Author:
SuzanneSchuh
Description
Lower respiratory tract infection with airway inflammation and bronchoconstriction
Etiology
- Respiratory syncytial virus (RSV) in 85-90% of cases
- Influenza
- Parainfluenza
- Adenovirus
- Normally occurs during the winter months
Signs and Symptoms
- Usual age ≤12 mo. Bronchiolitis is generally the first episode of the combination of URI, cough, and respiratory distress in children <12 mo
- Nasal congestion, rhinorrhea
- Cough
- Crackles, wheezing, rhonchi
- Respiratory distress with tachypnea, nasal flaring, retractions, grunting
- Fever usually <39.5°C
- Hypoxemia may be present. Cyanosis rare
- Decreased fluid intake common, frank dehydration uncommon
- Apnea may occur, particularly in infants ≤2 mo of age, with a history of prematurity
- Synagis, RSV-specific immunoglobulin administered IM monthly to high-risk children during winter months. Reduces risk of developing bronchiolitis
Essential Workup
- Clinical diagnosis
- Assess ventilation clinically
- Pulse oximetry:
- Not predictive of disease course in mild bronchiolitis but useful in assessing patient when combined with clinical evaluation
- Confirms proper oxygenation if in any distress or on supplemental oxygen
Diagnostic Tests & Interpretation
Lab
- Most patients need no specific tests
- Nasopharyngeal aspirate/wash:
- Viral cultures
- Fluorescent antibodies; commercial kits available
- Not routinely indicated. Consider when:
- Clinical symptoms suggestive of other cause (pertussis, chlamydia)
- Critically ill child
- Febrile bronchiolitis in child <3 mo old (especially newborns); consider coexistent UTI
- Signs suggesting significant bacterial infection (positive aspirate does not exclude coexisting significant bacterial infection, but such infections are uncommon)
- Bronchopulmonary dysplasia, chronic lung disease, cardiac disease
- Prematurity
- Other conditions warranting antiviral therapy (rare)
Imaging
CXR:
- Not routinely indicated
- Usually hyperinflation, airway disease, atelectasis, variable infiltrate
- Atelectasis in young infants indicates more severe disease
- Minority have airway + airspace disease; pneumonia usually viral
- Rarely changes management
- Consider when:
- Need to exclude other diagnoses such as CHF, aspiration, congenital airway anomaly (rare)
- Chronic course with lack of resolution over 2-3 wk
- Critically ill with impending respiratory failure
- Atypical presentation in toxic or deteriorating child
Diagnostic Procedures/Surgery
- Septic workup in febrile bronchiolitis <28 d of age if respiratory status permits
- In febrile infants 1-3 mo of age, consider catheterized urine culture
- Continuous oximetry if significant distress. Oximetry and close clinical monitoring are useful in ongoing assessment. Variability in oximetry readings is present in those <90%
Differential Diagnosis
- Asthma/recurrent virus-induced wheezing: Severe bronchiolitis requiring hospitalization, and family history of atopy are risk factors for future asthma
- Pertussis: No respiratory distress between coughing spasms, no wheezing
- Bacterial pneumonia: Often toxic appearance, no wheezing, isolated airspace disease (consolidation) with no airway abnormality on CXR
- Foreign body: Sudden onset of symptoms, usually afebrile
- CHF: Pre-existing clinical red flags (failure to thrive [FTT], feeding problems)
Prehospital
ALERT |
- Young infants have limited respiratory reserve and decompensate rapidly with little warning
- Assess cardiorespiratory status and interpret oxygenation in clinical context
- Supplemental oxygen if saturation <90% (sea level) and /or marked respiratory distress
- Watch for apneic pauses:
- Greatest risk of developing apnea is in high-risk newborns, children <7 wk, weight <4 kg, respiratory rate >80/min, heart rate >180/min. Comorbidities and prematurity enhance risk
- Bag-mask ventilation if recurrent apneas
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Initial Stabilization/Therapy
- Pediatric advanced life support: Airway, ventilation, and fluid hydration
- Measure oximetry and assess work of breathing
- Emergent intubation if recurrent apneas, impending respiratory failure
- Nasal suctioning may be useful
ED Treatment/Procedures
- Supplemental oxygen if oxygen saturation <90% (measured awake at sea level) and /or respiratory distress. Monitor oximetry
- Nasal suctioning may improve nasal patency and feeding
- High-flow nasal cannula - while criteria not yet established, useful in infants in severe respiratory distress with increasing supplemental oxygen requirements to maintain acceptable oxygen saturations
- Parenteral hydration if dehydration or severe respiratory distress
- Bronchodilators (albuterol, racemic epinephrine, l-epinephrine), corticosteroids; not routinely indicated in bronchiolitis but may have short-term impact in seriously ill children and /or those with atopy
- Some clinicians administer bronchodilators on a trial basis of 2-3 consecutive treatments in those with moderate to severe distress and continue as part of management if there is a clear decrease in the work of breathing. Generally, does not change overall disease outcome
- Hypertonic saline is not beneficial
- Steroids: On their own, steroids do not change clinical course or rate of hospitalization in the majority of patients without recurrent episodes of bronchiolitis, prior atopy, or a family allergic history
- Antibiotics:
- Not generally indicated since viral etiology
