Paediatrics: Bronchiolitis

Question 1

Definition

Answer 1

Bronchiolitis describes inflammation and infection in the bronchioles, the small airways of the lungs.

This is usually caused by a virus. Respiratory syncytial virus (RSV) is the most common cause.

Question 2

When is bronchiolitis common and who does sit occur in?

Answer 2

Bronchiolitis is very common in winter. Bronchiolitis is generally considered to occur in children under 1 year. It is most common in children under 6 months.

Question 3

What happens to children if there is inflammation and mucus in airway?

Answer 3

The airways of infants are very small to begin with, and when there is even the smallest amount of inflammation and mucus in the airway it has a significant effect on the infants ability to circulate air to the alveoli and back out. This causes the harsh breath sounds, wheeze and crackles heard on auscultation when listening to a bronchiolitic baby’s chest.

Question 4

Presentation

Answer 4

Coryzal symptoms. These are the typical symptoms of a viral upper respiratory tract infection: running or snotty nose, sneezing, mucus in throat and watery eyes.

Signs of respiratory distress

Dyspnoea (heavy laboured breathing)

Tachypnoea (fast breathing)

Poor feeding

Mild fever (under 39ºC)

Apnoeas are episodes where the child stops breathing

Wheeze and crackles on auscultation

Question 5

Signs of Respiratory Distress

Answer 5

Raised respiratory rate
Use of accessory muscles of breathing, such as the sternocleidomastoid, abdominal and intercostal muscles
Intercostal and subcostal recessions
Nasal flaring
Head bobbing
Tracheal tugging
Cyanosis (due to low oxygen saturation)
Abnormal airway noises

Question 6

Abormal airway noises

Answer 6

Wheezing is a whistling sound caused by narrowed airways, typically heard during expiration
Grunting is caused by exhaling with the glottis partially closed to increase positive end-expiratory pressure
Stridor is a high pitched inspiratory noise caused by obstruction of the upper airway, for example in croup

Question 7

Typical RSV Course

Answer 7

Bronchiolitis usually starts as an upper respiratory tract infection (URTI) with coryzal symptoms.

From this point around half get better spontaneously. The other half develop chest symptoms over the first 1-2 days following the onset of coryzal symptoms.

Symptoms are generally at their worst on day 3 or 4. Symptoms usually last 7 to 10 days total and most patients fully recover within 2 – 3 weeks.

Children who have had bronchiolitis as infants are more likely to have viral induced wheeze during childhood.

Question 8

Admission into hospital

Answer 8

Aged under 3 months or any pre-existing condition such as prematurity
Downs syndrome or cystic fibrosis

50 – 75% or less of their normal intake of milk

Clinical dehydration

Respiratory rate above 70

Oxygen saturations below 92%

Moderate to severe respiratory distress, such as deep recessions or head bobbing

Apnoeas

Parents not confident in their ability to manage at home or difficulty accessing medical help from home

Question 9

What type of management do patients typically need?

Answer 9

Typically patients only require supportive management. This involves:

Ensuring adequate intake. This could be orally, via NG tube or IV fluids depending on the severity. It is important to avoid overfeeding as a full stomach will restrict breathing. Start with small frequent feeds and gradually increase them as tolerated.

Saline nasal drops and nasal suctioning can help clear nasal secretions, particularly prior to feeding

Supplementary oxygen if the oxygen saturations remain below 92%

Ventilatory support if required