Bronchiolitis (peds): Difference between revisions
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==Background== | ==Background== | ||
*<2yr old (peak 2-6mo age) | *<2yr old (peak 2-6mo age) | ||
*Respiratory | *[[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 | *Preemies, neonates, [[congenital heart disease]] are at risk for serious disease | ||
*Peaks in winter | *Peaks in winter | ||
*Duration = 7-14d (worst during days 3-5) | *Duration = 7-14d (worst during days 3-5) | ||
Line 9: | Line 9: | ||
==Clinical Features== | ==Clinical Features== | ||
*Symptoms | *Symptoms | ||
**Rhinorrhea, cough, irritability, apnea (neonates) | **[[Rhinorrhea]], [[cough]], irritability, apnea (neonates) | ||
*Signs | *Signs | ||
**Tachypnea, cyanosis, wheezing, retractions | **[[shortness of breath (peds)|Tachypnea]], cyanosis, [[wheezing]], retractions | ||
**[[Fever]] is usually low-grade or absent | **[[Fever (Peds)|Fever]] is usually low-grade or absent | ||
***If high-grade fever consider [[ | ***If high-grade fever consider [[otitis media]], [[UTI (peds)|UTI]] | ||
*Assess for dehydration (tachypnea may interfere with feeding) | *Assess for [[dehydration (peds)|dehydration]] (tachypnea may interfere with feeding) | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Pediatric SOB DDX}} | |||
== | ==Evaluation== | ||
* | *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: | ||
** | 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: | |||
Guidance Related To Criteria for Admission. Harbor-UCLA Pediatric Infectious Diseases, October 2017</ref></ref><ref>Schroeder AR, et al. Pediatrics 2013;132:e1194-201</ref> | |||
*CXR | *[[CXR]] | ||
**Not routinely necessary | **Not routinely necessary | ||
***May lead to unnecessary use of[[ antibiotics]] ( | ***May lead to unnecessary use of [[antibiotics]] (atelectasis mimics infiltrate) | ||
**Consider if | **Consider if | ||
***Diagnosis unclear | ***Diagnosis unclear | ||
Line 42: | Line 37: | ||
*Low risk of bacteremia and [[meningitis]] in RSV+, still appreciable [[UTI]] risk | *Low risk of bacteremia and [[meningitis]] in RSV+, still appreciable [[UTI]] risk | ||
**[[UTI]] 5.4% in RSV+, 10.1% RSV- | **[[UTI]] 5.4% in RSV+, 10.1% RSV- | ||
**Bacteremia 1.1% RSV+, 2.3% RSV- | **[[Bacteremia]] 1.1% RSV+, 2.3% RSV- | ||
**[[Meningitis]] 0% RSV+, 0.9% RSV- | **[[Meningitis]] 0% RSV+, 0.9% RSV- | ||
*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]]=== | ===[[Oxygen]]=== | ||
''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]</ref>'' | |||
*O2 (maintain SaO2 >90%) | *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> | **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> | ||
*High flow nasal cannula | |||
**multicenter randomized trial showed infants with bronchiolitis and hypoxemia required less escalation of therapy than standard oxygen <ref>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.</ref> | |||
===Suctioning=== | ===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 | ||
*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> | ||
===Hypertonic | ===[[Hypertonic saline]]=== | ||
AAP recommends as a possible intervention, but SABRE trial found no change in discharge or adverse events with nebulised HS.<ref>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.</ref> | ''AAP recommends as a possible intervention, but 2014 SABRE trial found no change in discharge or adverse events with nebulised HS.<ref>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.</ref>'' | ||
*Only consider | *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<ref>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.</ref> | ||
*Only consider administering 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 | ||
===Not Indicated=== | ===Not Indicated=== | ||
''Randomized controlled trials of | ''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]]/ | *[[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 | |||
*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 | |||
