Bronchiolitis

Bianda Dwida Pramudita

2016

Bronchiolitis
Bronchiolitis is a viral lower
respiratory tract infection, generally
affecting children under 12 months of
age. After 12 months of age consider
overlap with asthma

Assessment
Is the child improving, stable, or
likely to deteriorate over the next
few days? Peak severity is usually at
around day 2-3 of the illness with
resolution over 7-10 days. The cough
may persist for weeks

Risk Factors for Severe Bronchiolitis

Young, especially < 6weeks

Ex-premature infants
Congenital heart disease
Neurological conditions
Chronic respiratory illness
Pulmonary hypertension

Examination

Increasedwork of breathing
Widespread wheeze and crepitations
+/- fever
May have reduced oxygen saturation
Look for signs ofdehydration

Mild

Moderate

Severe

Behaviour

Normal

Some/intermitte Increasing
nt irritability
irritability and/or
lethargy

Tachypneu

Normal or
mildly increase
respiratory rate

Increased
respiratory rate

Increased or
markedly reduced
respiratory rate as
the child tires

Sign of increased
None or minimal Moderate
WoB
Retraction
- (intercostal,
suprasternal, costal
margin)
- Paradoxical
abdominal
breathing
Accessory muscle
use
- Nasal flaring
- Sternomastoid
contraction
- Forward posture

Marked increase in
accessorymuscle
use with prominent
chest retraction

Oxygenation

Cyanosis
SaO2 <85%

Assessment of Severity

Investigation
Nasopharyngeal aspirate NOT routinely
required for children with typical bronchiolitis
Chest X-ray NOT routinely required unless
diagnostic uncertainty eg localised signs on
auscultation, cardiac murmur with signs of
congestive cardiac failure. For children with
typical clinical picture of bronchiolitis X-ray
typically demonstrates hyperinflation,
peribronchial thickening, and often patchy areas
of consolidation and collapse.
Blood gas NOT routinely required

Acute Management
The main treatment of bronchiolitis is
supportive. This involves ensuring
oxygenation and fluid intake, as well
asminimal handling. Children are
often more settled if comfort oral
feeds are continued

Minimal Handling
-The sick child deteriorates with handling and distressing procedures.
-Increased distress in an unwell child can:
Increase heart rate, respiratory rate and blood pressure
Cause de-oxygenation (especially in neonates)
Tip a child's condition from moderate to severe
-Minimal handling is particularly important in:
Respiratory conditions, such as croup, asthma
Principles:
Keep the child with parent or care giver.
Try and keep the environment quiet and moderate lighting.
Allow the child comfort feeds if safe to do so.
Minimise interventions, including examination and investigations that are not going
to impact acute management
Group cares - eg observations and oral medications
Use comfort techniques for painful procedures such as intravenous catheters - EMLA
or Angel cream, distraction
Don't forcibly alter a child's posture - especially in respiratory conditions such as
croup. Children will naturally adopt the posture that facilitates the least airway
obstruction.

Management

Consider consultation with local

paediatric team when:
-Discharged prior to day 3 of illness
with other risk factors (see history).
-Abnormal oxygen saturations
-Less than half normal oral intake or
urine output
-Assessed as moderate or severe
bronchiolitis

Consider transfer when:

-severe bronchiolitis (see above)
-co-morbidities such as prematurity
-apnoeas
-Children requiring care above the
level of comfort of the local hospital.
-Children whose O2 requirement is
>50%

Discharge requirement
Children can be discharged when they
are
-maintaining adequate oxygenation
-maintaining adequate oral intake

Additional Notes
Bronchodilators such as salbutamol have not shown to alter the
course of acute bronchiolitis
There is some evidence for the use of nebulised saline, however
this is not currently recommended as standard therapy.
Antibiotics are not indicated for uncomplicated bronchiolitis.
Although there has been some recent evidence regarding the use
of intravenous steroids in combination with nebulised adrenaline
in bronchiolitis, this data should be considered exploratory only.
Use of steroids should be judicial as their use may have neurodevelopmental consequences, especially in younger infants. They
may also have a negative impact on lung development.
Ribavirin (antiviral) treatment is not supported by evidence of
significant benefit.
Immunoglobulins have no evidence of benefit.