Bronchiolitis (peds): Difference between revisions

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==Background==
==Background==
*<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>  
*[[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 dz are at risk for serious disease
*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)
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==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 [[Otitis Media]], [[UTI]]
***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==
*[[Asthma]]
{{Pediatric SOB DDX}}
*[[Croup]]
*[[PNA]]
*[[Foreign body]]
*[[Pertusis]]
*[[CHF]]
*Cystic fibrosis
*Vascular ring


==Diagnosis==
==Evaluation==
*Rapid RSV
*Consider rapid RSV testing
**Obtain if <1mo old
**However, RSV is NOT linked to apnea or acute severity (compared to other causes of bronchiolitis)<ref>Well-appearing Young Infants with RSV Infection:
**If positive then admit
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>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]] (atelectasis mimics infiltrate)
***May lead to unnecessary use of[[ antibiotics]] (atelectais mimics infiltrate)
**Consider if:
**Consider if
***Diagnosis unclear
***Diagnosis unclear
***Critically ill
***Critically ill
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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==
===[[Oxygen]]===
*Hydration for all infants
*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>
 
===[[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>''


*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%.


===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>
There is insufficient data to make a recommendation about suctioning.


===Hypertonic Saline===
===Nebulized Hypertonic Saline (3%)===
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 administer to infants who require hospitalization<ref name="AAP guides"></ref> ([[Evidence_Based_Recommendation_Levels|Class B]]))
*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]]))
**Suction nares / nasal saline drops
**Suction nares / nasal saline drops


===Not Indicated===
===Not Indicated===
''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 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]]/bronchodialater ([[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
*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==
===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
===Consider Discharge===
*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>


==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==

Latest revision as of 13:46, 9 December 2022

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

Differential Diagnosis

Pediatric Shortness of Breath

Pulmonary/airway

Cardiac

Other diseases with abnormal respiration

Evaluation

  • Consider rapid RSV testing
    • However, RSV is NOT linked to apnea or acute severity (compared to other causes of bronchiolitis)[2][3]
    • You should NOT use RSV status to drive admission decisions and admission locations (eg, ward, step-down unit, ICU)[4][5]
  • CXR
    • Not routinely necessary : May lead to unnecessary use of antibiotics (atelectasis 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
  • 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/High Flow

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 (for patients with O2 sat of 88% or above)[7]
  • High flow nasal cannula
    • Multicenter randomized trial showed infants with bronchiolitis and hypoxemia required less escalation of therapy than standard oxygen [8]
    • 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%.

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]

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.[9]

  • 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[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]

Disposition

Consider Admission

  • Age <3 months
  • Preterm (<34wks)
  • Underlying heart/lung disease
  • Initial SaO2 <88% [7]
    • Sa02 alone should not alone be used as a factor for admission
  • Unable to tolerate PO
  • Tachypnea with accessory muscle use

See Also

External Links

References

  1. ↑ Papadopoulos NG; Moustaki M; Tsolia M; Bossios A; Astra E; Prezerakou A (2002). Am J Respir Crit Care Med.
  2. ↑ Well-appearing Young Infants with RSV Infection: Guidance Related To Criteria for Admission. Harbor-UCLA Pediatric Infectious Diseases, October 2017
  3. ↑ Schroeder AR, et al. Pediatrics 2013;132:e1194-201
  4. ↑ Well-appearing Young Infants with RSV Infection: Guidance Related To Criteria for Admission. Harbor-UCLA Pediatric Infectious Diseases, October 2017
  5. ↑ Schroeder AR, et al. Pediatrics 2013;132:e1194-201
  6. ↑ 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
  7. ↑ 7.0 7.1 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
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ Bjornson CL. et al. A randomized trial of a single dose of oral dexamethasone for mild croup. NEJM. 2004;351:1306-1313.
  12. ↑ 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
  13. ↑ 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
  14. ↑ 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
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