Bronchiolitis

Question 1

Bronchiolitis - background (3)

Answer 1

1. Viral LRTI affecting children

Question 2

Bronchiolitis - RF for severe disease

Answer 2

1. Maternal smoking
2. Preterm delivery
3. Chronic lung disease of prematurity
4. Chronic cardiorespiratory distress (e.g. congenital heart disease, cystic fibrosis)
5. Congenital/anatomical defects of the airways

Question 3

Bronchiolitis - symptoms

Answer 3

Symptoms gradually increasing over 2-3d

1. Mild/no fever
2. Tachypnoea
3. Mild dry cough
4. Expiratory wheezing

With increasing severity
5. Feeding impaired + dyspnoea more marked

After 2-3d, the symptoms gradually resolve and the child should recover within a week (if no recovery within 2 weeks, further ix should be considered - e.g. sweat test)

Question 4

Bronchiolitis - signs

Answer 4

1. Increased WOB (5) - soft tissue recession on inspiration, paradoxical abdominal breathing, accessory muscle use (SCM contraction), nasal flaring, forward posture
2. Widespread wheeze and fine inspiratory crackles
3. +/- fever
4. May have reduced oxygen saturation. Note - correlation between SaO2 and bronchiolitis severity may vary significantly
5. Look for signs of dehydration

Question 5

Bronchiolitis - classification of severity

Answer 5

1. Mild (5)
   - Normal behaviour
   - Normal respiratory rate
   - No increased WOB
   - Normal feeding
   - No oxygen requirement (SaO2>93%)
2. Moderate
   - Intermittent behaviour
   - Increased respiratory rate
   - Increased WOB with tracheal tug, nasal flaring, moderate chest wall retraction
   - May have difficulty with feeding or reduced feeds
   - Mild hypoxaemia corrected by oxygen*
3. Severe
   - Increasing irritability +/- lethargy, fatigue
   - Marked increase or decrease in RR
   - Marked increase in WOB with tracheal tug, nasal flaring and marked chest wall retraction
   - Reluctant or unable to feed
   - Hypoxaemia, may not be corrected by oxygen (SaO2

Question 6

Bronchiolitis - ix

Answer 6

1. In most children, no investigations are required

Hospitalised children

2. Nasopharyngeal aspirate - viral detection by PCR
3. CXR - only if diagnostic uncertainty, e.g. localised signs on auscultation, cardiac murmur with signs of congestive heart failure

Question 7

Bronchiolitis - mx

Answer 7

1. Mild (3)
   - Can manage at home; advise parents of expected course of illness and when to return
   - Smaller, more frequent feeds
   - Consider further medical review if early in the illness, risk factors present or if child develops signs of increasing severity after discharge
2. Moderate (5)
   - Discuss admission with local paediatric team
   - Administer O2 to maintain adequate saturation (>92%)
   - Take care with infants who are reluctant to feeds. Aspiration can occur if oral fluids are pushed too hard or administration of NG fluids is accompanied by vomiting
   - In marked respiratory distress where the infant’s ability to cough or maintain an airway is impaired, IV fluids are given. Limit total fluids at 2/3 maintenance
   - 1 to 2-hourly observations dependent on condition
3. Severe (5+2)
   Same as moderate, plus:
   - Cardiorespiratory monitoring with close nursing supervision; notify local paediatric team early
   - Consider transfer to tertiary centre with ICU capabilities, as child may need CPAP or ventilation

Question 8

Bronchiolitis - follow-up

Answer 8

1. Recurrent cough, wheeze and tachypnoea may occur after RSV infection
2. These may require treatment and are best assessed in outpatients
3. Daily oral montelukast granules can sometimes help reduce the symptoms
4. A proportion of pts may develop asthma
5. They may have been predisposed to develop this problem irrespective of RSV in early infancy