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
- 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).
- Unable to maintain adequate hydration
- Working too hard to drink or too ill to care about drinking.
- 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).
- No single Pox value to help determine admission for everyone.
- Healthy kids on RA should have Pox >95%
- 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.
- Important to consider the dynamic nature of the disease and observe child at rest, while active, and while eating.
- 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%.
- Have High Risk Factors (listed above)
- 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.
- Consider the disease course
- Typically Bronchiolitis symptoms peak on days 3-5.
- If the patient has moderate symptoms on day 2… day 3 will likely be worse.
- If the child is doing fairly well on day 3, then the tough part is likely beyond them.
- Consider family ability to care for the kid (subjective I know…)
- 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.
- 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.