Bronchiolitis (peds)

Background

Lobes of the lung with related anatomy.
A - Alveoli AS - Septum alveolare BR - Bronchus respiratorius BT - Bronchus terminalis D - Mucous gland DA - Ductus alveolaris M - Musculus N - Nervus PA - Branch of Arteria pulm. PV - Branch of Vena pulm.
  • 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

CXR of a child with RSV showing the typical bilateral perihilar fullness.
  • 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
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