Paula Chilvers GPST2 November 2017 Bronchiolitis Paula Chilvers GPST2 November 2017

Background Commonest LRTI in children <12m, occurs up to 2yrs old, peak 3-6m Most cases: RSV (Respiratory Syncytial Virus) Oedema of airways – widespread narrowing – air trapping Majority of cases can be managed at home with support from Primary Care; usually self limiting, lasting 3-7 days Symptoms peak at 4-5 days – SAFETY NET Most common cause of hospital admission in infants <6m Can be life threatening, esp if pre-existing cardiac/respiratory disease

Presentation

Presentation Coryzal prodrome 1-3 days Then, persistent cough Wheeze/crackles on auscultation +/- fever Poor feeding – typically after 3 to 5 days Infant <6wks may present only with apnoea

Indications for hospitalisation

Indications for hospitalisation Poor feeding: <1/2 normal feeds Lethargy Tachypnoea (>70/min) or apnoea Nasal flaring or grunting Moderate to severe chest wall recession SpO2 <93% in air

Risk factors for severe disease Premature birth Age <12w at presentation Pre-existing cardiac/respiratory disease Immunodeficiency

Diagnosis Based on clinical hx and examination Clinical features: Early symptoms – coryzal, non specific 1-3 days, increasing breathlessness, cough, tachypnoea, varying degrees of respiratory distress Apnoea – esp very young, premature or low birth wt infants Auscultation: early – fine crackles, coarser during recovery; +/- expiratory wheeze Fever >38.5C in 50% of infants

Diagnosis History Risk factors eg pre-existing conditions Feeding pattern – duration & completion Breathlessness/ rapid breathing/ wheeze Cough, apnoea, cyanotic spells Wet nappies Fever? Examination Degree of distress; circulation, hydration status

Differential diagnosis

Differential diagnosis ?pneumonia if : high fever (over 39°C) and/or focal crackles ?viral-induced wheeze/early-onset asthma older infants and young children with: persistent wheeze no crackles or recurrent episodic wheeze or Personal/family history of atopy Note: Unusual <1 yr old

Investigations Mild cases – no Ix required All moderate to severe cases – NPA to microbiology for identification of respiratory viruses inc RSV

Investigations Any other Ix are not routine, may be requested after discussion +/- senior review CXR FBC Serum electrolytes – if IV therapy required Blood culture if temp > 38.5C Capillary blood gas

Treatment NICE: pharmacological agents NOT shown to give benefit above standard supportive care Oxygen (humidified) – single most useful therapy Airway support – CPAP – severe respiratory distress/fatigue/apnoea

Treatment Feeding – based on degree of tachypnoea, likelihood developing fatigue Bronchodilators – should NOT be routinely used (NICE – no evidence of definitive benefit). May give short term relief Nebulised 3% hypertonic saline (3HS) – questionable benefit

Treatment Antibiotics – only if secondary bacterial infection is strongly suspected. Areas of consolidation on CXR not necessarily an indication. Partial R upper lobe collapse quite common in uncomplicated RSV bronchiolitis Corticosteroids – no evidence for inhaled or systemic steroids in acute infection Ribavirin – no evidence significant benefit RSV prophylaxis – Palivizumab for at risk infants

Advice to carer Prevention of cross infection Incubation 2-8 days, viral shedding 3-8 days (up to 4 wks in young infants) Handwashing, hygiene Limit affected individual’s contact with others

Safety netting/Advice Trust Guidelines: Review with GP within 7 days of discharge There is strong evidence that smoking increases the risk of admission with bronchiolitis Re-infection may occur Red flags - Signs of increased work of breathing Reduced fluid intake (50-75% of normal/no wet nappy in 12hrs) Apnoea/cyanosis Fatigue Cough resolves in 90% by 3 wks Risk of wheeze increased after bronchiolitis – if no FHx atopy, should resolve by age 10 yrs(!)