Difference between revisions of "Bronchiolitis (peds)"

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==Disposition==
 
==Disposition==
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#Age <3months
 
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#Conventional treatment used (epi, dex) and no rebound stridor in 2h<ref>Ross JD, et al. The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department. J Emerg Med. 1998; 16:535-539.</ref><ref>Kelley PB, et al. Racemic epinephrine use in croup and disposition. J Emerg Med. 1992; 10:181-183.</ref>
 
#Conventional treatment used (epi, dex) and no rebound stridor in 2h<ref>Ross JD, et al. The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department. J Emerg Med. 1998; 16:535-539.</ref><ref>Kelley PB, et al. Racemic epinephrine use in croup and disposition. J Emerg Med. 1992; 10:181-183.</ref>
  

Revision as of 13:15, 11 February 2015

Background

  • <2yr old (peak 2-6mo age)
  • Respiratory Syncytial Virus (RSV) causes ~70% of cases[1]
  • 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

Differential Diagnosis

  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.[2][3][4]

Oxygen

  • The AAP guidelines also state that it is reasonable to not perform continuous oximetry on infants and children with bronchiolitis[5]
  • O2 (maintain SaO2 >90%)
    • oxygen saturation alone should not dictate admission[6]

Albuterol

  • Do not administer bronchodilator therapy[5](Class B)

Epinephrine

  • Do not administer racemic epinephrine[5] (Class B)

Hypertonic Saline

  • Only consider administer to infants who require hospitalization[5] (Class B))
  1. Suction nares / nasal saline drops

Although AAP recommends as a possible intervention. the SABRE trial found no support the use of nebulised HS in the treatment of acute bronchiolitis in regard to time to discharge or adverse events. [7]

Suctioning

  • Nasopharyngeal suctioning may temporarily relieve symptoms
  • Do not perform deep suctioning since it will increase length of stay with no added benefit[5]

Steroids

Do not administer steroids[5][8]

Disposition

Consider Admission

  1. Age <3months
  2. Preterm (<34wks)
  3. Underlying heart/lung disease
  4. Initial SaO2 <90%
    • Sa02 alone should not be used as the only factor for admission[9]
  5. Unable to tolerate PO

Consider Discharge

  1. Conventional treatment used (epi, dex) and no rebound stridor in 2h[10][11]

See Also

Croup

Source

  1. Papadopoulos NG; Moustaki M; Tsolia M; Bossios A; Astra E; Prezerakou A (2002). Am J Respir Crit Care Med.
  2. Bjornson CL. et al. A randomized trial of a single dose of oral dexamethasone for mild croup. NEJM. 2004;351:1306-1313.
  3. 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
  4. 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
  5. 5.0 5.1 5.2 5.3 5.4 5.5 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
  6. 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
  7. 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.
  8. 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
  9. Schuh S, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014; 312(7):712-718.
  10. Ross JD, et al. The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department. J Emerg Med. 1998; 16:535-539.
  11. Kelley PB, et al. Racemic epinephrine use in croup and disposition. J Emerg Med. 1992; 10:181-183.