Bronchiolitis

Question 1

Define bronchiolitis.

Answer 1

Respiratory condition characterised by coryza followed by a dry, wheezy cough, breathlessness, poor feeding, hyperinflation of the chest and expiratory wheeze in infants.

Question 2

Explain the aetiology/risk factors for bronchiolitis.

Answer 2

RSV (75%): There may be multiple causative agents (rhinovirus, parainfluenza, influenza or adenovirus).

Inflammation of the bronchioles with secretion of mucus, necrosis of ciliated epithelium, and oedema of the submucosa causing airway obstruction.

Question 3

What are risk factors for severe bronchiolitis?

Answer 3

Prematurity.

Chronic lung disease.

Congenital/acquired lung disease.

Congenital heart defects (CHD)

Immunodeficiency.

Family history of atopic disease.

Breastfeeding and parental avoidance of smoking are protective.

Question 4

Summarise the epidemiology of bronchiolitis.

Answer 4

Most common LRTI in infants, especially 3–6 months.

Winter epidemics: 3% infants are admitted to hospital.

Question 5

What are the presenting symptoms of bronchiolitis?

Answer 5

Cough

Wheeze

Fever

Poor feeding – Indicator for admission

Question 6

What are the signs of bronchiolitis?

Answer 6

General: Pyrexia. Tachycardia, irritability

Respiratory: Tachypnoea, subcostal/intercostal recessions, nasal flaring, grunting, expiratory wheeze, fine crepitations.

Severe: Cyanosis and lethargy.

Question 7

What is the admission criteria for bronchiolitis?

Answer 7

Inadequate feeding

Respiratory distress (apnoea, respiratory rate over 60)

Central cyanosis

Hypoxia

Child looks seriously unwell

Question 8

What are investigations for bronchiolitis?

Answer 8

Bloods: Increased white cell count, hyponatraemia

CBG is not usually recommended

CXR (only if there is suspicion of pneumonia)

Serology - RSV with nasopharyngeal aspirate

Question 9

What is the management plan for bronchiolitis?

Answer 9

Supportive management:

Oxygen via a nasal cannulae or mask (with Swedish nose to humidify the air)

Give fluids by nasogastric tube if children if they cannot take enough by mouth

Only consider physiotherapy in children with relevant comorbidities

Consider CBG with worsening respiratory distress

Consider CPAP in children with impending respiratory failure

Question 10

What are treatments should not be used for bronchiolitis?

Answer 10

Do not use any of the following to treat bronchiolitis in children:

• Antibiotics
• Hypertonic saline
• Adrenaline (nebulised)
• Salbutamol
• Montelukast
• Ipratropium bromide
• Systemic or inhaled corticosteroids

Question 11

What can be used as preventative measures for infants with congenital or acquired lung disease, CHD or immunodeficiency?

Answer 11

Palivizumab (RSV monoclonal antibody)

Question 12

What are possible complications for bronchiolitis?

Answer 12

Mortality 0.2%, intensive care unit admission 2.7% and need for ventilatory assistance 1.5%.

Question 13

What is the prognosis for bronchiolitis?

Answer 13

Difficulty breathing, wheeze and poor feeding.

Persistent cough and recurrent viral-induced wheeze recur in 20% of infants (up to 60% of infants hospitalised).

Recurrent wheeze is more common in the first 5 years after RSV bronchiolitis, but there is conflicting evidence as to whether RSV bronchiolitis predisposes to asthma.