PAEDIATRICS
BRONCHIOLITIS
Inflammation of the small airways of the lungs (Bronchioles) due to viral infection (usually RSV). Commonest in infants <1. Bronchioles become swollen, the lining cells die, and the tubes become blocked with debris and mucopus. This prevents air reaching the alveoli and the child becomes short of oxygen and breathless. More severe cases may require oxygen and feeding via NGT. Recurrent attacks may herald asthma.
PromptCauses of bronchiolitis
ResponseRSV (40-70%)
Metapneumovirus
Parainfluenza
Influenza
Adenovirus
Enterovirus
Rhinovirus
Metapneumovirus
Parainfluenza
Influenza
Adenovirus
Enterovirus
Rhinovirus
PromptRisk factors for more serious illness
ResponseSocial factors, disease factors, patient factors
Chronologic ages <10 weeks, Gestational age <37 weeks
Chronic lung disease
Congenital heart disease
Chronic neurologic conditions
Growth restriction
Indigenous
Immunodefficiency
Trisomy 21
Exposure to cigarette smoke
Chronologic ages <10 weeks, Gestational age <37 weeks
Chronic lung disease
Congenital heart disease
Chronic neurologic conditions
Growth restriction
Indigenous
Immunodefficiency
Trisomy 21
Exposure to cigarette smoke
PromptDifferential diagnosis of bronchiolitis
ResponseTHE MISFITS
Cardiac failure - murmur, hepatomegally, oedema
Bacterial pneumonia - asymetric chest signs, high fever, septic shock
Congenital respiratory abnormalities (eg Congenital lobar emphysema)
Tracheomalacia - stridor
Tracheo-oesophageal fistula - resp distress related to feeds
Cardiac failure - murmur, hepatomegally, oedema
Bacterial pneumonia - asymetric chest signs, high fever, septic shock
Congenital respiratory abnormalities (eg Congenital lobar emphysema)
Tracheomalacia - stridor
Tracheo-oesophageal fistula - resp distress related to feeds
PromptInvestigations in bronchiolitis
ResponseIn most children with bronchiolitis NO investigations are required or recommended
CXR
CXR
- Generally not indicated
- Do if focal findings suggesting consolidation or diagnostic uncertainty
- Some guidelines states “should not be done”
- Useful for cohorting/infection control
- Not usually indicated
- Indicated in deteriorating patient
- ICU admission remains clinical decision
PromptManagement of Bronchiolitis
Responseaim saturations >=90%
Moderate - Oxygen 2 L/min low flow
If fails or severe/life threatening - HFNP 2L/kg/min titrate FiO2 to aim saturations >=90%
NG tube placement
Feeds
Comfort feeds
Consider NG hydration at ⅔ maintenance (Safe in HFNP)
IV last resort if NG feeds not tolerated/contraindication
Superficial suction may be considered with mild-moderate disease to assist feeding
Nasal saline can be considered at time of feeding
Moderate - Oxygen 2 L/min low flow
If fails or severe/life threatening - HFNP 2L/kg/min titrate FiO2 to aim saturations >=90%
NG tube placement
Feeds
Comfort feeds
Consider NG hydration at ⅔ maintenance (Safe in HFNP)
IV last resort if NG feeds not tolerated/contraindication
Superficial suction may be considered with mild-moderate disease to assist feeding
Nasal saline can be considered at time of feeding
PromptDischarge criteria
ResponseSpO2 >=90%
Feeding well and maintaining hydration (>50%)
Mild to moderate bronchiolitis
Good parental understanding
Ability to return
Feeding well and maintaining hydration (>50%)
Mild to moderate bronchiolitis
Good parental understanding
Ability to return