UNM Family and Community Medicine Residency School Bronchiolitis 8/9/17 UNM Family and Community Medicine Residency School Alfonso Belmonte, MD

After the lecture the learner should be able to: Objectives After the lecture the learner should be able to: 1) Describe the pathophysiology of wheezing 2) List 2-3 features that differentiate bronchiolitis, asthma, foreign body and left to right heart lesions with heart failure 3) Discuss AAP policy on Diagnosis Risk Factor assessment Treatment 4) Discuss UNM policy and practices for bronchiolitis

After the lecture the learner should be able to: Objectives After the lecture the learner should be able to: 1) Describe the pathophysiology of wheezing 2) List 2-3 features that differentiate bronchiolitis, asthma, foreign body and left to right heart lesions with heart failure 3) Discuss AAP policy on Diagnosis Risk Factor assessment Treatment 4) Discuss UNM policy and practices

Wheezing asthma

Wheezing asthma Distal Wheezing Airway obstruction

Extra-luminal compression -interstitial edema -smooth muscle contraction Intra-luminal obstruction -mucus/cellular debris -foreign body

Asthma= extra-luminal compression

Bronchiolitis=intra-luminal obstruction

Foreign Body=intra-luminal obstruction

Pulmonary Edema=intra and extra luminal obstruction

Wheezing asthma Distal Wheezing Airway obstruction

Questions????? 1) Describe the pathophysiology of wheezing

After the lecture the learner should be able to: Objectives After the lecture the learner should be able to: 1) Describe the pathophysiology of wheezing 2) List 2-3 features that differentiate bronchiolitis, asthma, foreign body and left to right heart lesions with heart failure 3) Discuss AAP policy on Diagnosis Risk Factor assessment Treatment 4) Discuss UNM policy and practices

Tachypnea / resp. distress Common Symptoms Wheezing Tachypnea / resp. distress Hypoxemia Poor Feeding Pulmonary crackles Cough

Tachypnea / resp. distress Heart Failure in Left to right shunts Common Symptoms Wheezing Tachypnea / resp. distress Hypoxemia Poor Feeding Pulmonary crackles Cough Asthma Bronchiolitis Foreign Body

Tachypnea / resp. distress Heart Failure in Left to right shunts -cold forehead sweat -weak pulses -cardiomegaly -failure to thrive -6-12 weeks of age -no rhinorrhea -murmur, gallop -cough absent Common Symptoms Wheezing Tachypnea / resp. distress Hypoxemia Poor Feeding Pulmonary crackles Cough Asthma -Older (>4) OR -Younger than 4 with + asthma predictive index -Family History Bronchiolitis -Younger (<2) - URI progressing to LRI - Sick contacts -Older than 2 with neg API Foreign Body -FOCAL wheezing -Hyper-acute onset -no preceding URI -abnormal bilateral lateral decubitus

Questions???????? 2) List 2-3 features that differentiate bronchiolitis, asthma, foreign body and left to right heart lesions with heart failure

After the lecture the learner should be able to: Objectives After the lecture the learner should be able to: 1) Describe the pathophysiology of wheezing 2) List 2-3 features that differentiate bronchiolitis, asthma, foreign body and left to right heart lesions with heart failure 3) Discuss AAP policy on Diagnosis Risk Factor assessment Treatment 4) Discuss UNM policy and practices

2014 AAP policy on Bronchiolitis Inclusion 1-24 months old Exclusion Immunocompromised Recurrent wheezing Bronchopulmonary dysplasia aka chronic neonatal lung disease Cystic fibrosis Congenital heart disease Neuromuscular disease

Bronchiolitis Diagnosis Based on History and Physical (strong rec) Xray and labs should NOT be routinely obtained (moderate rec)

History Sick contacts URI (rhinorrhea, congestion, cough) progressing to LRI (hypoxemia, retractions, rales, wheezing, nasal flaring) Usually worst 3-7 days after URI starts

Physical 6 Months URI LRI: diffuse findings is key Clinical pearl: Children are obligate nasal breathers till age 6 months Retractions may improve with simple nasal suction Evaluate for FULL 1 minute

X-ray If done Lead to more antibiotics without improved outcomes Should be saved for PICU admissions or suspected complications (pneumothorax)

Viral testing? AAP recommends RSV testing for children on Synagis If + stop monthly Synagis “Apart from this setting, routine virologic testing is not recommended” More in the UNM specific section

