Bronchiolitis - GM Flashcards
what is bronchiolitis
lower respiratory tract infection in infants less than 12 months
due to inflammation of the bronchioles and build-up of mucous
common respiratory condition
peak age of incidence of bronchiolitis
a third of infants will develop it before the age of 1
peak incidence around 3-6 months
incidence linked with the winter period
less diagnostic certainty in the 12-24 month age range
aetiology of bronchiolitis
usually caused by viral infection
80% caused by RSV
less common causes include: parainfluenza virus, rhinovirus, adenovirus, influenza, human metapneumovirus
risk factors for admission to hospital with severe episode of bronchiolitis include
chronic lung disease
congenital heart disease
prematurity at less than 37 weeks gestation
<10 weeks old at presentation
postnatal exposure to cigarette smoke
breast-fed for less than 2 months
downs syndrome
cystic fibrosis
neuromuscular disease
indigenous ethnicity
typical symptoms of bronchiolitis include
persistent cough
wheeze
shortness of breath
apneoa - in infants younger than 6 weeks of age, also typically seen with RSV
poor feeding - young children are obligate nasal breathers, making it difficult to feed and breathe at the same time during bronchiolitis
dehydration - reduced urine output or fewer wet nappies
typical course of illness of bronchiolitis
a prodrome of upper respiratory tract features - fever, runny nose, cold
symptoms typically worsen during 2nd or 3rd night of illness
resolution over 7-10 days
typical clinical findings of bronchiolitis
respiratory status:
- bilateral polyphonic expiratory wheeze
- use of accessory muscles
- hypoxia
- tachypnoea
- cyanosis
hydration status:
- dry mucous membranes
- sunken fontanelle in young babies
tachycardia
low-grade fever <39°
irritability
how would you know if it was actually penumonia
fever >39°
focal crackles
how would you know if it was actually viral induced wheeze
persistent wheeze without crackles
recurrent wheeze associated with a viral illness
personal or family history of atopy
>1-year-old
responsive to salbutamol treatment
how would you know if it was actually early-onset asthma
persistent wheeze without crackles
recurrent wheeze associated with triggers
personal or family history of atopy
>1 year old
responsive to salbutamol treatment
how would you know if it was actually whooping cough
coryza
characteristic hacking cough followed by an inpiratory whoop
unvaccinated
how would you know if it was actually gastro-oesophageal reflux
chronic cough
poor weight gain
how would you know if it was actually foreign body aspiration
may have history of choking
monophonic wheeze
how would you know if it waas atcually chronic heart disease or failure
cyanosis
shortness of breath
hepatomegaly
murmurs
children can be diagnosed with bronchiolitis if
clinical diagnosis
children are diagnosed if they present with coryzal symptoms lasting up to 3 days, followed by
- persistant cough and
- tachypnoea or chest recession and
- wheeze or crackles on chest auscultation
what sort of investigations should be ordered
investigations to not influence the treatment of bronchiolitis
pulse oximetry: children should be admitted of oxygen saturation is <90%
criteria for admission to secondary care
bronchiolitis is self-limiting
not all children with bronchiolitis will require admission to hospital
criteria for admission to secondary care:
- apnoea
- reduced oxygen saturation <90%
reduced oral intake, 50-75% of normal
- persistent respiratory distress:significant chest recessions, grunting
- presence of risk factors for severe disease
- difficult social factors: living far from hospital, lack of parental confidence
are bronchodilators effective for bronchiolitis
no
bronchodilators are not effectoive because the respiratory tract narrowing is due to increased secretions, not bronchoconstriction
are antibiotics effective for bronchiolitis
no - due to viral cause
complications of bronchiolitis
clinical dehydration
syndrome of inappropriate antidiuretic hormone (SIADH) and subsequent hyponatraemia
apnoea and respiratory failure requiring intubation and ventilation
examination of child with bronchiolitis
assess respiratory status including resp rate, oxygen saturations, and work of breathing
child may look pale and unwell
decreased level of consciousness indicates exhaustion and impending risk of respiratory arrest
cyanosis is a late sign and indicates severe disease
fever may be present
signs of dehydration
bronchiolitis on chest auscultation
bilateral widespread wheeze and/or crackles
areas of decreased air entry (due to atelectasis from mucous plugging)
clinical signs of dehydration
sunken fontanelle, slow cap refill, dry mucous membranes, also: sunken eyes and skin turgor
signs of increased work of breathing
nasal flaring, head bobbing, tracheal tug, accessory muscle use and grunting
mild, moderate or severe disease classification
hydration and nutrition requirements
oxygen requirements
respiratory support requirements
bloods
no role for blood testing in infants with bronchiolitis
bacteriological testing of blood and urine is not recommended
baseline electrolytes (urea electrolytes and creatinine) should only be checked if commencing IV fluids
flocked nasopharyngeal swab NPS
well patients who are discharged from EED no NOT need a swab unless pertusis or COVID 19 is suspected
an NPS does not affect length of stay or management
consider an NPS in admitted patients who are clincally unwell or with possible covid, influenza or pertusis to aid treaatment decision
when does a child require non-oral hydration/nutrition
oral feeds can be continued if the child is able to take greater than 50% of the usual feeds without significantly increased work of breathing - feeding 2 to 3 hourly with decreased volumes may be helpful
what route should be used for non-oral rehydration
NG is preferred in the first instance if available
in moderate illness there is no evidence to suggest that the use of the IV route has any advantage over the NG route
if the child develops worsening respiratory distress aand cannot tolerate oral/NG fluids, then commence IV fluids and give nil by mouth
which IV fluid should be used
0.9% sodium chloride with glucose
glucose concentration will depend on the age of the infant
which medications are indicated
beta-2-agonists, costricosteroids, adrenaline, hypertonic sodium chloride, antibiotics and antivirals are all NOT indicated
adrenaline is only recommended in the arrest or peri-arrest situation
what sort of ongoing management may be needed
chest physiotherapy is not indicated
Humidified High Flow Nasal Cannula or Nasal CPAP theraapy may be considered in a ward setting
discharge planning
can be discharged when oxygen sats are greater than or equal to 90% for at least 4 hours and feeding is adequate
if child is persistently hypoxaemic
if child is still hypoxaemic after 2-3 hours of nasal prong treatment
monitoring infant response on HFNP
use of nasal suction
deep nasal suction beyond the nasopharynx is not recommended
superficial nasal suction may be considered in those with moderate disease to assist feeding
nasal saline drops may be considered at time of feeding
chest physiotherapy
not indicated
