Bronchiolitis in Children - PDF

Bronchiolitis in children Dr. Salah Abdulkareem Ibrahim M.B.Ch.B. F.K.B.M.S. College of medicine/University of Dohuk [email protected]  Bronchiolitis Bronchiolitis is a viral illness affecting infants under the age of two. Incidence is marked...

Bronchiolitis in children Dr. Salah Abdulkareem Ibrahim M.B.Ch.B. F.K.B.M.S. College of medicine/University of Dohuk [email protected]  Bronchiolitis Bronchiolitis is a viral illness affecting infants under the age of two. Incidence is markedly seasonal with peak incidence between November to March. The commonest cause is Respiratory Syncytial Virus (RSV) in approximately 75% of cases. Adenovirus, Metapneumovirus, Influenza and Parainfluenza may also be responsible. Pathologically, there is bronchiolar obstruction caused by oedema and mucus leading to overinflation, atelectasis and impaired gas exchange.  Presenting Features History Examination Coryzal symptoms (peak illness Low oxygen saturations at five days) Tachypnoea Dry, wheezy cough Recession / tracheal tug Wheeze Widespread fine inspiratory Difficulty in breathing crackles Cyanosis Wheeze * Apnoeas Fever > 38°C is not usually a Poor feeding (dyspnoea feature ** associated) * Absence of wheeze does not exclude the diagnosis ** Fever > 39°C should prompt careful examination for another cause  Admission Criteria Bronchiolitis is a clinical diagnosis – as is the requirement for admission. The following features should prompt consideration of admission:-  Oxygen saturations < 94% in air  Respiratory rate > 70 per minute  Marked recession / respiratory distress / grunting respirations  History of apnoeas  Taking < 50% usual feeds / concerning hydration status  Lethargic or appears unwell. Duration of illness is also a relevant factor. Peak of illness with bronchiolitis is typically 4-5 days, therefore infants with moderate symptoms presenting before this time should be considered for admission.  High Risk Infants The following have increased risk of severe illness and should have lower admission threshold-  Infants < 6 week age  Ex-preterm infants  Chronic Lung Disease  Congenital Heart Disease  Immunodeficiency  Trisomy 21 or other syndromic association  Investigations Nasopharyngeal aspirate (NPA) Pulse oximetry should be recorded on all patients. Chest radiography is not routinely required but should be considered after a sudden clinical deterioration. Bloods tests are not routinely required. FBC/cultures may be performed if sepsis suspected Blood gases may be useful if advanced respiratory support is being considered.  Recommended Management Supportive Management. Oxygenation Apnoea Monitoring Feeding. Nebulised Hypertonic Saline. Bronchodilators. Inhaled / Oral Corticosteroids. Antibiotics? Ribavirin Physiotherapy.  Oxygenation Supplemental oxygen should be initiated for oxygen saturations 90% or below. Aim to keep oxygen saturation > 92%. Humidified head box oxygen should be used if physically possible. In larger infants, nasal cannulae should be used if requiring less than 35% FiO2 (1 L/min). Otherwise, humidified facial mask oxygen will be required.  Feeding Small, frequent sucking feeds may be used for mild cases. Nasogastric feeds may be required if taking less than 50% requirements or respiratory rate >60 or in supplemental oxygen. Intravenous fluids should be reserved for severe illness with severe respiratory distress or when nasogastric feeds are not tolerated. Restrict to 70% of maintenance due to possible SIADH with RSV infection.  Nebulised Hypertonic Saline Prescribe on drug card as:  4ml of 3% sodium chloride AND 2.5mg salbutamol eight hourly via jet nebuliser Hypertonic saline administration has been demonstrated to decrease mean duration of admission in mild/moderate acute viral bronchiolitis by around one day3. Hypertonic saline therapy is generally well tolerated, although acute bronchospasm remains a concerning possible side effect. Therefore it is recommended that hypertonic saline be co-administered with salbutamol.  Bronchodilators Adrenaline: adrenaline nebulisers may be effective in reducing bronchiolitis admission rates during the first twenty four hours. It appears that combined adrenaline and dexamethasone reduce admission rates for 7 days after Emergency Department attendance. Routine use of adrenaline nebulisers in the Emergency Department is not recommended but may be considered as a Consultant or Registrar decision.  Bronchodilators Salbutamol/Ipratropium - There is no evidence to support routine use in bronchiolitis. Bronchodilators can produce modest short-term improvement in clinical features. A trial dose of inhaled bronchodilator may be reasonable, with further therapy predicated on response in the individual patient.  Outcome / Advice to Parents  Cough may persist for 2-4 weeks  There may be an increased chance of wheezy episodes in the future  Avoidance of cigarette smoke exposure is important.