Risk assessment Essentially the exclusion criteria plus age <3 months Immunocompromised Recurrent wheezing Bronchopulmonary dysplasia aka chronic neonatal lung disease Cystic fibrosis Congenital heart disease Neuromuscular disease

Treatment

Asthma= extra-luminal compression

Bronchiolitis=intra-luminal obstruction

Treatment Improve clinical symptom scores Does NOT alter need for hospitalization or length of stay Studies excluded severe disease

EPI

Pred RCT with placebo No effects

Chest Physiotherapy

Antibiotics ONLY if concurrent infection (usually AOM or UTI) Suggested reading: 1) AAP Policy on Acute Otitis Media 2) Costs and Infant Outcomes After Implementation of a Care Process Model for Febrile Infants. Pediatrics July 2012, VOLUME 130 / ISSUE 1

Hydration / Nutrition IVF NG Typically D5 NS 20KCl Additional reading: Isotonic Versus Hypotonic Maintenance IV Fluids in Hospitalized Children: A Meta-Analysis. Pediatrics January 2014, VOLUME 133 / ISSUE 1 NG Use expressed breast milk or formula

IV vs NG Both Are: Safe (as long as ISOTONIC fluids are used) No difference in: O2 time LOS ICU / Intubation Parental satisfaction IV Lower success rate in placement NG Higher success rate in placement

Hypertonic Saline Jury is still out 2014 AAP policy DON’T use in ED MAY use inpatient 2015 Systematic Review Zhang et al. Pediatrics. October 2015, Volume 136 / Issue 4. Decrease LOS 11 hours 20% decrease risk of hospitalization Lots of heterogeneity and inability to run met analysis Inconsistency in dosing and frequency

Oxygen / Pulse Ox ACTUALLY Not well studied!!! Makes sense though. Use for sats <90% Poor correlation of hypoxemia and respiratory distress Home O2 on =/< 0.5L is safe High flow nasal cannula can decrease intubation Pulse Ox “May choose not to use continuous pulse oximetry” –weak recommendation Pulse Ox: Poor reliability for 76-90% Healthy infants can have intermittent hypoxemia from period breathing Further Reading: Longitudinal assessment of hemoglobin oxygen saturation in healthy infants during the first 6 months of age. J Pediatr. 1999;135(5):580–586 Longitudinal assessment of hemoglobin oxygen saturation in healthy infants during the first 6 months of age. J Pediatr. 1999;135(5):580–586 80% of preterm and 65% of term kids have intermittent hypox. As low as 83%, median events per hour was 4-5. Lasting 5-30 seconds. Risk of Int Hypox was about equal once 43 weeks post menstruational age.

Bronchiolitis treatment Isotonic

Ouestions???? 3) Discuss AAP policy on Diagnosis Risk Factor assessment Treatment

After the lecture the learner should be able to: Objectives After the lecture the learner should be able to: 1) Describe the pathophysiology of wheezing 2) List 2-3 features that differentiate bronchiolitis, asthma, foreign body and left to right heart lesions with heart failure 3) Discuss AAP policy on Diagnosis Risk Factor assessment Treatment 4) Discuss UNM policy and practices

UNMH Cohorting!

UNMH Home Oxygen No need for room air sats >90 Room air trial ( Do NOT do till stable on </= 0.5L) If sats >85% on room air for 10 minutes get Rx in before 3PM Sleeping??? (depends on your attending, NOT and institutional requirement) No open flames as heat source, reliable PCP follow up

UNMH High Flow Nasal Cannula Reduces intubation If still having moderate to severe respiratory distress on 3L Transfer to Pediatrics as primary

UNMH https://sites.google.com/site/unmpedsinpt/protocols user name-unmpeds1 password-unmpeds! ​Tip- if it does not let you log on, log off of your individual google account then try logging in again. 

UNM

WARM SCORE -Wheezing -Air Exchange -Respirations -Muscle Use

UNMH WARM <4 (mild) WARM 4 (moderate) WARM 5 (severe) Supportive care WARM 4 (moderate) Trial Albuterol, continue only if score improves by 2 WARM 5 (severe) Trial Albuterol continue only if score improves by 2 Consider Rapid Response

Questions?????

References Swingler GH, Hussey GD, Zwarenstein M. Randomised controlled trial of clinical outcome after chest radiograph in ambulatory acute lower- respiratory infection in children. Lancet. 1998;351(9100):404–408 Nelsons Pedi