Bronchiolitis - GM

Question 1

what is bronchiolitis

Answer 1

lower respiratory tract infection in infants less than 12 months
due to inflammation of the bronchioles and build-up of mucous
common respiratory condition

Question 2

peak age of incidence of bronchiolitis

Answer 2

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

Question 3

aetiology of bronchiolitis

Answer 3

usually caused by viral infection
80% caused by RSV
less common causes include: parainfluenza virus, rhinovirus, adenovirus, influenza, human metapneumovirus

Question 4

risk factors for admission to hospital with severe episode of bronchiolitis include

Answer 4

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

Question 5

typical symptoms of bronchiolitis include

Answer 5

persistent cough
wheeze
shortness of breath
a prodrome of upper respiratory tract features - fever, runny nose, cold
symptoms typically worsen during 2nd or 3rd night of illness

Question 6

other symptoms of bronchiolitis include

Answer 6

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

Question 7

typical clinical findings of bronchiolitis

Answer 7

bilateral polyphonic expiratory wheeze
tachypnoea
tachycardia
low-grade fever <39°
irritability

Question 8

additional clinical findings

Answer 8

prolonged capillary refill time
cyanosis
signs of dehydration - dry mucous membranes, sunken fontanelle in young babies
reduced conscious level
recessions - this is a result of children having a compliant rib cage, which makes an increased work of breathing clearly visible externally

Question 9

how would you know if it was actually penumonia

Answer 9

fever >39°
focal crackles

Question 10

how would you know if it was actually viral induced wheeze

Answer 10

persistent wheeze without crackles
recurrent wheeze associated with a viral illness
personal or family history of atopy
>1-year-old
responsive to salbutamol treatment

Question 11

how would you know if it was actually early-onset asthma

Answer 11

persistent wheeze without crackles
recurrent wheeze associated with triggers
personal or family history of atopy
>1 year old
responsive to salbutamol treatment

Question 12

how would you know if it was actually whooping cough

Answer 12

coryza
characteristic hacking cough followed by an inpiratory whoop
unvaccinated

Question 13

how would you know if it was actually gastro-oesophageal reflux

Answer 13

chronic cough
poor weight gain

Question 14

how would you know if it was actually foreign body aspiration

Answer 14

may have history of choking
monophonic wheeze

Question 15

how would you know if it waas atcually chronic heart disease or failure

Answer 15

cyanosis
shortness of breath
hepatomegaly
murmurs

Question 16

children can be diagnosed with bronchiolitis if

Answer 16

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

Question 17

what sort of investigations should be ordered

Answer 17

investigations to not influence the treatment of bronchiolitis
pulse oximetry: children should be admitted of oxygen saturation is <92%

Question 18

criteria for admission to secondary care

Answer 18

bronchiolitis is self-limiting
not all children with bronchiolitis will require admission to hospital
criteria for admission to secondary care:
- apnoea
- reduced oxygen saturation <92%
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

Question 19

are bronchodilators effective for bronchiolitis

Answer 19

no
bronchodilators are not effectoive because the respiratory tract narrowing is due to increased secretions, not bronchoconstriction

Question 20

are antibiotics effective for bronchiolitis

Answer 20

no - due to viral cause

Question 21

complications of bronchiolitis

Answer 21

clinical dehydration
syndrome of inappropriate antidiuretic hormone (SIADH) and subsequent hyponatraemia
apnoea and respiratory failure requiring intubation and ventilation

Question 22

examination of child with bronchiolitis

Answer 22

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

Question 23

bronchiolitis on chest auscultation

Answer 23

bilateral widespread wheeze and/or crackles
areas of decreased air entry (due to atelectasis from mucous plugging)

Question 24

clinical signs of dehydration

Answer 24

sunken fontanelle, slow cap refill, dry mucous membranes, also: sunken eyes and skin turgor

Question 25

signs of increased work of breathing

Answer 25

nasal flaring, head bobbing, tracheal tug, accessory muscle use and grunting

Question 26

mild, moderate or severe disease classification

Answer 26

Question 27

hydration and nutrition requirements

Answer 27

Question 28

oxygen requirements

Answer 28

Question 29

respiratory support requirements

Answer 29

Question 30

bloods

Answer 30

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

Question 31

flocked nasopharyngeal swab NPS

Answer 31

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

Question 32

managment

Answer 32

most patients can be managed at home
management consists of supportive care only (oxygen and fluids) in the hospital

Question 33

when should oxygen therapy be instituted

Answer 33

when oxygen saturations are persistently below 92%
NOT for work of breathing alone
infants with bronchiolitis will have brief episodes of mild/moderate desaturation to levels <92%: this is not a reason to commence oxygen therapy

Question 34

when does a child require non-oral hydration/nutrition

Answer 34

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

Question 35

what route should be used for non-oral rehydration

Answer 35

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

Question 36

which IV fluid should be used

Answer 36

0.9% sodium chloride with glucose
glucose concentration will depend on the age of the infant

Question 37

which medications are indicated

Answer 37

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

Question 38

what sort of ongoing management may be needed

Answer 38

chest physiotherapy is not indicated
Humidified High Flow Nasal Cannula or Nasal CPAP theraapy may be considered in a ward setting

Question 39

discharge planning

Answer 39

can be discharged when oxygen sats are greater than or equal to 92% for at least 4 hours and feeding is adequate