Bronchiolitis

Overview

VIRAL INFLAMMATION OF THE BRONCHIOLES

produces small airway obstruction with air trapping and respiratory difficulty in infants

 Age: 0-1 years

An infant or child less than 18 months of age presenting with initial symptoms and signs of upper respiratory tract infection followed by cough, tachypnoea, inspiratory crepitations and wheeze is likely to have bronchiolitis

cause:

1. Respiratory Syncytial Virus (RSV) – most common 40-70%
2. Metapneumovirus
3. Rhinovirus
4. influenzae

usually a self-limiting condition.

often requiring no treatment.

A major source of confusion over therapies, especially in older infants, arises from the fact that viral bronchiolitis can be hard to distinguish from asthma with associated viral respiratory infection

Risk factors

1. Chronic lung disease
2. Congenital Heart disease
3. <3 months old
4. Prematurity
5. Neuromuscular disorders
6. Immunodeficiency
7. Smoking in household

Presentation

1. usually develops following one to three days of coryzal prodrome
   1. Nasal congestion and discharge
   2. mild cough 
   3. Fever
   4. Decreased appetite(typically after 3 to 5 days of illness)
2. time course:
   1. worsens for 3-5 days
   2. plateaus for few days
   3. gradual improvement over 2 weeks
3. day 3-5:
   1. persistent cough (cough resolves in 90% of infants within 3 weeks)
   2. tachypnoea or chest recession
   3. wheeze or crackles
   4. young infants with this disease (in particular those under 6 weeks of age) may present with apnoea without other clinical signs
4. Signs of severe bronchiolitis
   1. rapid, laboured breathing
   2. hypoxia, cyanosis
   3. tachycardia
   4. gross lung hyperinflation producing a barrelshaped chest
   5. prominent neck veins
   6. downward displacement of the liver
5. DDx from Asthma and Pneumonia
   1. Asthma: 
      1. usually presents with recurrent wheezing in a child >2 years old with a personal and/or family history of atopy or a family history of asthma. 
      2. Environmental or allergic precipitants are often present in older children.
   2. Pneumonia
      1. appear ‘toxic’ 
      2. have higher grade fevers 
      3. focal chest findings and usually do not have wheeze.

Diagnosis & Investigations & Management

Initial Severity Assessment: Treat in the highest category in which any symptom occurs
Symptoms	Mild	Moderate	Severe and Life Threatening
Appearance	Well	Mildly Unwell	Unwell
Respiratory Rate	Mild Tachypnoea	Moderate Tachypnoea	Apnoeas Severe Tachypnoea Greater than 70 Bradypnoea Less than 30
Work of Breathing	Normal	Mild to Moderate	Moderate to Severe Grunting
Cyanosis	No Cyanosis	No Cyanosis	May be Cyanosed or Pale
Oxygen Saturation Oxygen Requirement	Above 95% in Air	90 95% in Air	Less than 90% in Air Less than 92% in O2
Heart Rate	Normal	Mild Tachycardia	Tachycardia greater than 180
Feeding	Normal or Slightly Decreased	Difficulty feeding but able to take more than 50% of normal feed.	Difficulty feeding taking less than 50% of normal feed.
Treatment
Oxygen	No	Give O2 to maintain saturation at or above 95% and or to improve the work of breathing	Maintain oxygen saturations greater than 95% Ensure high inspired oxygen via high flow delivery device if required
Hydration	Recommend smaller more frequent feeds if required	Smaller more frequent feeds Consider NG feeds	IV fluids and NBM
Investigations	Nil required	Nil required	Consider – CXR and Blood Gas / BSL
Observation & Review	hourly	Continuous SaO2 monitoring Minimum hourly observation	Continuous cardio respiratory and SaO2 monitoring Constant observation
No or Poor response to Treatment		Check diagnosis Escalate treatment	Get Senior Help Consult PICU via NETS Consider CPAP May need intubation
Disposition	Likely to go home	Likely to admit Decisions around hospitalisation of infants with SaO2 between 92 & 95 % should be supported by clinical assessment, phase of the illness & social & geographical factors	Transfer to an appropriate paediatric unit via NETS If in a children’s hospital, may need PICU.

