MANAGEMENT

OF

BRONCHIOLITIS
Presented by: Tonyan Thompson

Definition
Bronchiolitis is a common seasonal viral infection of the upper and
lower respiratory tract, characterized by acute inflammation, edema
and necrosis of airway epithelium leading to increased mucus
production and bronchospasm.
Respiratory syncytial virus (RSV) is the most common cause.
May be caused by other viral agents, including:
human metapneumovirus,
adenovirus,
influenza,
rhinovirus, and
parainfluenza viruses.

Epidemiology
The most common lower respiratory tract infection in infants and
children 2 years of age.
It is the leading cause for hospitalization in children <1 year of age
Within the first 2 years of life, up to 90% of children will have been
infected by RSV. Of those, 40% manifest with a lower respiratory tract
infection.
Peak incidence during winter months* between November to March

Pathophysiology
Bronchiolitis is inflammation of the lower respiratory tract, with edema, epithelial
cell necrosis, bronchospasm, and increased mucus production within the
bronchioles
This leads to variable degrees of atelectasis or hyperinflation of the lower
airways.
Resulting in increase in airway resistance and development of lower airway
obstruction leading to increased work of breathing.
RSV - transmitted by direct contact with contaminated secretions, (large droplets
into the mucosa of the eyes and nose)
Infected secretions found on fomites remain contagious for several hours.
RSV is highly infectious, thus self-contamination and nosocomial spread are
common.
Hand washing and contact precautions are important to limit the spread of
disease.
The incubation period for RSV ranges from 2 to 8 days.

Presentation
Initial symptoms clear rhinorrhea, diminished appetite, fever
Later Symptoms tachypnea, coughing, wheezing, dyspnea,
irritabiltiy
Use of accessory muscles, nasal flaring, and fever may also occur.
Associated symptoms include irritability, cyanosis, and poor feeding.
A subset of infants may present with severe disease and apnea*
Symptoms last on average 7 to 14 days and are often the
worst in the initial 3 to 5 days of the illness

Presentation
On chest examination, wheezing and crackles are heard diffusely
throughout both lung fields.
Respiratory rates may vary from within normal ranges to tachypnea,
which can be profound.
Accessory muscle use and intercostal or subcostal retractions develop
as respiratory distress worsens.
Assess for signs of dehydration such as dry mucous membranes,
inadequate urine output, and a sunken fontanelle*

Differential Diagnosis
Aspiration Pneumonitis and
Pneumonia

Cystic Fibrosis

Heart Failure

Mycoplasmal Pneumonia

Pediatric Apnea

Pediatric Foreign Body Ingestion

Pediatric Pneumonia

Chronic Obstructive
Pulmonary Disease (COPD)

Pediatric Sepsis

Pertussis

Croup

Viral Pneumonia

Aspiration Syndromes
Asthma
Bacterial Pneumonia
Chlamydial Pneumonias

Work up
The diagnosis of bronchiolitis is based on history, clinical
presentation, the patients age, seasonal occurrence, and findings
from the physical examination. When all of these are consistent
with the expected diagnosis of bronchiolitis, few laboratory studies
are necessary
Tests are typically used to exclude other diagnoses (eg, bacterial pneumonia,
sepsis, or congestive heart failure) or to confirm a viral etiology and
determine required infection control for patients admitted to the hospital.
The Respiratory Distress Assessment Instrument, which is composed of
measurements of wheezing, retractions, and respiratory rate, is the most
widely used scoring system

 The most common tests are:

Rapid viral antigen testing of nasopharyngeal secretions
forrespiratory syncytial virus (RSV),
Arterial blood gas (ABG)analysis (in severely ill patients, especially
those requiring mechanical ventilation),
White blood cell (WBC) count with differential,
C-reactive protein (CRP) level, and
Chest radiography.
Other common tests are pulse oximetry*, blood culture, urine analysis
and culture, and cerebrospinal fluid (CSF) analysis and culture. Urine
specific gravity may provide useful information regarding fluid
balance and possible dehydration. Serum chemistries are not affected
directly by the infection but may aid in gauging severity of
dehydration.

