UMEM Educational Pearls

Category: Pediatrics

Title: Risky Business in Bronchiolitis

Keywords: Pediatrics, Bronchiolitis, Respiratory Decompensation, Risk factors (PubMed Search)

Posted: 10/6/2017 by Megan Cobb, MD
Click here to contact Megan Cobb, MD

Takeaways

Bronchiolitis season will soon be upon us. Here are some risk factors for children under 2 y/o with bronchiolitis, who may be more likely to suffer respiratory decompensation:

1. Age under 9 months

2. Black race

3. Hypoxia documented in the ED

4. Persisent accessory muscle use. 

Bottom Line: Consider providing respiratory support sooner than later in bronchiolitic infants with risk factors for decompensation. For HFNC, start at 1.5 - 2.0 L/kg/min, and titrate to work of breathing and  0saturations. 

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Pathophysiology: Bronchiolitis is a disease process that leads to inflammation of lower airways, causing bronchiolar edema, epithelial hyperplasia, mucus plugging, and air trapping or atelectasis. Common viral causes include RSV, Human Metapneumovirus, Rhinovirus, Influenza, and Parainfluenza. 

Clinical Course: For most strains, the disease course is often 5-7 days with the worst days being 3-5. The disease process can last longer, especially in neonates. The predominant presenting symptoms are often rhinorrhea, low grade fevers, and cough, but apnea can be the primary symptom in younger infants. As a result of increased work of breathing, PO feeding tolerance decreases and leads to dehydration. 

Treatment: Primarily supportive care with suctioning, hydration, supplemental oxygen via standard NC, HFNC, and in severe cases BiPAP, CPAP or intubation. Trial of bronchodilator is often used, but there is no role for repeated bronchodilator use if no benefit is seen in pre and posttreatment respiratory effort. Hypertonic saline is not recommended for routine use in the ED. Corticosteroids have no role for routine use in viral bronchiolitis, either.

In-Depth

References

Dadlez NM, et al. Risk Factors for Respiratory Decompensation Among Healthy Infants with Bronchiolitis. Hosp Pediatr. 2017 Sep; 7(9): 530-535.
 
Schlapbach LJ, et al. Burden of disease and change in practice in critically ill infants with bronchiolitis. Euro Resp J. 2017; 49.
 
Ralston SL, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. Nov 2014; 134(5).
 
Weiler T, et al. The Relationship between High Flow Nasal Cannula Flow Rate and Effort of Breathing in Children. J Pediatr. Oct 2017; 189: 66-71.