ED Respiratory Presentation
2 case reports
CASE 1
 7/12 boy presents with 1/7
history of cough and wheeze,
tolerating feeds, passing
urine, no vomiting / diarrhoea
 FHx – aunty has asthma, older
sibling has flu-like illness
 Immunisations up-to-date
 O/E – pink, well-perfused, no
apparent distress, active
/alert
 RESP – no recessions, no
flaring, good AE, bilat clear no
wheezing, transmitted sounds
bilaterally, afebrile
 ENT – rhinorrhoea, R TM dull
CASE 2
 3/12 boy presents with respiratory
distress and wheezing, repeated
chest infections
 FHx – 4 older siblings in daycare (also
unwell), father asthmatic
 Immunisations – delayed but current
 O/E – pink, well-perfused
 RESP – increased work of breathing,
minimal subcostal recession,
afebrile, transmitted sounds
bilaterally, cough++
 ENT – yellowish thick nasal
secretions, ears erythematous, no TM
bulging, throat normal
Acute bronchiolitis
Emergency management

Luke A Danaher
Radiographer / medical student Thursday 8th November 2007
Acute bronchiolitis
Epidemiology

16

14

12  Typically children < 2

 Common for kids < 5 yrs
10  Winter peak
8  Peak 2 to 6 months
 A leading cause of
6 hospitalisation (M > F)
4
Cases of acute
2 bronchiolitis
presenting to
0 HBH ED 2007
MAR MAY JUL SEPT NOV
Acute bronchiolitis
Common pathogens

 Coronavirus

 Human metapneumovirus (HMPV)

 Influenza virus

 Respiratory syncytial virus (RSV)

 Rhinovirus

 Parainfluenza virus (type 3 > 1 & 2)

Mnemonic for pathogens / time of year “CHIRP – spring”

Acute bronchiolitis
Risk factors

 Small kids
 Premature
 Low birth weight
 Aged < 6-12 weeks

 Sick kids
 Respiratory
 CHD
 Immunodeficiency
 Neurologic

 Environmental
 Older siblings
 Child care attendance
 Passive smoke
 Overcrowding
Acute bronchiolitis
Pathogenesis

 Virus penetrates respiratory epithelium

 Direct damage and inflammation in the small airways
 Cell destruction
 Ciliary disruption
 Peribronchiolar lymphocyte ingress

 Oedema
 Excessive mucous
 Sloughed epithelial cells

 Mechanical and inflammatory small airway obstruction

Acute bronchiolitis
Clinical features

Clinical diagnosis

 Viral upper respiratory symptoms + increased respiratory effort +

wheeze in a child younger than 2 years

History

 Nasal congestion
 Mild cough
 Fever < 38.3ºC

 Mild respiratory distress

 Approx 1 in 5 will present with apnoea
Acute bronchiolitis
Differential diagnosis
Acute bronchiolitis
Signs of severity – hospitalisation?

 Dehydration
 Mucous membranes
 Heart rate / BP
 Red flags
 Respiratory distress
 Tachypnoea  Looks ill / toxic
 Nasal flaring  SiO2 < 95
 Subcostal recession / intercostal recession
 Use of accessory muscles of respiration  Younger than 3
 Grunting  RR > 70

 Cyanosis  Atelectasis on CXR

 Indicates profound hypoxaemia

 Restlessness / lethargy
 May indicate hypoxaemia and/or type 1 respiratory failure
Acute bronchiolitis
Examination

AOM conjunctivitis nasal flaring

SiO2 < 95%

tachypnoea

pharyngitis
poor peripheral
perfusion expiratory grunting

  
intercostal recession

wheeze and crackles

subcostal recession
cyanosis bad
Acute bronchiolitis
Complications

Complications

 Apnoea

 Respiratory failure

 Secondary bacterial infection

Acute bronchiolitis
Investigations

Laboratory tests e.g. FBC not routinely indicated

Determination of the responsible virus (with nasopharyngeal

aspirate- NPA) in hospitalised patients may be useful to allow
cohorting and reduce nosocomial infection

ABG is used in severe disease to assess respiratory failure

Acute bronchiolitis
Do I need a CXR?

“Chest x-rays are not necessary in the routine evaluation of bronchiolitis”

Who doesn’t get an x-ray?

 “Routine” – radiologists hate this on a request form!
 Mild disease

Why don’t they get an x-ray?

 Radiographs are unlikely to alter management
 May lead to inappropriate use of AB

Who does get an x-ray?

 In infants with moderate to severe disease
 Focal examination finding
 Cardiac murmur
 To exclude a feasible differential diagnosis
 Limited response to initial management
Acute bronchiolitis
CXR findings

Which child got admitted?

Do chest x-rays give children pneumonia?
Acute bronchiolitis
Management – supportive care

Monitoring is the mainstay of management

Respiratory support
 Oxygen by nasal cannula or face mask to keep SiO2 > 90%
 Infants with arterial CO2 tension > 55, hypoxaemia despite
supplementation, and/or apnoea may require mechanical ventilation

Fluid administration
 Hydration status and electrolytes should be monitored in moderate
to severe illness

Chest physiotherapy is not recommended

Acute bronchiolitis
Management – pharmacotherapy

Bronchodilators (2 agonists and adrenaline)

 0.15mg / kg (2.5mg to 5.0mg) or
 4 to 6 puffs by MDI
 If no response in 1 hour, administer a single
dose of nebulised adrenaline (0.05mL / kg)
 If no response to adrenaline after 1 hour –
cease
 Response – continue every 4 to 6 hours
 Oral 2 agonists not useful

Corticosteroids (inhaled or systemic)

 Only useful if there is underlying medical
condition
 Therefore steroids are not used in first episode
of mild to moderate bronchiolitis
 Chronic exacerbations – prednisolone (1 to 2
mg/kg per day for 3 to 7 days)
Acute bronchiolitis
Management – pharmacotherapy

Ribavirin
 Nucleoside analogue
 Conflicting evidence in acute bronchiolitis
 Costly
 Useful if patient is at risk of serious infection

Antibiotics
 Only indicated if evidence of infection such as
positive urine culture, AOM, or consolidation on
CXR
Acute bronchiolitis
Natural history and discharge

Natural history
 Onset over 3 days
 Viral URT symptoms
 Clinical features as discussed previously
 Hospitalisation (if required) is typically for 3 days
 Respiratory status usually improves over 2 to 5 days
 Wheezing may persist for a week or longer
 The course may be longer in younger infants (<6/12) or
those with underlying medical conditions

Discharge criteria
 RR < 70
 Stable without supplemental oxygen
 Adequate oral intake
 Caretaker is confident they can provide care at home
Acute bronchiolitis
References / acknowledgements

References

 Up-to-date : Acute Bronchiolitis

 Evidence Based Paediatrics and Child Health
 Paediatric Emergency Medicine
 Australian Doctor (How to Treat) : Wheeze in Childhood
 Robbins Pathology
 Therapeutic Guidelines : Antibiotics
 Australian Medicines Handbook

Acknowledgements

 Steve in x-ray
 ED nurses