Question 28

College Answer

(a) Assessment

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.

Discussion

Assessment:

History

• Background (looking for the risk factors of severe bronchiolitis)
• Duration of illness (normal course is 7-10 days, should completely resolve within 1 month)
• History of complications
• Feeding history (i.e. adequate oral intake)
• Episodes of restlessness or lethargy
• History of unusual, severe or prolonged course (makes you think of congenital heart disease or some sort of defect in the immune system)

Examination

• Clinical features consistent with bronchiolitis
• Clinical features of severity
• Assessment for the need for intubation or NIV
• Clinically may also have mayconjunctivitis, pharyngitis, or acute otitis media

Investigations

• PCR for RSV, usually from nasal swabs
• Bloods will have a low yield
• CXR has no role to play unless you strongly suspect foreign body aspiration

Management:

• Airway: ​ 
  • Assess the need for intuibation (rarely required)
  • Nasal suctioning to clear upper airway (not deep nasopharyngeal, but rather shallow nasal suctioning)
  •  
• Ventilation:
  • Just oxygen to begin with
  • Aim for sats of over 90%
  • CPAP or HFNP may be the next step of escalation. With infants, maximum flow rate is about L/min. 
  • Invasive mechanical ventilation may be required, but HFNP frequently prevents the need for this.
  • Respiratory distress will escalate whenever the child is handled; the key to respiratory success is to minimise handling and to group all routine cares so that the child gets long breaks between distressing events.
  • Apnoeas may be helped by caffeine or aminophylline
• Advanced strategies to improve gas exchange
  • ​Nebulised hypertonic saline 
  • Nebulised surfactant
  • Heliox
  • ECMO
  • None of these are strongly based in any sociaety recommendations, and sucess is mainly known from case reports
• Circulation:
  • ​IV maintenance fluids and resuscitation of dehydration
  • Assessment for any coexisting cardiac disease with TTE
• Electrolytes
  • Watch for SIADH: apparently that is one of the possible complications
• Nutrition
  • ​Nasogastric feeding to make up for recent deficit
• Antibiotics
  • ​Routine use of IV antibiotics is not indicated
  • Ribavirin has been trialled, and is also not recommended for routine treatment of RSV
    infection but may be considered in select immunocompromised individuals
  • Palivizumab, a humanized monoclonal antibody (IgG) directed against RSV, may be used in at-risk populations for prevention (eg. premature infants during RSV season).
• Strategies which have been trialled and which clearly do not work:
  • ​Nebulised bronchodilators
  • Montelucast
  • Corticosteroids (no evidence of benefit, and may even increase the duration of viral shedding)
  • Chest physiotherapy (probably no benefit)
  • Caffeine or aminophylline (they were supposed to decrease the risk of apnoeas, but they do not seem to work)
  • However, it must be mentioned that the trials of all these interventions excluded the "severe" category of patients.

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).