Back to Basics: Bronchiolitis
Mon, 02/05/2018 - 12:03am
Micro: RSV most common cause, highly contagious via respiratory droplets.
Clinical:
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Affects children < 2 years old → if wheezing and >2 years old may be reactive airway disease or other conditions that mimic wheezing and bronchiolitis.
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1 to 2 days of URI symptoms followed by increased WOB, tachypnea, hypoxia on days 3 to 5 of illness → give good reassurance and return to ER precautions if suspect early.
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Minute to minute variation of comfortable breathing to respiratory distress
Evaluation → this is a clinical diagnosis
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CXR only if diagnosis uncertain or suspect co-infection or patient critically ill.
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Respiratory panel → truly helpful to determine if RSV+ if high risk for apnea.
Management:
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Saline and Nasal suction as children under 2 years are obligate nose breathers.
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Hydration, anti-pyretics
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Use WARM score to determine if trial of Albuterol is appropriate
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If child is sicker, may need high flow nasal cannula (HFNC or vapotherm) or NIPPV and admission
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Steroids and antibiotics have no role
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Hypertonic saline without benefit in ED but may have benefit in admitted patients
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Epinephrine likely with transient effects at best → leads to faster ED discharge rates
Disposition:
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Discharge if full-term (48 week post conception) + healthy (no cardiac, pulmonary, neuromuscular or metabolic disease) who is euvolemic + not hypoxic + no evidence of increased work of breathing (retractions, tachypnea).
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If < 12 weeks and RSV+ have low threshold to admit as have apnea risk.
Discharge Instructions:
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Suction and saline and cool mist humidifier.
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Slower feeds → decreased volume, increase frequency of meals
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Elevate head of crib
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No daycare until afebrile.
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Return to ER for:
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Increased work of breathing → show parents a video.
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Persistent fever, dehydration or poor feeding
References
Meissner HC. Viral Bronchiolitis in Children. N Engl J Med. 2016 Jan 7;374(1):62-72.