Bronchiolitis - ACEM Fellowship Notes

[patient information sheet](https://www.rch.org.au/kidsinfo/fact_sheets/Bronchiolitis/) [cameron paeds bronchiolitis](x-devonthink-item://E383FFBD-9FD8-4DE9-B350-0F6F60D3E600?page=648) > [!Key points] > - can be a/w aponea, especially in premature infants > - admit if risk factors for more severe illness, aponea, O2 requirement > - consider d/c if day 3 of illness or beyond and doing well (likely to improve) - clinical diagnosis - doesn't need investigations - no medications (especially not bronchodilators, etc) **DDx** - [[paediatric pneumonia|pneumonia]] - [[Congenital heart disease|congenital heart failure]] - [[inhaled foreign body]] - pertussis **Risk factors for developing more serious illness** - gestational age <37/40 or chronological age <10-12 weeks - chronic lung disease - congenital heart disease - post-natal exposure to cigarette smoke - breast fed <2/12 - [[Aboriginal health|indigenous]] ethnicity - chronic neurological condition - failure to thrive **Features of severe bronchiolitis** - lethargy or irratibility - marked increased or decreased resp rate - Marked chest wall retractions , Marked suprasternal retraction , Marked nasal flaring - o2 sats <90% RA - unable to feed # Severity Assessment | |**MILD**|**MODERATE**|**SEVERE**| |---|---|---|---| |**Behaviour**|Normal|Some / intermittent irritability|Increasing irritability and / or lethargy Fatigue| |**Respiratory rate**|Normal–mild tachypnoea|Increased respiratory rate|Marked increase or decrease in respiratory rate| |**Use of accessory** **muscles**|Nil to mild chest wall retraction|Moderate chest wall retractions Suprasternal retraction Nasal flaring|Marked chest wall retractions Marked suprasternal retraction Marked nasal flaring| |**Oxygen saturation/** **oxygen requirement**|Oxygen saturations >92% (in room air)|Oxygen saturations 90–92% (in room air)|Oxygen saturations <90% (in room air) Hypoxemia may not be corrected by oxygen| |**Apnoeic episodes**|None|May have brief apnoea|May have increasingly frequent or prolonged apnoea| |**Feeding**|Normal|May have difficulty with feeding or reduced feeding|Reluctant or unable to feed| ## Risk factors ↑ risk for more serious illness - gestational age <37/40 or age <10 weeks - post-natal exposure to cigarette smoke - breast fed <2/12 - chronic lung disease - congenital heart disease - indigenous ethnicity - immunodeficiency - trisomy 21 **risk factors for aponea** - <3 months old - prematurity/low body weight - chronic lung disease - comorbidities/immunodeficiency # Treatment | |**MILD**|**MODERATE**|**SEVERE**| |---|---|---|---| |**Likelihood** **of admission**|Suitable for discharge Consider admission if risk factors present|Likely admission, may be able to be discharged after a period of observation Management should be discussed with a local senior physician|Requires admission and consider need for transfer to an appropriate children’s facility/PICU Threshold for referral is determined by local capacity but should be early| |**Observations** **Vital signs** **(respiratory rate,** **heart rate,** **Oxygen saturations,** **temperature)**|Adequate assessment in ED prior to discharge (minimum of two recorded measurements or every four hours)|1-2 Hourly (not continuous) Once improving and not requiring oxygen for 2 hours discontinue oxygen saturation monitoring|Hourly with continuous cardiorespiratory (including oximetry) monitoring and close nursing observation| |**Hydration / nutrition**|Small frequent feeds|If not feeding adequately (<50% over 12 hours), administer NG hydration|If not feeding adequately (<50% over 12 hours), or unable to feed, administer NG hydration| |**Oxygen** **saturation/oxygen** **requirement**|Nil requirement|If oxygen saturations fall below 90%, administer oxygen to maintain saturations ≥90% Once improving and not requiring oxygen for 2 hours discontinue oxygen saturation monitoring|Administer oxygen to maintain saturations ≥90%| |**Respiratory** **support**||Begin with nasal prong oxygen [ ](http: "High flow nasal prong (HFNP) therapy to be used only if nasal prong oxygen has failed")[High flow nasal prong (HFNP) therapy](https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/High_Flow_Nasal_Prong_(HFNP)_therapy/ "High flow nasal prong (HFNP) therapy") to be used only if nasal prong oxygen has failed|Consider [HFNP therapy](https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/High_Flow_Nasal_Prong_(HFNP)_therapy/ "HFNP therapy") or Continuous positive airway pressure (CPAP)| |**Disposition /** **escalation**|Consider further medical review if early in the illness and any risk factors are present or if child develops increasing severity after discharge|Decision to admit should be supported by clinical assessment (including risk factors), social and geographical factors, and phase of illness|Consider escalation if severity does not improve Consider ICU review/ admission or transfer to local centre with paediatric HDU/ICU capacity if: - severity does not improve - persistent desaturations - significant or recurrent apnoea associated with desaturations - has risk factors| |**Parental education**|Provide advice on the expected course of illness and when to return (worsening symptoms and inability to feed adequately)|Provide advice on the expected course of illness and when to return (worsening symptoms and inability to feed adequately)|Provide advice on the expected course of illness| # Oxygen Therapy - Oxygen therapy should be instituted when oxygen saturations are persistently <90% - Infants with bronchiolitis will have brief episodes of mild/moderate desaturations to levels <90%. These brief desaturations are not a reason to commence oxygen therapy - Oxygen should be discontinued when oxygen saturations are persistently ≥90% - **Once not requiring oxygen for 2 hours, discontinue oxygen saturation monitoring.** Continue other observations 2–4 hourly and reinstate intermittent oxygen monitoring if deterioration occurs # unnecessary treatments regardless of severity, don't give - beta agonists (eg salbutamol) - steroids - adrenaline - nebulised saline - abx / azithro - antivirals # Discharge Child maintaining adequate oxygenation >93%, minimal accessory muscle use, and maintaining adequate oral intake, no significant chronic medical problems , no apnoea - maintaing SaO2 >92% RA and mild work of breathing - adequate oral nutrition >50% baseline - parents understand condition and parameters for return or futher review - parents have a means to access medical review - no high risk historical features # Indications for admission - Oxygen requirement - Apnoeic episodes - Mod- severe WOB - Decreased feeding to require NGT or IVF - Poor social supports - Geographical isolation - Early phase of illness (expected to become worse) # Related Questions ## bronchiolitis - [x] 2Q: [Bronchiolitis](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=29) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=30) - [x] 3Q: [Bronchiolitis](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=29) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=28) - [x] 4Q: [Bronchiolitis](x-devonthink-item://1442A590-B32E-40BE-9C29-6401A71DC2DC?page=8) -- [Answer](x-devonthink-item://0C9617AB-8E16-4A75-ADF0-AB06FA726B0A?page=3) - [x] 5Q: [Bronchiolitis](x-devonthink-item://6092BF31-E542-4019-8E17-0C628DD3B0F1?page=5) -- [Answer](x-devonthink-item://E15CEB64-C6A5-4A7D-84B4-E7D1DC667B0E?page=3) - [AFEM 2021.1 Q5](x-devonthink-item://6AA65429-F81B-4D2A-8AD1-14075DA7A42B?page=16)