BRONCHIOLITIS

Question 1

Approach to the Critically Ill Bronchiolitis

Answer 1

Titrate 02 concentration to Sp02 >90-92%:

HFNC: 4-8 L/min in children <2 years

CPAP:
Start at 5 cm H2O and titrate up as needed (up to 20 cm H2O)

BPAP:
Start at 5 cm H2O and inspiratory PAP of 8-10 cm H2O

Administer IV fluids at a bolus dose of 20 mL/kg

Question 2

Etiology

Answer 2

Respiratory Syncytial Virus (RSV) – MCC (70%)

Human metapneumovirus
Adenovirus
Influenza
Rhinovirus
Parainfluenza virus type 3

Question 3

History & Physical

Answer 3

< 2 years

Peak is early winter

Prodrome URTI day 1-2

Lower Resp Symptoms
cough, Audible Wheeze, Apnea day 2-3

ASK ABOUT WITNESSED APNEA

a/w: fever, irritability, malaise, Difficulty Feeding

Sick Contacts

Tachypnea
Cough
Intercostal and subcostal retractions
Expiratory wheezing / rales (course or fine crackles)

Severe:
Diffuse Retractions (subcostal, intercostal, supraclavicular)
Nasal Flaring
Expiratory grunting

Question 4

DDx

Answer 4

Anaphylaxis

Foreign body
Croup
Epiglotittis
Retropharyngeal / Peritonsilar abscess
Bascterial Tracheitis

Bronchiolitis
Pneumonia
Asthma

CHF
Myocarditis
Malignancy

Question 5

Diagnosis

Answer 5

Clinical

First episode of respiratory distress a/w wheezing and cough in a child under 2 can be presumed bronchiolitis

Question 6

Risk factors for severe disease and apnea

Answer 6

Prematurity (<37 wk)
Age < 12 weeks
Previous episodes of apnea
CP disease
Immunodifecient
Chronic Lung Disease

Question 7

Investigations

Answer 7

Clinical Diagnosis

Consider NPS

Avoid CXR and BW unless focal lung findings, severe presentation

CXR: may be normal, hyperaeration, viral pattern (peribronchial cuffing) OR overt consolidation (partial lung collapse)

Question 8

ED Treatment: Mild-Moderate

Answer 8

Frequent instillation of saline into nares followed by suctioning (weak evidence)

Nasal suction prior to feeds with frequent, smaller feeds

Continuous pulse ox. Keep sats >=90%.

Discontinue pulse ox when clinically improving not requiring 02

Assess hydration (supplement with IV or NG as necessary)

Question 9

Outpatient Management: Mild - Moderate

Answer 9

Frequent instillation of saline into nares followed by suctioning

More frequent, smaller feeds with prefeed suctioning

Question 10

Criteria for Admission

Answer 10

Severe respiratory distress (indrawing, grunting)

RR>70

Sat < 90% off 02

Dehydration / Poor intake

Cyanosis or history of apnea at home or in ED

High risk infant (Preemie <35 wks GA, <3 mo old, hemodynamically significant CP disease, immunodeficiency)

Family unable to cope

Question 11

Management: Severe, Life-Threatening Apnea

Answer 11

Aggressive nasal suction
Intermittent / Continuous pulse ox
Supplemental oxygen maintaining SaO2 >90%
Assess hydration (supplement with IV / NG PRN)
COnsider epinephrine nebulization (0.1% solution-0.5 mL in 3.5 mL NaCl) q 1-2 hr
Consider dexamethasone (1mg/kg) combined with epinephrine
Consider ICU