Not much gets more exciting than bronchiolitis in pediatrics! Defined as inflammation of BRONCHIOLES (smallest air passages of lungs). Lower airway disease. Do not confuse with bronchitis-> inflamm of bronchi (medium size passages)
Epidemiology:
• Most common cause of lower resp tract infection: 70% RSV (others: influenza, parainfluenza, coronavirus, adenovirus, rhinovirus, metapneumovirus)
• Outbreaks: Nov-April in Northern Hemisphere, peak Jan/Feb
• Almost all children affected by 2 years of age, with reinfection very common
• Transmitted: inoculation of nasopharyngeal/ocular mucous membranes after contact with virus containing secretions from direct contact or large aerosol droplets
Clinical dx: rhinitis, tachypnea, hypoxia, wheezing, coughing, crackles, and nasal flaring. As Dr. Feingold says, usually a “happy tachypnea.”
• Develop URT infection before developing into lower respiratory tract.
• Incubation period 4-6 days
Dx modalities: Clinical dx, do not need to test for specific virus (RSV, influenza etc), as management will be the same.
• Cxray indicated if suspicious for pneumonia
• ****Those with cong. heart defects, premature birth, SCIDS, or cystic fibrosis may require admission/obs for 24 hour period
American Academy of Physician RSV Bronchiolitis Guidelines
1) Diagnosis
a. Diagnose and assess severity based in history and physical (strong rec)
b. Assess for risk factors for severe disease (mod rec)
i. Age less than 12 weeks
ii. History of prematurity
iii. Underlying cardiopulmonary disease
iv. Immunodeficiency
c. No need for radiographic or laboratory studies (mod rec)
2) Treatment
a. Should not administer albuterol, salbutamol, or epinephrine to children or infants (strong rec)
b. Should not give nebulized hypertonic saline in ED to infants (mod rec)
c. May consider nebulized hypertonic saline to infants and children hospitalized for bronchiolitis (weak rec)
d. Should not administer systemic corticosteroids to infants in any setting (strong rec)
e. May not give supplemental O2 if O2 sat >90% in infants and children (weak rec)
f. May choose not to use continuous pulse ox (weak rec)
g. Should not use chest physiotherapy for infants and children (mod rec)
h. Should not administer antibacterial medications to infants and children unless there is a concomitant bacterial infection or strong suspicion of one (strong rec)
i. Give IVF or nasogastric fluids for infants who can’t maintain oral hydration (strong rec)
3) Prevention
a. No palivizumab to healthy infants with gestational age of 29 weeks or greater (strong rec)
b. Give palivizumab during first year of life to: (mos rec)
i. Infants with hemodynamically significant heart disease
ii. Infants with chronic lung disease of prematurity defines as preterm infant <32 weeks who require >21% O2 for at least first 28 days of life
c. Give max 5 monthly doses (15 mg/kg/dose) of palivizumab during RSV season to infants stated above (mod rec)
d. Use alcohol based rubs for hand decontamination when caring for children with bronchiolitis, if no alcohol based rubs then use soap and water (strong rec)
e. Inquire about exposure to tobacco smoke (mod rec)
f. Counsel care givers about exposing children to tobacco smoke and smoking cessation (strong rec)
g. Encourage exclusive breastfeeding for at least 6 months to decrease morbidity of respiratory infections (mod rec)
h. Educate personnel and family members on evidence-based diagnosis, treatment, and prevention in bronchiolitis (mod rec)
AAP Section on Clinical Algorithm for Bronchiolitis in the Emergency Department Setting
References:
Pediatric Society of New Zealand (2005). “Best Practice Evidence Based Guideline: Wheeze and Chest Infection in Infants Under 1 Year” (PDF). The Society.
Wright, M; Mullett CJ; Piedimonte G; et al. (October 2008). “Pharmacological management of acute bronchiolitis”. Veterinary Research. 4 (5): 895–903. PMC 2621418 . PMID 19209271.
Zhang, L; Mendoza-Sassi, RA; Klassen, TP; Wainwright, C (October 2015). “Nebulized Hypertonic Saline for Acute Bronchiolitis: A Systematic Review.”. Pediatrics. 136 (4): 687–701. doi:10.1542/peds.2015-1914. PMID 26416925.
Post by: Dr. Hima Khamar, MD, Christine Ju, MD, Sarah Bolan, MD