Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age

Question 1

What is bronchiolitis?

Answer 1

Viral lower respiratory tract infection characterized by obstruction of small airways caused by acute inflammation, edema, and necrosis of the epithelial cells lining the small airways as well as increased mucus production

Question 2

What viruses cause bronchiolitis?

Answer 2

1. RSV (most common)
2. HMPV
3. Influenza
4. Rhinovirus
5. Adenovirus
6. Parainfluenza
7. Multiple viruses 10-30%

Question 3

What is the prevalence of bronchiolitis?

Answer 3

1/3 of children in the 1st 2y of life. 3% of all infants are hospitalized

Question 4

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

Answer 4

Bronchiolitis

Question 5

What are the symptoms and signs of viral bronchiolitis?

Answer 5

1. Preceding viral URTI, cough and/or rhinorrhea
2. Exposure to individual w/ viral URTI
3. Tachypnea
4. Intercostal and/or subcostal retractions
5. Accessory muscle use
6. Nasal flaring
7. Grunting
8. Colour change or apnea
9. Wheezing or crackles
10. Lower O2 saturations

Question 6

What is the differential diagnosis for wheezing in young children?

Answer 6

1. Viral bronchiolitis
2. Asthma
3. Other pulmonary infections e.g. pneumonia
4. Laryngotracheomalacia
5. Foreign body aspiration
6. GERD
7. Congestive heart failure
8. Vascular ring
9. Allergic reaction
10. Cystic fibrosis
11. Mediastinal mass
12. Tracheoesophageal fistula

Question 7

What diagnostic studies are recommended in bronchiolitis?

Answer 7

None

1. CXR only if severity or course suggests alternate diagnosis
2. Nasopharyngeal swab only if required for cohorting admitted patients
3. CBC generally not helpful in routine cases
4. Blood gas only if concerned about potential respiratory failure
5. BCx not recommended routinely, maybe required based on clinical findings and a child’s age

Question 8

What groups are at higher risk for severe disease?

Answer 8

1. Infants born prematurely <35wks GA
2. <3mo at presentation
3. Hemodynamically significant cardiopulmonary disease
4. Immunodeficiency

Question 9

What are the guidelines for admission?

Answer 9

1. Signs of severe respiratory distress (indrawing, grunting, RR>70)
2. Supplemental O2 required to keep sats >90%
3. Dehydration or history of poor fluid intake
4. Cyanosis or history of apnea
5. Infant at high risk for severe disease
6. Family unable to cope

Question 10

What interventions are recommended?

Answer 10

1. Oxygen

2. Hydration

Question 11

What interventions have equivocal evidence?

Answer 11

1. Epinephrine nebulization
2. Nasal suctioning
3. 3% hypertonic saline nebulization
4. Combines epinephrine and dexamethasone

Question 12

What interventions are not recommended?

Answer 12

1. Salbutamol
2. Corticosteroids
3. Antibiotics
4. Antivirals
5. Cool mist therapies or therapy with saline aerosol
6. Chest physiotherapy

Question 13

What are indications for discharge from hospital?

Answer 13

1. Tachypnea and work of breathing improved
2. Maintain O2 sats >90% without supplemental oxygen OR stable for home oxygen therapy
3. Adequate oral feeding
4. Educations provided and appropriate follow-up arranged

Question 14

What measures of hydration are effective?

Answer 14

NG hydration is equally effective as IV hydration

Question 15

Which patients should have continuous CRM?

Answer 15

Those with previous apneic episode or young age (<1m or <48 wks post-conception in premature infants)

Question 16

Which patients should have continuous saturation monitoring?

Answer 16

High risk patients early in the course of disease

Question 17

Which patients should have intermittent saturation monitoring?

Answer 17

Lower risk patients

All patients once they are feeding well, weaned from supplemental O2 and showing improvements in WOB

Question 18

What are the recommendations for IV hydration?

Answer 18

Isotonic solution is recommended (0.9%NaCl/5% dextrose) with routine monitoring for serum Na

Question 19

What is the specific evidence for hypertonic saline?

Answer 19

No firm recomemndation. There is insufficient evidence to support its use in ambulatory settings but some evidence suggesting potential benefit in children hospitalized >3 days