Investigations

• Infants (Age 0 – 28 days)

1. Approximately 5-10% of infants who present with Bronchiolitis will concurrently be suffering from a serious bacterial infection (SBI). 
2. FEBRILE infants require a full septic workup and be started on empiric IV antibiotics, regardless of any suspicion for bronchiolitis. 
3. All febrile infants who display signs of septic shock or impending septic shock should have a full septic work up and be started on empriric IV antibiotics. 
4. The risk of UTI is approximately 5% in febrile infants with bronchiolitis age 12 months, therefore our experts recommend obtaining a urinalysis and culture for these children

Nasopharyngeal swab for

1. expremature
2. ventilated
3. recently discharged
4. immunocompromised on chemotherapy

Chest Xray

1. No role for routine xray but done when the diagnosis is not clear
2. pneumonia is suspected due to focal lung findings
3. response to treatment is not as expected
4.  ‘toxic’ appearance or severe respiratory distress

Urine dipstick

1. High SG = dehydrated
2. Ketosis = starvation
3. WCC, nitrates = infection

Watch for Signs of deterioration:

1. increased work of breathing
2. subcostal or intercostal recession tracheal tug
3. increased respiratory rate
4. increasing fatigue
5. increasing difficulty with feeding
6. apnoea (very late sign) – high risk if:
   1.  Small for gestational age (<2.3 kg)
   2. Age < 2 months
   3. Oxygen saturations < 90%
   4. Previous episode of apnea
   5. Resp rate>70

Specific Treatment

Summary of Management of Acute Bronchiolitis as per eTG

Recommended for All Children with Acute Bronchiolitis:

• Reassure carers
• Educate carers about minimal handling
• Provide carer information sheet (available from The Royal Children’s Hospital (Melbourne) website)
• Give small, frequent feeds

Recommended for Children with Moderate to Severe Acute Bronchiolitis:

• Provide symptomatic care in hospital
  • Supplemental oxygen, if required, to maintain SpO2 92% or more
  • Nasogastric feeds or intravenous fluids if normal feeding is not possible (nasogastric feeds may be preferred)
• Other:
  • Nasal toileting 
    • Infants are nasal breathers until 2 months and URTI from mucous can contribute to significant breathing difficulties
    • Trial of suctioning is not unreasonable
  • Analgesics and antipyretics
    • Infants and children with bronchiolitis and fever may be treated with paracetamol or ibuprofen to bring their temperature down and reduce irritability
    • Carefully consider and exclude other potential causes of fever, irritability and pain
  • Positioning
    • Infants and children with bronchiolitis should be allowed to adopt the position they find most comfortable. 
    • Infants unable to position themselves may be placed in either a prone or supine position, with head slightly elevated
    • Because of the risk of SIDS, infants and children with bronchiolitis who are placed in a prone position should have continuous pulse oximetry monitoring, and the reasons for positioning the child this way should be explained to the parent
  • Feeding and hydration
    • Infants and children with bronchiolitis are prone to becoming dehydrated as a result of the combined effects of poor oral intake and increased water loss due to increased respiratory rate and work of breathing.
    • There is no evidence to determine whether infants or children with bronchiolitis should continue oral feeding while acutely unwell. 
    • Oral feeding is important in infants and children with bronchiolitis as it helps to avoid dehydration. 
    • However, it may also increase respiratory distress, particularly in infants and children with severe or life threatening bronchiolitis.
    • Recommendation: Infants or children with mild or moderate bronchiolitis may continue oral feeding unless it increases their respiratory distress

Recommended for Children with Severe Bronchiolitis:

• Noninvasive ventilation (e.g., CPAP)
• High-flow nasal cannula therapy
• Invasive ventilation may be required

Not Recommended:

• Bronchodilators
  • No evidence for Bronchiolitis
  • Not recommended as they do not reduce hospital length of stay or requirement for supplemental oxygen
  • considering a trial of salbutamol for patients in whom there is a strong family history of asthma, atopy, or in the patient who has had multiple wheezing episodes.
  • ipratropium be reserved for asthmatic patients and should not be trialed in bronchiolitis. 
  • Approximately 15-25% of infants with bronchiolitis will respond to bronchodilators.
    • A one-off trial may be considered in children hospitalised with severe bronchiolitis who are older than 10 months
      • If symptoms do not improve, do not continue therapy
      • If symptoms improve, bronchodilator use may be continued with specialist input; dosage is lower than that used in asthma
      • If asthma is suspected, refer to a specialist
• Antibiotics
  • Do not routinely give antibiotics
  • In very ill hospitalised children with bronchiolitis and suspected secondary bacterial infection, antibiotics may be indicated (refer to Community-acquired pneumonia in children)
• Corticosteroids
  • Do not prescribe corticosteroids
  • Steroid medication used in isolation for bronchiolitis is not recommended (Cochcrane review 2013)
  • Oral steroids and nebulized epinephrine combination decreased admission rates(RCT by Plint et al. in 2009)
• Nebulised hypertonic saline
  • Do not prescribe nebulised hypertonic saline
  • reduce airway edema and mucous plugging
  • reduce length of stay and severity scores
• Adrenaline (nebulised)
  • Do not prescribe adrenaline except in peri-arrest or arrest situations
  • A Cochrane Review from 2011 found that nebulized epinephrine reduced admission rates on day 1
  • may provide short term benefit with significantly decreased at 60 and 120 mins after administration of nebulized epinephrine

Severe Bronchiolitis

1. liaison with paediatric team
2. regular observation
3. N/G tube to decompress stomach, continuous feeding
4. titrated O2
5. NIV: via nasopharyngeal tube or bubble or high flow nasal prong O2 or BIPAP
6. IV fluids
7. Paracetamol
8. caffeine if apnoea (especially if premature), aminophyline is an alternative
9. minimal handling
10. antibiotics if superinfection suspected
11. a few children require mechanical ventilation (particularly if retrieval required) > this will prolong PICU course by 23 days

Indications to call PICU:

1. commencing CPAP early in disease
2. if staff not confident in use of CPAP
3. need for intubation
4. not comfortable with plan

indications to intubate:

increased WOB despite NIV

deterioration despite CPAP

not tolerating CPAP and continuing to desaturate

apnoea

transport

precautions to take when intubating:

• little respiratory reserve (become hypoxic quickly)
• always preoxygenate
• decompress stomach to allow for bagging
• ensure can ventilate prior to intubating
• have atropine and adrenaline drawn up
• sedation: ketamine, morphine, fentanyl (beware of chest wall rigidity > relax straight away)
• relaxants: sux, rocuronium, atracurium

Safety Netting

Take baby to the nearest hospital emergency department if they develop symptoms of bronchiolitis and they:

1. were born prematurely
2. are younger than 10 weeks old
3. have chronic lung disease, congenital heart disease, chronic neurological conditions or they are immunocompromised (have a weakened immune system)
4. Aboriginal or Torres Strait Islander.

go back to see GP if baby has bronchiolitis and:

1. cough that is getting worse
2. less than half their normal feeds or are refusing drinks
3. seem very tired or are more sleepy than usual
4. worried for any reason.

Go to the nearest GP or hospital emergency department if:

1. has difficulty breathing, irregular breaths or fast breathing at rest
2. cannot feed normally because of coughing or wheezing
3. is changing colour in the face when they cough
4. has skin that is pale and sweaty.

Call an ambulance immediately if your baby is struggling to breathe or if their lips start to turn blue.

Key points to remember

• Bronchiolitis is a common chest infection, caused by a virus, that affects babies up to 12 months old.
•  Babies are usually sick for seven to 10 days. They are infectious in the first few days of illness.
• Seek medical attention if your baby is having trouble breathing, feeding or drinking.
• Medicine is not usually used to treat bronchiolitis. Babies need to rest and drink small amounts more often.
• Ensure your baby is in a smoke-free environment.