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CPS Acute Care > Bronchiolitis > Flashcards

Bronchiolitis Flashcards

1
Q

Define Bronchiolitis

A

Viral LRTI characterized by small airways obstruction caused by acute inflammation, edema and necrosis of the epithelial cells lining small airways and increased mucus production

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2
Q

What is the most common cause of bronchiolitis?

A

RSV

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3
Q

List other viruses that commonly cause bronchiolitis

A
  • HMPV
  • Influenza
  • Rhinovirus
  • Adenovirus
  • Parainfluenza virus
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4
Q

What is the rate of co-infection with bronchiolitis?

A

10-30%

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5
Q

When does bronchiolitis season start in Canada?

A

Between November and January

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6
Q

How long does bronchiolitis season last?

A

4-5 months

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7
Q

What is the incidence of bronchiolitis?

A

1/3 children affected in the first 24 months of life

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8
Q

What is the most common cause for admission to hospital in the first year?

A

Bronchiolitis

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9
Q

What is the rate of hospitalization for bronchiolitis?

A

Hospitalization rate has increased from 1-3% in the past 30 years

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10
Q

What is the goal of the CPS statement for bronchiolitis?

A

Decrease in unnecessary diagnostic studies and ineffective medications and interventions

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11
Q

Who is excluded from this statement?

A
  • Chronic lung disease
  • Immunodeficiency
  • Serious underlying chronic disease
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12
Q

What is the typical first presentation of bronchiolitis?

A

First episode of wheezing before the age of 12 months

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13
Q

What is the history of bronchiolitis?

A
  • 2-3 day viral prodrome of fever, cough and rhinorrhea
  • Progresses to tachypnea, wheeze, crackles and respiratory distress
  • Exposure to an individual with viral URI
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14
Q

LIst 5 signs of respiratory distress

A
  • Grunting
  • Nasal flaring
  • Indrawing
  • Retractions
  • Abdominal breathing
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15
Q

What are signs of respiratory illness?

A
  • ​Intercostal/subcostal retractions
  • Accessory muscle use
  • Nasal flaring
  • Grunting
  • Colour change/apnea
  • Wheezing/crackles
  • Hypoxia
  • Tachypnea
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16
Q

List a differential diagnosis for wheezing

A
  • Laryngotracheomalacia
  • FBA
  • Pneumonia
  • Viral bronchiolitis
  • CF
  • Asthma
  • Allergic reaction
  • TEF
  • Mediastinal mass
  • Vascular ring
  • CHF
  • GERD
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17
Q

List physical examination findings in bronchiolitis

A
  • Respiratory distress
  • Crackles/wheezing
  • Tachypnea
  • Hypoxia
  • Dehydration
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18
Q

What is the typical CXR in bronchiolitis?

A
  • CXR shows patchy nonspecific areas of hyperinflation and atelectasis
  • May be interpreted as consolidation
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19
Q

When to order a CXR in bronchiolitis?

A
  • Diagnosis of bronchiolitis unclear
  • Rate of improvement not as expected
  • Disease severity raises other diagostic possibilities (pneumonia)
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20
Q

What is the value of nasopharyngeal swabs in bronchiolitis?

A
  • Not helpful from a diagnostic perspective
  • Don’t change management
  • ?useful for cohorting as the rate of infection is up to 30%
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21
Q

What is the value of CBC in bronchiolitis?

A

Not been found to be useful in predicting serious bacterial infections

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22
Q

Which patients have the greatest risk of SBI?

A

Infants in the first two months of life, especially UTI

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23
Q

What is the rate of SBI in infants with bronchiolitis?

A

0-6.1%

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24
Q

What is the incidence of bacteremia in bronchiolitis?

A

<1%

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25
Q

What is the indicence of meningitis complicating bronchiolitis?

A

Extremely rare

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26
Q

When to order a blood gas in bronchiolitis?

A

When concerned about impending respiratory failure

27
Q

Which groups are at higher risk for severe disease?

A
  • Infants born prematurely (< 35 weeks)
  • < 3 months at presentation
  • Hemodynamically significant cardiopulmonary disease
  • Immunodeficiency
28
Q

What are criteria for admission in bronchiolitis?

A
  • Signs of severe respiratory distress (grunting, indrawing, RR > 70)
  • Supplemental O2 required to keep sats > 90%
  • Dehydration or history of poor fluid intake
  • Cyanosis or history of apnea
  • Infant at high risk for severe disease
  • Family unable to cope
29
Q

What is the natural history of bronchiolitis?

A

Disease worsens over the first 72 hours

30
Q

List predictors of hospitalization in bronchiolitis

A
  • Accessory muscle score of >6/9
  • O2 saturation < 92%
  • RR > 60
  • Poor hydration
31
Q

What is the role of pulse oximetry in clinical decision making?

A
  • Setting arbitrary thresholds for oxygen therapy will influence admission rates
  • Significant increase in recommending admission by reducing saturation from 94% to 92% in clinical vignettes
32
Q

What are the mainstays of treatment in bronchiolitis?

A
  • Supportive care
  • Gentle nasal suctioning
  • Minimal handling
  • Assisted feeding
  • Oxygen therapy
33
Q

Which therapies are recommended in bronchiolitis?

A
  • Oxygen
  • Hydration
34
Q

For which therapies in bronchiolitis is the evidence equivocal?

A
  • Epinephrine nebulization
  • Nasal suctioning
  • 3% hypertonic saline
  • Combined epinephrine and dexamethasone
35
Q

Which therapies are not recommended for bronchiolitis?

A
  • Salbutamol
  • Antibiotics
  • Antiviral
  • Cool mist therapies or nebulized saline
  • Corticosteroids
  • Chest physiotherapy
36
Q

When to administer supplemental oxygen?

A

If saturations fall below 90% and used to maintain saturations above 90%

37
Q

What percentage of hospitalized patients will need fluid supplementation?

A

30%

38
Q

When is PO feeding contraindicated?

A

With RR > 60

39
Q

What route of fluid administration is most effective?

A

NG and IV routes equally effective with no difference in LOS

40
Q

What type of IV fluids should be used in bronchiolitis?

A

Isotonis fluids like D5NS with regular monitoring of serum sodium because of the risk of hyponatremia

41
Q

What is the role of nebulized epinephrine in bronchiolitis?

A
  • Epinephrine and steroids together reduce hospital admissions
  • Evidence insufficient to recommend routine use of nebulized epinephrine in the ED
  • Resonable to administer a dose and monitor for a clinical response
  • ​Epinephrine doesn’t reduce LOS, therefore insufficient evidence to support its use for inpatients
42
Q

What types of suctioning are associated with increased LOS?

A

Deep and infrequent suctioning

43
Q

What is the hypothesized mechanism of action for hypertonic saline?

A
  • Increases mucociliary clearance and rehydrates airway surface liquid
44
Q

What are the results of the cochraine review evaluating the use of hypertonic saline in bronchiolitis?

A

Cochrane review of 11 trials found reduced LOS by one day where the admission was longer than three days

45
Q

What is the optimal dosing regimen for hypertonic saline?

A

Remains unclear
Q8H most commonly used

46
Q

What is the best evidence for use of hypertonic saline?

A

For admitted patients rather than outpatient
For patients with an anticipated longer LOS

47
Q

What is the role for combination epi and dex in bronchiolitis?

A
  • Reduced hospitalization rate
  • NNT = 11
  • Results rendered nonsignificant when adjusted for multiple comparisons
  • ​​Not currently recommended for the therapy of otherwise well kids with bronchiolitis
48
Q

Why is ventolin not recommended for bronchiolitis?

A
  • Pathophysiology of asthma is constricted airways vs. obstructed airways seen in bronchiolitis
  • Infants have inadequate B receptor agonist lung receptor sites and immature bronchiolar smooth muscles
  • Ventolin does not reduce admission rates
  • Ventolin does not shorten LOS
  • Ventolin does not improve saturation
49
Q

What is the role of corticosteroids in bronchiolitis?

A
  • Not associated with clinically significant improvement in disease measured by reduced clinical scores, rates of hospitalization and LOS
  • Any benefit must be weighed against the risksk of steroid administration
50
Q

When is it appropirate to use antibiotics in the management of bronchiolitis?

A
  • When there is clear documented evidence of a secondary bacterial infection
51
Q

What is the role of antiviral therapy in bronchiolitis?

A
  • Antivirals are expensive, cumberson to administer, provide limited benefit and are potentially toxic to care providers
  • Antivirals can be considered in patients at risk for particularly severe disease
  • Decision should be made on an individual basis in consultation with appropriate subspecialists
52
Q

What is the role of chest physiotherapy in bronchiolitis?

A
  • Neither vibration or percussion techniques shown to improve clinical scores, reduce hospital stay or duration of symptoms
  • Not recommended for the treatment of bronchiolitis
53
Q

What is the role of cool mist therapies and aerosol therapies in bronchiolitis?

A

Recent cochrane review concluded there is no evidence suporting or refuting the use of cool mist and aerosols for managing bronchiolitis

54
Q

How reduce the nosocomial transmission of bronchiolitis?

A
  • Contact isolation
  • Conflicting evidence regarding the benefits of cohorting patients
55
Q

What is the most important component of monitoring infants admitted with bronchiolitis?

A

Regular and repeated clinical assessments

56
Q

What are the drawbacks of continuous monitoring in bronchiolitis?

A
  • May prolong LOS especially if staff respond to normal transient dips in oxygen saturation or changes in heart and respiratory rates with interventions
  • Accuracy of pulse oximetry is relatively poor, especially at saturations < 90%
57
Q

What is the primary rationale for cardiorespiratory monitoring in bronchiolitis?

A

To detect episodes of apnea requiring intervention

58
Q

What is the rate of apnea in RSV bronchiolitis?

A

In a large study with 691 infants < 6 months old, 2.7% had a documented apnea and all had high risk criteria

59
Q

Who is at higher risk for apneas with bronchiolitis?

A
  • < 1 month old
  • < 48 weeks postconception in prems
60
Q

Who should have continuous cardiorespiratory monitoring?

A
  • High risk patients in the acute phase of illness
  • Continuous monitoring is good for identifying infants who are deteriorating and need escalation of therapy
  • Many healthy infants exhibit typical transient O2 saturation dips
  • LOS can be prolonged if O2 therapy is based on arbitrary targets
61
Q

Who can be switched to intermittent O2 sat monitoring?

A
  • Lower risk patients
  • All patients once they are feeding well, weaning from suppemental O2 and have improved WOB
62
Q

What are the criteria for discharge?

A
  • Tachypnea and WOB improved
  • Maintain O2 sats > 90% without supplemental O2 or stable for home O2 therapy
  • Adequate PO feeding
  • Education provided and adequate follow up arranged
63
Q
A

CPS Acute Care (2 decks)

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