Summary of UptoDate articles on Bronchiolitis, as well as the Clinical Practice Guidelines for Bronchiolitis from the AAP 2014 (most recent)
Bronchiolitis: Characterized by upper respiratory symptoms followed by lower respiratory tract infections of viral etiology in children under 2y. Symptoms are caused by acute inflammation, edema and necrosis of epithelial cells lining small airways and increased mucus productions. Symptoms are rhinitis, cough, tachypnea, wheezing and respiratory distress.
Risk factors for severe disease: Age <12 weeks, hx prematurity, cardiopulmonary disease, immunodeficiency
Causes of Bronchiolitis: RSV (a paramyxovirus), rhinovirus, human metapneumovirus, influenza, adenovirus, coronavirus, parainfluenza.
90% of children are infected with RSV in the first 2 years of life. Infection does not guarantee future immunity.
Diagnosis: Based on history and physical. This means: No routine labs or xrays! They do not change outcomes, unless a patient is sick enough to need ICU admission or has signs of pneumothorax or other resp issues, then get CXR. That’s the academic standpoint. In reality, when you see a baby who isn’t breathing well, you will get a chest xray.
Treatment: Doing nothing is really difficult! Treat dehydration with NG feeds or IVF, treat hypoxia/distress with O2. Nasal suctioning. That’s it. That’s all we’ve got. Keep O2 sats 90% or higher. No steroids. No chest PT. No albuterol per AAP. (From an academic standpoint. In reality, you will try Albuterol in moderate to severe cases to see if it helps, which it may help 10-20% of the time. Per UptoDate, a one time trial is okay.) No racemic epi. No hypertonic saline. (If hospitalized – it is “weakly recommended” to give nebulized hypertonic saline. UptoDate says no.)
HFNC = High flow nasal cannula – the greatest new thing! “Heated humidified high-flow nasal cannula therapy and/or continuous positive airway pressure (CPAP) are used to reduce the work of breathing, improve gas exchange, and avoid the need for endotracheal intubation in children with bronchiolitis who are at risk for progression to respiratory failure.” (UptoDate) There’s nothing about this in the 2014 AAP Guidelines because it wasn’t used as much back then. The liter per minute flow is age based, and babies can be started on high flow with room air, then oxygen percentage titrated as needed. Humidification and warming of air is so important because shooting cold/dry air up someone’s nostrils is very drying and irritating. At flow rates of 6L or greater, you’re basically providing CPAP.
Suctioning: Deep suctioning may do more harm than good, causing trauma, edema and laryngospasm. UptoDate recommends just nasal suctioning with saline to remove obstructive mucus. This can also be done by parents at home with nasal saline drops and bulb suction. Especially helpful before feeds to clear out mucus so they can eat and breathe at the same time. Also makes parents feel like they’re doing something.
A note on oxygen: Criteria for admission include O2 sat of 95% or higher, although once hospitalized you only need to keep their sats 90% or higher. Academically, you don’t necessarily need a continuous pulse ox, you can have it spot checked because “The effect of brief periods of hypoxemia caused by bronchiolitis on the developing brain has not been adequately addressed.” per UptoDate. Realistically, if a child is ill, you will put him on a continuous pulse ox. But if she is improving, you can switch over to spot checks q2h initially then q4h (that’s a personal preference, no evidence).
Please do not give pseudoephedrine products/decongestants to children under 2y.
Prevention: Encourage breastfeeding exclusively for at least the first 6 months to decrease morbidity of respiratory infections.
Palivizumab: Given during first year of life to infants with significant heart disease, chronic lung disease of prematurity, 5 monthly doses. Not for well babies gestational age of 29wks or greater.
PHYSICAL EXAM: Count RR over one full minute. > or = 60 is tachypnea, reason to make NPO, observe more closely.
Gen: Watch baby in mom’s arms (or wherever baby is most comfortable), and observe: color, resp rate, head bobbing, nasal flaring, grunting, level of consciousness. Have mom unbundle baby so you can see retractions: subcostal, suprasternal, intercostal etc. Nasal/chest congestion will be grossly audible (without stethescope).
CV: will be tachycardic due to distress. Check cap refill for hydration.
Lungs: Note use of accessory muscles, lungs will have B/L rhonchi, like they’re breathing under water. May have inspiratory and expiratory wheezes.
Neuro: Lethargic versus fussy (never write “irritable” unless you’re prepared to do LP), vigorous crying is a great sign of neurologic wellness
This is what the CXR will look like. It may be read as RML infiltrate or peribronchial cuffing. There is nothing bacterial or lobar here.
(From the personal collections of Melvin L. Wright, DO and Giovanni Piedimonte, MD)
Plan:
- Respiratory: If baby is in distress: Start HFNC with room air, titrate as needed to keep pulse ox 90% or higher. Continuous pulse ox or q2h/q4h spot checks. Suctioning with nasal saline q4h and prn congestion.
2. Fluids/Electrolytes/Nutrition: IVF at 1.5 x maintenance (or OG/NG feeds, although the tube may lead to increased fussiness). Monitor urine output, daily weight for hydration. PO ad lib as long as RR <60, NPO for RR 60 or above.
3. Infectious Disease: RSV requires contact precautions, other viruses require droplet precautions as well. Do not start antibiotics for bronchiolitis. If baby is <1 mo old and has fever of 100.4 or higher, get blood, urine and CSF and start empiric antibiotics. Babies older than this with bronchiolitis have a known source for their fever and can be observed unless they look toxic, then culture and treat empirically until results are back. Tylenol PO/PR q4h prn fever or fussiness. (Can also use Ibuprofen if age >6 months.)
Who do we hospitalize? Babies in respiratory distress, with underlying illnesses that put them at risk, in need of O2, dehydrated in need of fluids, or if parents cannot care for them at home. FYI: ” Approximately 30 percent of infants hospitalized for bronchiolitis are at an increased risk for recurrent wheezing.” per UptoDate. Not asthma, per se, but recurrent wheezing.
When can baby go home? When she can eat and breathe comfortably on her own. She needs to be off O2 for 12h and maintaining her own hydration (ie feeding well enough, likely not as well as normal).
What do we tell parents of babies who don’t need to be hospitalized? Count your baby’s breathing for one full minute. If it is 60 or higher, come back to the office or go to the ER. Also go to the ER or call an ambulance if your baby turns blue or is having difficulty breathing. Explain to parents to look for retractions. You can use nasal saline drops and bulb suction to get mucus out of the nose especially before feeds. However, you will not be able to reach the mucus you hear in baby’s lungs. Your baby will be sick for at least a week. It will get worse after 2-3 days, then gradually improve. She is contagious for 2 weeks after illness begins. Older kids have likely already had this virus, which doesn’t mean they’re immune, but their larger airways and lungs, and the ability to blow their nose will make it more like a regular upper respiratory infection or a cold. You can give Tylenol (PO: 15mg/kg, PR: 15-20mg/kg) for low grade fevers or fussiness. However, if a baby less than one month old has a fever of 100.4 or higher rectally, it’s an emergency and he should go to the ER. If a baby 1-3 months old has the same fever he should at least be evaluated, parents can go to ER if they’re concerned or call the office and make an appointment. Also call office if baby is feeding well, is making less wet diapers, or seems very sleepy.
Additional info:
You can copy and paste this link for the Seattle Children’s bronchiolitis management and HFNC pathways:
https://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdf
