Bronchiolitis (peds)

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

Differential Diagnosis

Evaluation
  • Consider rapid RSV testing
    • However, RSV is NOT linked apnea or acute severity (compared to other causes of bronchiolitis)[2][3]
    • You should NOT use RSV status to drive admission decisions and admission locations (eg, ward, step-down unit, ICU)[4]</ref>[5]
  • CXR
    • Not routinely necessary
      • May lead to unnecessary use of antibiotics (atelectasis 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
  • Recommended to still obtain UA in cases of bronchiolitis w/ fever. BCx and CSF not necessary if >28 days old

Management
  • Hydration for all infants

Oxygen

It is reasonable to not perform continuous oximetry on infants and children with bronchiolitis[6]

  • O2 (maintain SaO2 >90%)
    • oxygen saturation alone should not dictate admission[7]
  • High flow nasal cannula
    • multicenter randomized trial showed infants with bronchiolitis and hypoxemia required less escalation of therapy than standard oxygen [8]

Suctioning

There is insufficient data to make an evidence-based recommendation about 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 [6]

Hypertonic saline

AAP recommends as a possible intervention, but 2014 SABRE trial found no change in discharge or adverse events with nebulised HS.[9]

  • No decrease in hospital admission using 3% HS in 2017 multi-center, RCT for moderate-severe bronchiolitis, with mild adverse events such as worsening of cough were significantly higher in the HS group[10]
  • Only consider administering to infants who require hospitalization[6] (Class B))
    • Suction nares / nasal saline drops

Not Indicated

Randomized controlled trials of bronchodilator or corticosteroid therapy have shown mixed results. Bronchodilators could aggravate the symptoms.[11][12][13]

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[15]
  • Unable to tolerate PO
  • Tachypnea with accessory muscle use

See Also

References
  1. Papadopoulos NG; Moustaki M; Tsolia M; Bossios A; Astra E; Prezerakou A (2002). Am J Respir Crit Care Med.
  2. Well-appearing Young Infants with RSV Infection: Guidance Related To Criteria for Admission. Harbor-UCLA Pediatric Infectious Diseases, October 2017
  3. Schroeder AR, et al. Pediatrics 2013;132:e1194-201
  4. Well-appearing Young Infants with RSV Infection: Guidance Related To Criteria for Admission. Harbor-UCLA Pediatric Infectious Diseases, October 2017
  5. Schroeder AR, et al. Pediatrics 2013;132:e1194-201
  6. 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
  7. 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
  8. Franklin, D., Babl, F. E., Schlapbach, L. J., Oakley, E., Craig, S., Neutze, J., … Schibler, A. (2018). A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. The New England Journal of Medicine, 378(12), 1121–1131.
  9. 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.
  10. Angoulvant F et al. Effect of Nebulized Hypertonic Saline Treatment in Emergency Departments on the Hospitalization Rate for Acute BronchiolitisA Randomized Clinical Trial. June 5, 2017. JAMA Pediatr. Published online June 5, 2017. doi:10.1001/jamapediatrics.2017.1333.
  11. Bjornson CL. et al. A randomized trial of a single dose of oral dexamethasone for mild croup. NEJM. 2004;351:1306-1313.
  12. 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
  13. 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
  14. 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
  15. Schuh S, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014; 312(7):712-718.
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