Work Up
The use of reverse-transcriptase polymerase chain reaction testing to
detect nucleic acid offers greater sensitivity.
Results of viral culture are not available for several days and are not
useful for guiding ED treatment
Ancillary tests, such as blood work and radiographs, are not
routinely needed unless other diagnoses need to be excluded
Chest radiographs are not routinely indicated, but may be considered
when the illness is severe or the course is atypical to ensure that
pneumonia is not present. Although the chest radiograph in bronchiolitis
may demonstrate patchy atelectasis and hyperinflation, bacterial
pneumonia is unusual.

Treatment
Because no definitive treatment for the specific virus exists, therapy is
directed toward symptomatic relief and maintenance of hydration and
oxygenation.
Medical therapies used to treat bronchiolitis in infants and young
children arecontroversial. Although numerous medications and
interventions have been used to treat bronchiolitis, at present, only
oxygen appreciably improves the condition of young children with
bronchiolitis

Treatment
Supplemental oxygen therapy - Maintain O2 Sat above 90%
Maintenance of hydration - it is vital to maintain adequate hydration.
The goal of fluid therapy is to replace deficits and to provide
maintenance requirements.
Ventilatory Support - must be provided if supplemental oxygen does
not correct hypoxia, or if respiratory distress worsens.
The use of bi-level positive airway pressure (BiPAP) or continuous
positive airway pressure often allows intubation to be avoided.
However, intubation with assisted ventilation is sometimes
necessary

Treatment
Bronchodilators NOT routinely used. There is no consistent evidence that
either - or -adrenergic bronchodilators are of benefit for the standard
treatment of bronchiolitis.
Corticosteroids NOT routinely used. The role of corticosteroids in treatment of
bronchiolitis is controversial. No difference was found in hospitalization rates or
respiratory status between those infants who received a 1-milligram/kg dose of
dexamethasone and those who received a placebo.
Heliox Heliox administration can be a temporizing measure for moderate to severe
bronchiolitis
Nebulized Hypertonic Saline Nebulized 3% hypertonic saline solution is an
alternative treatment for bronchiolitis that has produced improvement in clinical scores
in several recent studies.
Nebulized hypertonic saline is thought to decrease mucus production and airway
inflammation,
In hospitalized children, the use of 4 mL of 3% hypertonic saline solution both with
and without epinephrine led to decreases in length of stay as well as clinical
improvements in infants with bronchiolitis.

Treatment

Complications
Complications of therapy include the following:
Ventilator-induced barotrauma
Nosocomial infection
Beta-agonistinduced arrhythmias

Admission/Discharge criteria
The majority of children with bronchiolitis can be discharged from the ED.
Assurance of an adequate home environment and follow-up care is
essential for discharge.
Factors for predicting safe discharge from the ED (See Below)
Oxygen saturation of <95% or the inability to adequately feed and
maintain hydration are the most common reasons for admission for
bronchiolitis.
Infants with witnessed episodes of apnea require admission.
Admission is recommended for those with risk factors for apnea
even when they are clinically well appearing.
Most experts recommend admission of all infants <1 month of age who
test positive for RSV, regardless of severity of symptoms, as apnea can
develop without respiratory distress in these patients.

Follow Up
Those children with mild bronchiolitis who demonstrate no significant
increase in respiratory effort and are able to maintain adequate oral
intake should follow up with their primary care provider within 24
hours.
Caregivers should be educated regarding the signs and symptoms of
increasing respiratory distress, including an increase in respiratory
rate, presence of retractions, and inability to feed.
They should be advised to bring the child for immediate reevaluation
if any of these develop.
Parents should be counseled that symptoms may persist for 1 to 2
weeks to help avoid unnecessary ED returns for persistent mild
symptoms.

Summary
Bronchiolitis is a common seasonal viral infection of the upper and
lower respiratory tract, most commonly seen in children less than 2
years.
RSV Most common cause ( others adeno, parainfluenza,
metapneumo virus)
Presentation Variable and dynamic from Rhinorrhea, tachypnea,
wheezing to apnea
Diagnosed based on findings of the history and physical examination
ancillary tests often unnecessary
Treatment Mostly supportive Oxygen, hydration
Bronchodilators, corticosteroids not routinely used
Consider hospitalization if patient <12 weeks, h/o prematurity,
underlying cardiopulmonary disease or immunodeficiency.