Episode 33 Acute Bronchiolitis Assessment and Management in the Emergency Department Pharmaco

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Show Notes • • Differentiating bronchiolitis from asthma and reactive airway disease in young children can be challenging, and a rapidly changing clinical presentation can confound accurate assessment of the severity of the illness. This episode reviews risk factors for apnea and severe bronchiolitis; discusses treatments/therapies and provides evidence-based recommendations for the management of pediatric patients with bronchiolitis. • • Show More v (#showNotes) • • Pathophysiology • • • • • Bronchiolar narrowing and obstruction is caused by: • • • • • Increased mucus secretion • • • • Cell death and sloughing • • • • Peri-bronchiolar lymphocytic infiltrate • • • • Submucosal edema • • • • • • • Smooth muscle constriction seems to have a limited role, perhaps explaining the lack of response to bronchodilators. • • • • Median duration of illness is 12 days in children ＜24 months • • • • 18% still ill at 3 weeks.2 • • • • 9% still ill at 4 weeks.2 • • • Etiology • • • • • RSV accounts for 50-80% of cases, but rare in children ＞2 yo.3 • • • • • Late fall epidemic peaking Nov-March, in the US.4 • • • • • • • Human Metapneumovirus (HMPV) accounts for 3-19% 5,6 • • • • • Similar seasonal variation to RSV. • • • • • • • Parainfluenza, influenza, adenoviruses, coronaviruses, rhinoviruses, and enteroviruses are other causes.4-6 • • • • Rhinoviruses have been shown to play a larger role in Asthma.7 • • • Presentation • • • • • The American Academy of Pediatrics defines it as any of the following in infants: 1 • • • • • Rhinitis • • • • Tachypnea • • • • Wheezing • • • • Cough • • • • Crackles • • • • Use of accessory muscles • • • • Nasal flaring • • • • • • Differential Diagnosis • • • • • Emergent Causes • • • • • Infection: pneumonia, chlamydia, pertussis • • • • Foreign body: aspirated or esophageal • • • • Cardiac anomaly: congestive heart failure, vascular ring • • • • Allergic reaction • • • • Bronchopulmonary dysplasia exacerbation • • • • • • • Non-acute Causes • • • • • Congenital anomaly: tracheoesophageal fistula, bronchogenic cyst, laryngotracheomalacia • • • • Gastroesophageal reflux disease • • • • Mediastinal mass • • • • Cystic fibrosis • • • • • • • Clinical Pearls • • • • • Vomiting, wheezing, and coughing associated with feeding; consider GERD. • • • • Wheezing associated with position changes; consider tracheomalacia or great vessel anomalies. • • • • Wheezing exacerbated by flexion of neck and relieved by neck hyperextension; consider vascular ring. • • • • Multiple respiratory tract infections and failure to thrive; consider cystic fibrosis or immunodeficiency. • • • • Wheezing with heart murmur, cardiomegaly, cyanosis, exertion or sweating with feeding; consider cardiac disease. • • • • Sudden onset of wheezing and choking; consider foreign body. • • • • • • Risk Factors for Severe Bronchiolitis • • • • • Age ＜ 6-12 weeks11-13 • • • • Prematurity ＜ 35-37 weeks’ gestation11-13 • • • • Underlying respiratory illness such as bronchopulmonary dysplasia1 • • • • Significant congenital heart disease; immune deficiency including HIV, organ or bone marrow transplants, or congenital immune deficiencies14,15 • • • • Altered mental status (impending respiratory failure) • • • • Dehydration due to inability to tolerate oral fluids • • • • Ill appearance12 • • • • Oxygen saturation level ≤ 90%1 • • • • Respiratory rate: ＞ 70 breaths/min or higher than normal rate for patient age1,12 • • • • Increased work of breathing: moderate to severe retractions and/or accessory muscle use1 • • • • Nasal flaring • • • • Grunting • • • Risk Factors for Apnea • • • • • Full-term birth and ＜ 1 month of age16,17 • • • • Preterm birth (＜ 37 weeks’ gestation) and age ＜ 2 months post birth11-13,17 • • • • History of apnea of prematurity • • ...

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