Bronchiolitis (peds): Difference between revisions

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==Background==
==Background==
*Most common reason for infant hospitalizations in the US<ref>Suh M, Movva N, Jiang X, Bylsma LC, Reichert H, Fryzek JP, Nelson CB. Respiratory Syncytial Virus Is the Leading Cause of United States Infant Hospitalizations, 2009-2019: A Study of the National (Nationwide) Inpatient Sample. J Infect Dis. 2022 Aug 15;226(Suppl 2):S154-S163. doi: 10.1093/infdis/jiac120. PMID: 35968878; PMCID: PMC9377046.</ref>
*[[Respiratory syncytial virus]] (RSV) causes ~70% of cases of bronchiolitis<ref>Papadopoulos NG; Moustaki M; Tsolia M; Bossios A; Astra E; Prezerakou A (2002). Am J Respir Crit Care Med.</ref>
*<2yr old (peak 2-6mo age)
*<2yr old (peak 2-6mo age)
*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 disease]] are at risk for serious disease
*Preemies, neonates, [[congenital heart disease]] are at risk for serious disease
*Peaks in winter
*Peaks in winter (November to March)
*Duration = 7-14d (worst during days 3-5)
*Duration = 7-14d (worst during days 3-5)
*Inflammation, edema, and epithelial necrosis of bronchioles
*Inflammation, edema, mucus production, and epithelial necrosis of bronchioles lead to lower airway obstruction
**Hypoxemia due to V/Q mismatch of poorly ventilated alveolar units


==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]], respiratory distress (retractions, nasal flaring)
**[[Fever]] is usually low-grade or absent
**[[Fever (Peds)|Fever]] is usually low-grade or absent
***If high-grade fever consider [[Otitis Media]], [[UTI]]
***If high-grade fever consider [[otitis media]], [[UTI (peds)|UTI]], or other bacterial infections
*Assess for dehydration (tachypnea may interfere with feeding)
*Assess for [[dehydration (peds)|dehydration]] (tachypnea may interfere with feeding)
**Sunken fontanelle, decreased PO intake, decreased wet diapers, and lethargy


==Differential Diagnosis==
==Differential Diagnosis==
*[[Asthma]]
{{Pediatric SOB DDX}}
*[[Bacterial tracheitis]]
*[[Croup]]
*[[Pneumonia]]
*[[Foreign body]]
*[[Pertusis]]
*[[CHF]]
*Cystic fibrosis
*Vascular ring


==Evaluation==
==Evaluation==
*Bronchiolitis is a clinical diagnosis
*Consider rapid RSV testing
*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:
**However, RSV is NOT linked to 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>
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:
**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>
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>
*Consider CBC and CRP to assess the risk of superimposed bacterial infection


*[[CXR]]
*[[CXR]]
**Not routinely necessary
**Not routinely necessary : May lead to unnecessary use of [[antibiotics]] (atelectasis from airway plugging mimics infiltrate)
***May lead to unnecessary use of[[ antibiotics]] (atelectasis mimics infiltrate)
**Consider if patient is critically ill or diagnosis unclear
**Consider if
***Diagnosis unclear
***Critically ill


===Concurrent infection risk===
===Concurrent infection risk===
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*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==
==Management==
*Note that supportive care remains the mainstay of therapy
*Hydration for all infants
*Hydration for all infants
===[[Oxygen]]===
 
===[[Oxygen]]/High Flow===
''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>''
''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 (for patients with O2 sat of 88% or above)<ref name="Schuh">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>
**Primary benefits is from the high flow rate; optimize the flow upon initiation.
**Initial Settings
***Temperature: 37C (usually)
***Initial flow rate: Based on age/weight. Can be started at 1-2 L/kg per min.
***Oxygen (FiO2): 21% to 100%, based on patient’s prior oxygenation; goal of 94% to 99%.


*High flow nasal canula
*Nasal CPAP or intubation may be necessary for evolving respiratory failure
**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.''
''There is insufficient data to make an evidence-based recommendation about suctioning.''
*Nasopharyngeal suctioning may temporarily relieve symptoms
*Nasopharyngeal suctioning may temporarily relieve symptoms due to decrease in total airway resistance
*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 Saline===
===Nebulized Hypertonic Saline (3%)===
''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>''
''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>''
*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>
*No decrease in hospital admission 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]]))
*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
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===Not Indicated===
===Not Indicated===
''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>
''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]]/bronchodialator ([[Evidence_Based_Recommendation_Levels|Class B]])<ref name="AAP guides"></ref>
*[[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, as this may present a greater reactive airway component
*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
**Note that AAP recommends against systemic steroids in any settings<ref>Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics November 2014; 134 (5): e1474–e1502. 10.1542/peds.2014-2742</ref>
*Antibiotics
**Only indicated if there is strong suspicion of, or proven bacterial infection


==Disposition==
==Disposition==
===Consider Admission===
===Consider Admission===
*Age <3months
*Age <3 months
*Preterm (<34wks)
*Preterm (<34wks)
*Underlying heart/lung disease
*Underlying heart/lung disease
*Initial SaO2 <90%
*Initial SaO2 <88% <ref name="Schuh"/>
**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 alone be used as a factor for admission
*Unable to tolerate PO
*Unable to tolerate PO
*Tachypnea with accessory muscle use
*Tachypnea with accessory muscle use
*Caregiver unreliable or otherwise unstable home situation


==See Also==
==See Also==
Line 91: Line 101:
==External Links==
==External Links==
*[http://pemplaybook.org/podcast/bronchiolitis/ Pediatric Emergency Playbook Podcast: Bronchiolitis]
*[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==

