Bronchiolitis – Who Needs to Stay?

Admission Ticket

 

Well, this “winter” in Charlotte has been delightful – temperatures in the 60’s, blue skies, and birds singing (literally).  While this makes for fun times outside of the hospital, it seems to have spawned a never-ending stream of kids with upper and lower airway phlegm. I am pretty sure that I wrote “bronchiolitis” on the chart of a patient with a laceration the other day.   We have discussed some aspects of Bronchiolitis Management in the past, and many of these kids can be sent home.  But then that leads to the question of who needs to stay?

Apnea is not the only concern!

  • Apnea … certainly that is bad.
    • We have all learned that RSV can cause apnea…
    • RSV isn’t the only culprit of bronchiolitis
    • Human Metapneumovirus, Influenza, Parainfluenza, Adenovirus, rhinovirus, etc.
    • So Synagis (monoclonal antibody against RSV) may not prevent Bronchiolitis.
    • RSV does seem to cause more “Severe” disease though.
  • Fatigue (it is tough to breath 70 times a minute)
  • Hypoxia and cyanosis (serious VQ mismatch)
  • Dehydration (tough to drink when you are breathing 70 times a minute)
  • Pneumonia (actually an uncommon complication)

High Risk Factors for Complications

  • Prematurity
    • GA < 37 weeks
    • Post-Conception Age < 42 weeks
  • Age < 3 months
  • Chronic Lung Disease (ex. CLD, requiring Home Oxygen therapy, Cystic Fibrosis)
  • Hemodynamically significant heart disease
  • Neurological disease (with hypotonia particularly)
  • Immunocompromised state
  • Airway Anomalies

 

Who needs to stay?

  • There are no well-drawn guidelines on this as the disease process of bronchiolitis is so varied, often has overlap with other entities (reactive airway disease), and is relatively difficult to study… but that means your CLINICAL EXAM is paramount (I love when that happens).
  1. Unable to maintain adequate hydration
    1. Working too hard to drink or too ill to care about drinking.
    2. They don’t need to be drinking as much as “normal” – remember that they are normally consuming enough to grow; during times or illness, we don’t care about growing as much as staying hydrated.  So assess hydration clinically (see ORT Morsel).
  2. Hypoxia
    1. No single Pox value to help determine admission for everyone.
    2. Healthy kids on RA should have Pox >95%
    3. Oxyhemoglobin dissociation curve has significant inflection point at ~90%, so we’d like everyone to stay above that. But that curve gets shifted to the right with fever, so I usually aim for >92% on RA.
      1. Important to consider the dynamic nature of the disease and observe child at rest, while active, and while eating.
      2. The alert child with Pox 91% who feeds easily and has no significant work of breathing is better off than the one who cannot feed and has retractions with a Pox of 93%.
  3. Have High Risk Factors (listed above)
    1. Again, nothing is written in stone… the 2 month old who looks fantastic and is feeding well and not hypoxic does not need to stay just because he is 2 months old.
  4. Consider the disease course
    1. Typically Bronchiolitis symptoms peak on days 3-5.
    2. If the patient has moderate symptoms on day 2… day 3 will likely be worse.
    3. If the child is doing fairly well on day 3, then the tough part is likely beyond them.
  5. Consider family ability to care for the kid (subjective I know…)

 

Bonus Morsel

  • Overall, despite the plethora of research out there on the subject, the care for the child with bronchiolitis is primarily supportive.
  • On occasion, severe disease will mandate more aggressive measures to be taken.
  • Attempt to prevent intubation if you are able; consider:
    • Nasal Prongs for high-flow oxygen therapy or nCPAP.
    • Heliox
    • BiPap
  • If you have to intubate, and you are able to, use the largest ETT possible with a Cuff to help manage the pulmonary pressures and secretions.
  • See AAP Bronchiolitis Algorithm for Clear and Concise Approach

 

 

Wilson DF, Landrigan CP, Horn SD, Smout RJ. Complications in infants hospitalized for bronchiolitis or respiratory syncytial virus pneumonia. J. Pediatr: 2003; 143(5), pp.S142-S149.

McKiernan C, Chua LC, Visintainer PF, Allen H. High Flow Nasal Cannulae Therapy in Infants with Bronchiolitis. Journal of Pediatrics: 2010; 156(4), pp.634-638.

Schibler A, Pham TMT, Dunster KR, Foster K, Barlow A, Gibbons K, Hough JL. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Medicine: 2011; 37(5), pp. 847-852.

Papoff P, et al. Incidence and predisposing factors for sever disease in previously healthy term infants experiencing their first episode of bronchiolitis. Acta Paediatrica: 2011; 111(7), pp. e17-e23.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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5 Responses

  1. John says:

    Great practical pointers as usual!

  2. Ariel Cohen says:

    Hey, happy new year and long time no speak. How are you? I’m now 7 months into fellowship which is crazy. I still read and reference your morsels frequently, but I recently had a case that highlighted how valuable your site is and wanted to let you know. You do an awesome job of addressing topics that are usually not concisely discussed, in this case, bronchiolitis disposition. Without your article, I would have had to do hours of digging to answer my question (which I did after my shift of course).
    I had full term 2 wk old who had URI sxs, saw PCP new years eve, was dx’d as RSV+ and sent home. Later in the day developed intermittent grunting. Perfectly normal in the ED though, no grunting, tolerating feeding. I had recently had a discussion with an experienced attending who said most of the faculty would admit an infant < 1mo old just for being RSV+, which was news to me. I got pushback when I tried to admit my patient so was left confused when it seemed to be such a common practice according to my attending. So, thanks for the honesty and helpful info in the article.

    Out of curiosity, do you admit RSV+ neonates? And would you or do you get pushback from the inpatient team?
    Best wishes.

    Ariel Cohen, D.O.
    Pediatric Emergency Medicine Fellow
    Johns Hopkins Hospital

    • Sean Fox says:

      Hello Ariel!!
      So glad that you are doing well and I’m sure you are enjoying Baltimore (I still love Baltimore very much)!

      RSV is the specific virus that is associated with apnea in the at risk patients (as highlighted in Morsel), but RSV positivity itself would not cause me to admit a neonate. The clinical condition of bronchiolitis is what warrants concern in that patient. If I am see a neonate who I am diagnosing bronchiolitis my threshold to hospitalize for observation is very low… And if you tell me that the kid was grunting, done. No further thought is needed. Adding RSV + just is part of the story and I might use to accentuate the need for caution, but alone wouldn’t be the reason I would take action.

      I would have had no “push back” for admitting a neonate with bronchiolitis— even if the kid wasn’t grunting.
      Have a great New Year,
      sean

  1. August 6, 2015

    […] Patients who definitely need admission – those who are dehydrated, who have an oxygen requirement, ex-prems and very young babies (especially if there is a history of apnoeas), and those with co-existing pathology (respiratory, cardiac or neurological/neuromuscular). […]

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