitis.1

Antibiotics:

Antibacterial medications are indicated in children with coexistence of a bacterial infection. When present, bacterial infection should be treated in the same manner as in the absence of bronchiolitis.1

Oxygen:

Supplemental oxygen is indicated if oxygen saturations fall persistently below 90% in previously healthy infants to keep SaO2 on room air at or above 90%. Oxygen may be discontinued if oxygen saturations are at or above 90% and the infant is feeding well with minimal respiratory distress.

Infants with known history of significant heart or lung disease and prematurity require close monitoring as the oxygen is being weaned.1

Arguments against the above recommendations state that the AAP fails to address impact of chronic or intermittent hypoxia on cognitive and behavioral outcomes long-term which can occur at SaO2 values of 90-94%. Discretion and informed parental input recommended informing clinical decisions.6

Nebulized hypertonic saline???7
Kuzik BA, et al. J Pediatr 2007;151:266-70

  • Prospective, double-blinded multicenter RCT
  • 96 admitted moderately ill bronchiolitics
  • 3 winter seasons 2003-06
  • Randomized to repeat doses of 3% HS or NS
  • Principal outcome measure = hospital LOS
  • 26% reduction LOS among HS group
    • 2.6 + 1.9 days (HS) vs. 3.5 + 2.9 days (NS) (p = .05)
  • No adverse effects
  • Mechanism: removal of inspissated secretions via osmotic hydration, decreases mucosal edema

What predicts severe disease?8,9

Ill or toxic appearance
Gestational age < 34 weeks
Young age, less than 3 months
Respiratory rate > 70/minute
Cyanosis
Oxygen saturation < 90-95%

Risk of apnea: 10,11

High risk criteria determined in one study captured all patients with inpatient apnea (100% sensitivity) using the following:

  • Age below 1 month in term infants
  • Preterm
  • Witnessed apnea by caregiver

Another study determined age less than 2 months to be the strongest independent risk factor for apnea. Also, apnea in the ED or at home increased the risk of further apneic episodes and need for mechanical ventilation.

Proposed ED Nursing Management

Identify patients who might be at increased risk for severe disease by the above criteria; if patient meets above criteria, bring them to a room asap and get MD involved.

For those patients who do not meet above criteria and show evidence of being well-hydrated, mild tachypnea with mild increased work of breathing and are overall stable:

  • Do NOT call RT; Await MD eval as treatments may not be necessary
  • Begin with deep naso-pharyngeal deep suctioning by nursing staff
  • Education to family on nasal bulb suction with saline by nursing staff
  • Evaluation by MD
  • Per above evidence, diagnosis and treatments as indicated but overall unnecessary.
  • Is there a history of eczema or allergies in the patient? Family history of eczema, allergies or asthma?
  • Consider a trial of albuterol in those patientsÉbut if it doesnÕt work, DO NOT send them home with it!

Admission criteria:

  • See section above regarding prediction of severe disease.
  • Also consider admission for those infants with co-morbid conditions, especially cardiopulmonary disease.
  • Asses hydration status and ability of infant to feed and keep him/herself hydrated.
  • Risk of apnea in premature infants and term infants 1-2 months of age
  • Apneic events at home or in the ED

Discharge instructions:

  • Nasopharyngeal suctioning with bulb suction and saline.
  • Give family verbal and written parameters on reasons to return such as increased work of breathing, hydration issues etc.

References

  1. Diagnosis and Management of Bronchiolitis. Pediatrics 2006;118(4):1774-93.
  2. Bordley WC et al. Diagnosis and Testing in Bronchiolitis. Arch Pediatr Adolesc Med 2004;158:119-26
  3. Kellner JD, et al. Cochrane Database Syst Rev 2000;(2):CD001266
  4. Patel H, et al. Cochrane Database Syst Rev 2004;(3):CD004878.
  5. Corneli HM, et al A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med 2007;357:331-9.
  6. Bass JL, Gozal D. Oxygen therapy for bronchiolitis. Pediatrics 2007;119:611.
  7. Kuzik BA, et al. J Pediatr 2007;151:266-70
  8. Mulholland EK, et al. Lancet 1990;335:1259-61.
  9. Shaw KN, et al. Am J Dis Child 1991;145:151-5
  10. Willwerth, Bm, Harper MB, Greenes DS. Identifying hospitalized infants who have bronchiolitis and are at high risk for apnea. Annals of Emerg Med 2006; 48(4):441-447.
  11. Knebyer MC et al. Risk factors for RSV associated apnoea. Eur J Pediatr 1998; 157(4):331-5.

 

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