Bronchiolitis is an infectious inflammation of the bronchioles. It is primarily a disease of the very young – 95% of cases occur in children < 2 years old. It is almost always viral in origin, most commonly caused by the Respiratory syncytial virus (RSV). Other causes include parainfluenza, adenovirus, metapneumovirus, and bocavirus.
- ATS/AACP recommendations for bronchiolitis
- Diagnosis is based on clinical findings, not laboratory or radiographic findings
- Risk factors should be assessed
- Beta-agonists should not be routinely used. If they are used, continue only if there is a positive clinical response.
- Supplemental O2 is necessary for patient with SpO2 <90%
- Assess hydration and ability for PO intake
- Avoid antibiotics
- Steroids should not be used
- Ribavirin should not be used
- Risk factors
- Maternal smoking
- Low birth weight or prematurity
- Perinatal complications
- Perinatal or neonatal Antibiotic exposure
- Chronic disease
- Poor nutrition in utero
- Environmental allergens or smoke
- Crowded conditions
- Poor Socioeconomic Status
- Risk factors for severe (complicated) bronchiolitis
- Preterm
- Low birth weight or Preterm
- Age ≤ 12 weeks
- Chronic pulmonary disease
- Anatomic defect of the airway
- Hemodynamically Significant Congenital Heart Disease
- Immunodeficiency
- Neurologic disease
- Patient History
- Signs and symptoms
- Wheezing
- Sneezing
- Clear rhinorrhea
- Coryzal symptoms may precede
- Reluctance to feed
- Low-grade fever in some cases
- Severe Symptoms
- Tachypnea
- Wheezy cough
- Dyspnea,
- Irritability
- Apnoea
- Physical examination
- Monitor respiratory rate and SpO2
- Signs of respiratory distress: retractions, nasal flaring
- Signs of chronic hypoxia: finger clubbing, which indicates repeated bouts of respiratory tract infections
- Auscultation:
- Wheezing (Monophonic or polyphonic?)
- Prolonged expiratory phase
- Is there stridor?
- Are the adventitious sounds louder in the neck?
- Differentials
- Asthma
- Acute bronchitis
- Bacterial pneumonia
- Viral pneumonia
- Investigations
- Chest X-ray if the diagnosis is uncertain
- Hyperinflation (≥ 9 posterior ribs in children, ≥ 11 posterior ribs in adults)
- Flattening of the diaphragm
- Patchy atelectasis
- Wall thickening
- Peribronchial cuffing with air bronchograms
- Increased AP diameter
- Nasopharyngeal swab or aspirate for viral detection: not used routinely for diagnosis
- Complete blood count and CRP if bacterial infection is suspected
- Blood gas analysis for children with severe respiratory distress
- Electrolytes, if there are concerns about dehydration or SIADH
- Chest X-ray if the diagnosis is uncertain
- Indications for admission
- Under 3 months old
- Persistent resting SpO2 <92%
- Respiratory rate of > 70-80 breaths per minute
- Any signs of respiratory distress: Especially accessory muscle use, retractions, and cyanosis
- Pre-existing chronic lung disease
- Congenital heart defect
- Prematurity
- Inability to maintain oral hydration
- Intractable feeding difficulties
- Home care issues
- Treatment
- Monitor respiratory rate and SpO2
- Supplemental O2: mainstay of treatment.
- Mandatory if SpO2 <90%
- Titrate to 91 – 95%
- Nebulized salbutamol and/or hypertonic saline
- Check for clinical response
- Nasal and oral suctioning
- IV fluids maintenance – if dehydrated and cannot tolerate oral fluids