==Disposition== | ==Disposition== | ||
Line 76: | Line 79: | ||
**Sa02 alone should not be used as the only factor for admission<ref>Schuh S, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014; 312(7):712-718.</ref> | **Sa02 alone should not be used as the only factor for admission<ref>Schuh S, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014; 312(7):712-718.</ref> | ||
*Unable to tolerate PO | *Unable to tolerate PO | ||
*Tachypnea with accessory muscle use | |||
* | |||
==See Also== | ==See Also== | ||
*[[Croup]] | *[[Croup]] | ||
==External Links== | |||
*[http://pemplaybook.org/podcast/bronchiolitis/ Pediatric Emergency Playbook Podcast: Bronchiolitis] | |||
*[https://pedemmorsels.com/tag/bronchiolitis/ PEM Morsels: Bronchiolitis Archives] | |||
*[https://www.cdc.gov/rsv/index.html CDC: Respiratory Syncytial Virus] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Pediatrics]] [[Category:Pulmonary]] | ||
[[Category:ID | [[Category:ID]] |
Revision as of 23:42, 6 March 2021
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
- Rhinorrhea, cough, irritability, apnea (neonates)
- Signs
- Tachypnea, cyanosis, wheezing, retractions
- Fever is usually low-grade or absent
- If high-grade fever consider otitis media, UTI
- Assess for dehydration (tachypnea may interfere with feeding)
Differential Diagnosis
Pediatric Shortness of Breath
Pulmonary/airway
- Airway obstruction
- Structural
- Infectious
- Other
Cardiac
- Congenital heart disease
- Vascular ring
- Cardiac tamponade
- Congestive Heart Failure (peds)
- Myocarditis (peds)
Other diseases with abnormal respiration
- Normal neonatal periodic breathing (misinterpreted by caregivers as abnormal)
- Brief resolved unexplained event
- Anemia
- Abdominal distension (e.g. SBO, liver failure
- Neonatal abstinence syndrome
- Decreased perfusion states
- Metabolic acidosis
- CO Poisoning
- Diaphragm injury
- Renal Failure
- Electrolyte abnormalities
- Organophosphate toxicity
- Tick paralysis
- Fever (Peds)
- Panic attack
- Porphyria
Evaluation
- Consider rapid RSV testing
- CXR
- Not routinely necessary
- May lead to unnecessary use of antibiotics (atelectasis mimics infiltrate)
- Consider if
- Diagnosis unclear
- Critically ill
- Not routinely necessary
Concurrent infection risk
Infants <60 days with RSV bronchiolitis and fever
- Low risk of bacteremia and meningitis in RSV+, still appreciable UTI risk
- UTI 5.4% in RSV+, 10.1% RSV-
- Bacteremia 1.1% RSV+, 2.3% RSV-
- Meningitis 0% RSV+, 0.9% RSV-
- 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]
- Albuterol/bronchodilator (Class B)[6]
- May trial if strong family hx of asthma/atopy in older infants
- Racemic Epinephrine (Class B)[6]
- Steroids[6][14]
- Consider dexamethasone 0.6-1mg/kg PO or IM x1 in severe cases
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
External Links
- Pediatric Emergency Playbook Podcast: Bronchiolitis
- PEM Morsels: Bronchiolitis Archives
- CDC: Respiratory Syncytial Virus
References
- ↑ Papadopoulos NG; Moustaki M; Tsolia M; Bossios A; Astra E; Prezerakou A (2002). Am J Respir Crit Care Med.
- ↑ Well-appearing Young Infants with RSV Infection: Guidance Related To Criteria for Admission. Harbor-UCLA Pediatric Infectious Diseases, October 2017
- ↑ Schroeder AR, et al. Pediatrics 2013;132:e1194-201
- ↑ Well-appearing Young Infants with RSV Infection: Guidance Related To Criteria for Admission. Harbor-UCLA Pediatric Infectious Diseases, October 2017
- ↑ Schroeder AR, et al. Pediatrics 2013;132:e1194-201
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 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
- ↑ 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
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Bjornson CL. et al. A randomized trial of a single dose of oral dexamethasone for mild croup. NEJM. 2004;351:1306-1313.
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ Schuh S, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014; 312(7):712-718.