- Consider if associated signs of focal bacterial disease (otitis media), radiographic evidence of isolated lobar consolidation without airway disease (usually bacterial pneumonia rather than bronchiolitis), significant toxicity, suspected sepsis
- Ribavirin:
- No role in ED management and rarely used in the inpatient setting
Medication
- Pharmacotherapy is not generally indicated for the first episode of mild bronchiolitis in those <12 mo
- Asthma therapy with bronchodilators and corticosteroids often utilized in children around 1 yr of age with repetitive bronchiolitis-like episodes, esp with family history of asthma. A therapeutic trial can be considered and agent continued if there is improvement in work of breathing
- Albuterol: 2.5 mg/3 mL; 2-3 doses by nebulizer or 400 mcg via MDI/spacer 20-30 min apart in the ED. Therapeutic trial should be the basis of continuing therapy. Rarely changes outcome
- L-epinephrine: 3 mL (1:1,000 soln): 2 doses via nebulizer 30 min apart
- Racemic epinephrine 2.25%: 0.25-0.5 mL nebulized in 2.5 mL NS
- Prednisolone (15 mg/5 mL): 1-2 mg/kg/d PO b.i.d/3-5 d if recurrent bronchiolitis or atopy/asthma
- Dexamethasone: 1 mg/kg/dose PO in ED, then 0.15 mg/kg/d for 5 d
Disposition
Admission Criteria
- Need for supplemental oxygen (oxygen saturation on room air is <90% at sea level while awake)
- Need for parenteral hydration
- Severe retractions, nasal flaring, grunting irrespective of saturations
- Witnessed or suspected apnea
- Comorbidity such as underlying chronic lung disease or cardiac disease
- Suspicion of alternative diagnosis/underlying systemic disease, immunodeficiency, or immunosuppressive therapy
- Strongly consider in infants <2 mo, respiratory rate >70 breaths per min, heart rate >180 beats per min, prematurity
- Caretaker noncompliant or unable to monitor child closely
Discharge Criteria
- Feeding well and hydrated
- Acceptable room air saturation (see above)
- Absence of significant respiratory distress or increased work of breathing
- Follow-up available within 24 hr
- Compliant home environment
- Protocols for discharge on home oxygen are evolving
- Meets all inclusion criteria:
- Upper airway infection associated with wheezing ± crackles
- 2 mo-2 yr of age (> 44 wk gestational age)
- First-time wheezing
- ED visit between December and April
- Secretions manageable by suctioning
- Smoke-free home environment
- Reliable family. Access EMS. Follow-up in 24 hr
- Lives in altitude ≤6,000 ft
- NO identified exclusion criteria:
- Toxic appearance or evidence of bacterial disease
- ALTE occurring with illness
- Cardiac, chronic lung, or neuromuscular disease
- Oxygen requirement at baseline
- Immunodeficiency
- Recent admission or ED visit during prior 7 d
- Clinical evidence of mild illness after suctioning and observation for ≥4 hr
- Alert, active, and feeding well
- None to minimal retractions
- Respiratory rate <50 breaths/min
- Adequate oxygenation (≥90% measured awake at sea level) on ≤0.5 L/min on oxygen
- Discharge instructions:
- Symptoms may persist for 2-3 wk
- Frequent small feeds. Monitor hydration/urination
- Nasal suctioning prior to feeds
- Clear follow-up appointment in 24-48 hr
Follow-up Recommendations
- Ability to feed and carry out usual activities that provide reassurance
- Inappropriate lethargy, poor feeding, and poor urine output are worrisome and require immediate evaluation
- Critical to inform parents about need for nasal patency, frequent feeding, and red flags signifying deterioration
- Arrangements for follow-up within 24-48 is essential
- CorneliHM, ZorcJJ, MahajanP, et al. A multicenter, rand omized, controlled trial of dexamethasone for bronchiolitis . N Engl J Med. 2007;357:331-339.
- CunninghamS, RodriquezA, AdamsT, et al. Oxygen saturation targets in infants with bronchiolitis: A double-blind rand omized equivalency trial . Lancet. 2015;386:1041-1048.
- FlettKB, BreslinK, BraunPA, et al. Outpatient course and complications associated with home oxygen therapy with mild bronchiolitis . Pediatrics. 2014;133:769-774.
- FosterSJ, CooperMN, OosterhofS, et al. Oral prednisolone in preschool children with virus-associated wheeze: A prospective, rand omized, double-blind, placebo-controlled trial . Lancet Respir Med. 2018;6(2):97-106.
- FranklinD, BablFE, SchlapbachLJ, et al. A rand omized trial of high-flow oxygen therapy in infants with bronchiolitis . New Eng J Med. 2018;378:1121-1131.
- KepreotesE, WhiteheadB, AttiaJ, et al. High-flow warm humidified oxygen versus stand ard low-flow cannula oxygen for moderate bronchiolitis: An open, phase 4 rand omized controlled trial . Lancet. 2017;389:930-939.
- PrincipiT, CoatesAL, ParkinPC, et al. Effect of oxygen desaturations on subsequent medical visits in infants discharged from the emergency department with bronchiolitis . JAMA Pediatr. 2016;170(6):602-608.
- RalstonSL, HillV, WatersA. Occult serious bacterial infection in infants younger than 60 days with bronchiolitis . Arch Pediatr Adolesc Med. 2011;165:951-956.
- RalstonSL, LieberthalAS, ArchMeissnerHC, et al. Clinical practice guidelines: The diagnosis, management and prevention of bronchiolitis . Pediatrics. 2014;134:e1474-e1502.
- RossPA, NewthCJL, KhemaniRG. Accuracy of pulse oximetry in children . Pediatrics. 2014;133:22-29.
- SchuhS, BablFE, DalzielSR, et al. Practice variation in acute bronchiolitis: A pediatric emergency research Networks study . Pediatrics. 2017;140(6):e20170842.
- SchuhS, FreedmanS, CoatesA, et al. Effect of oximetry on hospitalization in bronchiolitis—A rand omized clinical trial . JAMA. 2014;312(7):712-718.
See Also (Topic, Algorithm, Electronic Media Element)
Asthma, Pediatric