Bronchiolitis

Question 1

A 2 month old boy is brought into the emergency department by his mother with 3 days of fevers, rhinorrhoea, decreased oral intake, and increasing lethargy. His observations include a heart rate of 160 bpm, capillary refill of approximately 2s, respiratory rate of 40 brpm, temp 39.5, 02 sats 95% on RA, and he is irritable

Answer 1

Impression
This infant is presenting in a rather unwell picture. Given the significant respiratory infective sx and the patient’s age I am provisionally concerned about bronchiolitis (RSV infection of bronchioles), however would want to consider systemic infection with sepsis in this patient given the fevers. Irrespective, this patient is HD unstable and requires emergent management for which I would be calling senior colleagues and initiating an A to E assessment.

DDX
- infective: sepsis, bacterial epiglottitis, croup, pertussis, pneumonia, other infective source (urine, skin, GIT), other viral such as COVID.
- non-infective: FB, anaphylaxis (do not fit infective picture)

Question 2

Bronchiolitis - Assessment

Answer 2

Assessment
- call for senior help
- consider NETs retrieval

A - patent, maintaining, position to sniff morning air (neutral, slightly extended), intubate pending AVPU
B - RR, SP02, provide supplemental if low; assess for WOB (tracheal tug, head bobbing, intercostal and subcostal recession, grunting,
C - Central cap refill, HR, BP, colour, peripheral pulses. Gain IV access
D - AVPU, tone, BSL
E - Temperature, examine for any rashes

Escalate to seniors, disposition is likely for PICU if further deterioration or not able to be stabilised, for intubation

Question 3

Bronchiolitis - History

Answer 3

History
- PC: onset, progression, , prodrome (URTI sx, etc
- RISKS: recent sick contacts, immunocompromised premature, chronic heart, lung or neurological condition; indigenous, passive smoking, prematurity, CF, age <6 weeks, apnoea’s
Paeds history
- development, growth, pregnancy, birth, immunisations, PMHx, etc

Question 4

Bronchiolitis - Examination

Answer 4

Examination
- General appearance
- Cardioresp: wheeze + crackles (clinical signs of bronch), WOB
- hydration status assessment (given poor oral intake recently)

Question 5

Bronchiolitis - Investigations

Answer 5

Investigations
Clinical diagnosis
- consider nasopharyngeal aspirate and PCR for other viral infections/confirm RSV?
- consider CXR if diagnostic uncertain, other bloods

Otherwise, given fever in neonate <3 months old then requires a full sepsis work-up
- LP, cultures, FBC, CRP, CXR, Viral PCR, Skin/eye swab, Blood gas, urine MCS.

Question 6

Bronchiolitis - Management

Answer 6

Management
Management for bronchiolitis is purely supportive;

Mild
- generally doesn’t require admission
- patient education, safety netting: only day three, could get worse and begins improving by day 5 of symptoms.
- go home if can manage >50% of feeds
- paracetamol
- Wrap (keeps them feel comfortable) and Suck (suck out all of excess mucous)
- Feeding support: smaller more frequent feeds, NGT, IV feeds
- Breathing support: NP all the way through to ventilation

Mod- Sev
- hospital admission, referral to tertiary centre
- Respiratory support: 02 therapy if low sats
- rehydration with oral fluids: NS + % dextrose
- encourage oral feeds, consider NGT insertion
- analgesia, antipyretics

Under senior clinician advice;
- monoclonal RSV immunoglobulin (Pavlizumab)