Bronchiolitis (peds): Difference between revisions
No edit summary
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*Inflammation, edema, and epithelial necrosis of bronchioles
*Inflammation, edema, and epithelial necrosis of bronchioles


==Diagnosis==
==Clinical Features==
*Symptoms
*Symptoms
**Rhinorrhea, cough, irritability, apnea (neonates)
**Rhinorrhea, cough, irritability, apnea (neonates)
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*Assess for dehydration (tachypnea may interfere with feeding)
*Assess for dehydration (tachypnea may interfere with feeding)


==Work-Up==
==Differential Diagnosis==
*[[Asthma]]
*[[Croup]]
*[[PNA]]
*[[Foreign body]]
*[[Pertusis]]
*[[CHF]]
*Cystic fibrosis
*Vascular ring
 
==Diagnosis==
*Rapid RSV
*Rapid RSV
**Obtain if <1mo old
**Obtain if <1mo old
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***Critically ill
***Critically ill


*Infants <60 days with RSV bronchiolitis and fever
===Concurrent infection risk===
**Concern is for SBI with RSV
''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-
**[[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-
**CONCLUSION-Low risk of bacteremia and [[meningitis]] in RSV+, still appreciable [[UTI]] risk
==Differential Diagnosis==
*[[Asthma]]
*[[Croup]]
*[[PNA]]
*[[Foreign body]]
*[[Pertusis]]
*[[CHF]]
*Cystic fibrosis
*Vascular ring


==Treatment==
==Treatment==
;Randomized controlled trials of bronchodilater 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>
;Randomized controlled trials of bronchodilater 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>


===Oxygen===
===[[Oxygen]]===
*The AAP guidelines also state that 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>
*The AAP guidelines also state that 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>


Line 54: Line 54:
**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>


===Albuterol===
*Do not administer bronchodilator therapy<ref name="AAP guides"></ref>([[Evidence_Based_Recommendation_Levels|Class B]])
===Epinephrine===
*Do not administer racemic epinephrine<ref name="AAP guides"></ref> ([[Evidence_Based_Recommendation_Levels|Class B]])
===Hypertonic Saline===
===Hypertonic Saline===
*Only consider administer to infants who require hospitalization<ref name="AAP guides"></ref> ([[Evidence_Based_Recommendation_Levels|Class B]]))
*Only consider administer to infants who require hospitalization<ref name="AAP guides"></ref> ([[Evidence_Based_Recommendation_Levels|Class B]]))
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*Do not perform deep suctioning since it will increase length of stay with no added benefit<ref name="AAP guides"></ref>
*Do not perform deep suctioning since it will increase length of stay with no added benefit<ref name="AAP guides"></ref>


===Steroids===
===Not indicated===
Do not administer 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>
*[[Albuterol]]/bronchodialater ([[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>


==Disposition==
==Disposition==

Revision as of 00:17, 22 September 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

Clinical Features

  • 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)

Differential Diagnosis

Diagnosis

  • 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

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-

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]

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]

Not indicated

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.
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