You have been asked to review a six week old infant in the emergency department with a presumptive diagnosis of bronchiolitis.
(a) Outline your approach to the assessment and
(b) management of this baby.
Important points include:
a) Past medical history. Premature delivery, neonatal ventilation, any previous respiratory disease, congenital heart disease or other syndromes (eg trisomy 21). All of these worsen the prognosis, and increase the likelihood of the need for respiratory support.
b) Diagnosis: must exclude undiagnosed congenital cardiac condition;
is this RSV bronchiolitis? PCR analysis of the naso-pharyngal aspirate is the usual way of making this diagnosis. Other differentials include pertussis and influenza, both of which have the potential to be worse.
Length of history of this illness. In the normal child, RSV bronchiolitis runs a course of 7 – 10 days. So a severe presentation in the first 3 days is more serious than the fifth or sixth day, although a biphasic disease suggests possible secondary infection (Staphylococcus or Streptococcus) .
c) Current observation. Pulse and respiratory rate, severity of respiratory distress, and history of apnoeas requiring resuscitation.
d) If the child has very significant respiratory distress, has had more than one significant apnoea, has very high pulse or respiratory rate, is desaturating despite significant oxygen therapy (such as >60% FiO2), or presence of exhaustion –then ICU/HDU admission is indicated and consideration of transfer to a paediatric facility.
(b) Management includes
1) oxygen therapy,
2) Minimal handling with grouped cares
3) consideration of IV fluids and fasting whilst under assessment.
4) If ventilatory support is required this can be with CPAP via N/P tube/ bubble
CPAP/high flow nasal prong oxygen or face mask BIPAP.
5) Antibiotics are indicated if there are grounds for suspecting a superadded bacterial infection.
6) Aminophylline or Caffeine may be useful in reducing the number of apnoeas if the child has been premature.
7) A few children, usually in the high risk groups above, will need mechanical ventilation or if there is consideration of transportation/retrieval. Comment that intubation and ventilation will prolong the PICU course by 2- 3 days.
Could also mention other advocated therapies
Eg nebulized adrenaline/salbutamol/heliox /Ribavarin– and comment that these therapies have not been proven to be effective in all cases but a few may respond.
Plint, Amy C., et al. "Epinephrine and dexamethasone in children with bronchiolitis." New England Journal of Medicine 360.20 (2009): 2079-2089.
Lowell, Darcy I., et al. "Wheezing in infants: the response to epinephrine." Pediatrics 79.6 (1987): 939-945.
Ralston, S. L., A. S. Lieberthal, and H. C. Meissner. American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. "Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis". Pediatrics 134.5 (2014): e1474-e1502.
Osvald, Emma Caffrey, and Jane R. Clarke. "NICE clinical guideline: bronchiolitis in children." Archives of disease in childhood-Education & practice edition (2015): edpract-2015.
Alansari, Khalid, et al. "Caffeine for the Treatment of Apnea in Bronchiolitis: A Randomized Trial." The Journal of pediatrics (2016).