Latest revision as of 02:40, 7 November 2023

Background

  • Most common reason for infant hospitalizations in the US[1]
  • Respiratory syncytial virus (RSV) causes ~70% of cases of bronchiolitis[2]
  • <2yr old (peak 2-6mo age)
  • Preemies, neonates, congenital heart disease are at risk for serious disease
  • Peaks in winter (November to March)
  • Duration = 7-14d (worst during days 3-5)
  • Inflammation, edema, mucus production, and epithelial necrosis of bronchioles lead to lower airway obstruction
    • Hypoxemia due to V/Q mismatch of poorly ventilated alveolar units

Clinical Features

  • Symptoms
  • Signs
    • Tachypnea, cyanosis, wheezing, respiratory distress (retractions, nasal flaring)
    • Fever is usually low-grade or absent
      • If high-grade fever consider otitis media, UTI, or other bacterial infections
  • Assess for dehydration (tachypnea may interfere with feeding)
    • Sunken fontanelle, decreased PO intake, decreased wet diapers, and lethargy

Differential Diagnosis

Pediatric Shortness of Breath

Pulmonary/airway

Cardiac

Other diseases with abnormal respiration

Evaluation

  • Bronchiolitis is a clinical diagnosis
  • Consider rapid RSV testing
    • However, RSV is NOT linked to apnea or acute severity (compared to other causes of bronchiolitis)[3][4]
    • You should NOT use RSV status to drive admission decisions and admission locations (eg, ward, step-down unit, ICU)[5][6]
  • Consider CBC and CRP to assess the risk of superimposed bacterial infection
  • CXR
    • Not routinely necessary : May lead to unnecessary use of antibiotics (atelectasis from airway plugging mimics infiltrate)
    • Consider if patient is critically ill or diagnosis unclear

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

  • Note that supportive care remains the mainstay of therapy
  • Hydration for all infants

Oxygen/High Flow

It is reasonable to not perform continuous oximetry on infants and children with bronchiolitis[7]

  • O2 (maintain SaO2 >90%)
    • Oxygen saturation alone should not dictate admission (for patients with O2 sat of 88% or above)[8]
  • High flow nasal cannula
    • Multicenter randomized trial showed infants with bronchiolitis and hypoxemia required less escalation of therapy than standard oxygen [9]
    • Primary benefits is from the high flow rate; optimize the flow upon initiation.
    • Initial Settings
      • Temperature: 37C (usually)
      • Initial flow rate: Based on age/weight. Can be started at 1-2 L/kg per min.
      • Oxygen (FiO2): 21% to 100%, based on patient’s prior oxygenation; goal of 94% to 99%.
  • Nasal CPAP or intubation may be necessary for evolving respiratory failure

Suctioning

There is insufficient data to make an evidence-based recommendation about suctioning.

  • Nasopharyngeal suctioning may temporarily relieve symptoms due to decrease in total airway resistance
  • The use of routine “deep” suctioning may lead to increased length of stay based on one small study [7]

Nebulized Hypertonic Saline (3%)

AAP recommends as a possible intervention, but 2014 SABRE trial found no change in discharge or adverse events with nebulised HS.[10]

  • No decrease in hospital admission 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[11]
  • Only consider administering to infants who require hospitalization[7] (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.[12][13][14]

  • Albuterol/bronchodilator (Class B)[7]
    • May trial if strong family hx of asthma/atopy in older infants, as this may present a greater reactive airway component
  • Racemic Epinephrine (Class B)[7]
  • Steroids[7][15]
    • Consider dexamethasone 0.6-1mg/kg PO or IM x1 in severe cases
    • Note that AAP recommends against systemic steroids in any settings[16]
  • Antibiotics
    • Only indicated if there is strong suspicion of, or proven bacterial infection

Disposition

Consider Admission

  • Age <3 months
  • Preterm (<34wks)
  • Underlying heart/lung disease
  • Initial SaO2 <88% [8]
    • Sa02 alone should not alone be used as a factor for admission
  • Unable to tolerate PO
  • Tachypnea with accessory muscle use
  • Caregiver unreliable or otherwise unstable home situation

See Also

External Links

References

  1. Suh M, Movva N, Jiang X, Bylsma LC, Reichert H, Fryzek JP, Nelson CB. Respiratory Syncytial Virus Is the Leading Cause of United States Infant Hospitalizations, 2009-2019: A Study of the National (Nationwide) Inpatient Sample. J Infect Dis. 2022 Aug 15;226(Suppl 2):S154-S163. doi: 10.1093/infdis/jiac120. PMID: 35968878; PMCID: PMC9377046.
  2. Papadopoulos NG; Moustaki M; Tsolia M; Bossios A; Astra E; Prezerakou A (2002). Am J Respir Crit Care Med.
  3. Well-appearing Young Infants with RSV Infection: Guidance Related To Criteria for Admission. Harbor-UCLA Pediatric Infectious Diseases, October 2017
  4. Schroeder AR, et al. Pediatrics 2013;132:e1194-201
  5. Well-appearing Young Infants with RSV Infection: Guidance Related To Criteria for Admission. Harbor-UCLA Pediatric Infectious Diseases, October 2017
  6. Schroeder AR, et al. Pediatrics 2013;132:e1194-201
  7. 7.0 7.1 7.2 7.3 7.4 7.5 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
  8. 8.0 8.1 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
  9. 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.
  10. 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.
  11. 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.
  12. Bjornson CL. et al. A randomized trial of a single dose of oral dexamethasone for mild croup. NEJM. 2004;351:1306-1313.
  13. 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
  14. 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
  15. 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
  16. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics November 2014; 134 (5): e1474–e1502. 10.1542/peds.2014-2742