Bronchiolitis Flashcards
Define
- 2-3% of all infants admitted each year; peak in winter; <2yo (90% between 1m and 9m; 3-6m peak)
- Inflammation of the small airways caused by an acute viral infection
- Cause = RSV (80%), parainfluenza, rhinovirus, adenovirus, influenza, human metapneumovirus (rare; but PICU care)
Co-infection -> more severe illness Bronchiolitis (0-1yo) -> VIF (1-5yo) -> Asthma (>5yo)
- RSV highly infectious so infection control measures
- Transmitted through air droplets
RFs: pre-term/BPD (bronchopulmonary dysplasia), passive smoking, LBW, chronic heart disease, hypotonia, underlying lung disease (BREASTFEEDING PROTECTIVE)
CHECK IF EITHER PARENTS SMOKE!!
Rarely, the illness may cause permanent damage to the airways (bronchiolitis obliterans)
Symptoms
1st: Coryzal symptoms (1-3 days) FOLLOWED by
2nd:
* persistent dry cough
* And Tachypnoea or chest recession (or both)
* And high-pitched wheeze (expiratory > inspiratory) and/or fine end-inspiratory crackles usually throughout the whole chest –> caused by smaller airways being compressed - primarily expiratory wheeze
- Increasing breathlessness
- Feeding difficulty due to increasing dyspnoea
- Recurrent apnoea (SERIOUS complication)
- Subcostal and intercostal recession
- Hyperinflation of the chest
- Fever
- Feeding difficulty (from SoB) - this is typically after 3-5 dys of illness -> admission
Traffic light: worried about 1) breathing 2) feeding
Investigations
1st line:
clinical diagnosis with SpO2 (pulse ox) but can
2nd line: Nasopharyngeal aspirate (immunofluorescence of secretions) to confirm (not really done in practice)
If there is significant respiratory distress + fever -> carry out a CXR/ blood gases to help rule out pneumonia
Management
Mild disease:
* Symptoms peak between 3-5 days of onset
* Most infants will recover within 2 weeks
* Paracetamol or ibuprofen for symptomatic relief (fever and distress)
* Encourage regular fluid intake
* Should be fed small and frequently as it can make breathing more difficult if they are fed as normal
* Seek medical advice if: RR increases, apnoea episodes, cyanosis, increased breathing effort, fluid intake reduced by 50-75%, dehydration, less responsive or difficult to rouse, persistent worsening of fever
* Do not smoke in the home as increases risk of severe symptoms
Severe disease:
- Persistent oxygen saturation < 92% on air
- Inadequate oral fluid intake (50-75% of usual volume)
- Severe respiratory distress > 70RR
(apnoea, Child looks seriously unwell, Grunting, Marked chest recession, Central cyanosis, Congenital heart disease (pre-existing lung disease or immunodef, Sig hypotonia e.g., trisomy 21, Survivor of extreme prematurity )
Goal is SpO2 > 90%
- Humidified oxygen (via tight nasal cannulae or using a head box) if O2 saturation is persistently < 92%
* Consider CPAP if impending respiratory failure - Consider upper airway suction if there is evidence of increased airway secretions (this should definitely be performed if they are presenting with apnoea/ have resp distress / feeding difficulties)
- Give fluids by NG or orogastric tube if they cannot take enough fluid by mouth
- Nebulised hypertonic saline may modestly reduce length of stay among infants hospitalised with acute bronchiolitis and improve clinical severity score
Supportive care- paracetamol, ibuprofen for fever
Complications
Can increase risk of chronic respiratory conditions, e.g. asthma
RARELY, the illness may cause permanent damage to the airways (bronchiolitis obliterans)- usually with adenovirus
Resp distress
* Grunting
* Marked chest recession
* RR>70
Prognosis
- Self-limiting, lasting between 3-7 days
- More severe in infants with chronic lung disease/Congenital heart disease, < 3 months, born prematurely (< 32 weeks), Down’s syndrome
- Cough resolves within 3 weeks
Prevention
Palivizumab (monoclonal antibody against RSV) reduces the number of hospital admissions in high-risk preterm infants- given monthly via IM injection until 1 y/o
This is given to babies if immunocompromised, ex-premature, congenital cardiac problems etc.
PACES
Name of Diagnosis:
Harriet has a chest infection called bronchiolitis
Briefly explain what it is:
It is usually caused by a virus and is very common in infants
It is an infection of the lower airways and children has smaller airways than adults which is why children get ill as air struggles more to get out, which is why you are hearing the wheeze
It typically causes mild symptoms like a dry cough and wheezing and will usually resolve within 2 weeks.
How is it managed:
We measured her oxygen saturation (a measure of how well her lungs are able to provide her blood with oxygen) and it shows that she is still oxygenating very well.
We think her condition is very mild and she doesn’t need any medications.
Should be fed small and frequently as it can make breathing more difficult if they are fed as normal
Risks/Safety net:
However, you should make sure that she’s still feeding as much as normal and getting fluid on board.
If you find that she’s feeding a lot less than usual then bring her into hospital.
Leaflets/Offer more information:
Does this all make sense? Do you have any questions?
Management Key Points
Reassure and discharge
Advise maintaining adequate fluid intake and to seek medical attention
if not enough fluid is being taken in (e.g. <75% of usual volume)
Avoid contact with other infants as it is highly contagious
Most infants recover within 2 weeks
Palivizumab may be considered in high-risk preterm infants
