City and Hackney Bronchiolitis Pathway Manpreet Sahemey – GP & EM Registrar Dr Sanjay Wazir – Consultant Paediatrician

What is bronchiolitis? Cough and increased work of breathing – affects a child’s ability to feed Most commonly seen in the winter months in children aged under 2 years (peaks 3-6 months) caused by RSV In most cases, symptoms last a few days and the child will improve 1/3 children will develop bronchiolitis in the first year of life 3% of children with bronchiolitis require hospital admission (5-10% for severe bronchiolitis) The majority of cases can be managed at home

Diagnosing Bronchiolitis A coryzal prodrome lasting 1 to 3 days followed by: - persistent cough  - either tachypnoea or chest recession (or both)  - either wheeze or crackles on chest auscultation (or both) Infants aged 6 weeks or less may present with apnoeas and no other clinical signs

Videos of bronchiolitic children https://www.youtube.com/watch?v=TUWk4t_RTq4 https://www.youtube.com/watch?v=SsxsiISkLZA

Brochiolitis severity

Red flag features worsening work of breathing e.g. grunting, nasal flaring, marked chest recession fluid intake is 50-75% of normal no wet nappy for 12 hours

Bronchiolitis management What can be helpful? - regular saline nasal drops (available over the counter) propping up Humidity e.g wet towel over radiator (evidence base is lacking – Cochrane review 2011) Do not use the following to treat bronchiolitis: Antibiotics, salbutamol, montelukast, ipratropium bromide, systemic or inhaled corticosteroids

Risk factors for severe bronchiolitis Chronic lung disease Congenital heart disease Age < 3 months Prematurity <32/40 Neuromuscular disease Immunodeficiency

When to refer to hospital Signs of exhaustion or increased respiratory effort e.g. grunting, marked chest recession Apnoea (observed or reported) Failure to maintain oxygen saturation >92% (where saturation monitoring is available) RR>60/min Difficulty feeding or reduced oral fluid intake to 50-75% of usual volume Clinical dehydration Decrease in wet nappies Take into account other factors such as social circumstances, confidence of a carer in looking after the child at home and spotting red flag symptoms

NICE guidance

The pathway document

Traffic light system

Management flowchart

Case study 9 month old female attended ED with fever and increased WOB, reduced oral intake and wetting nappies slightly less than usual, no rash, no D&V One of twins – born at 36/40 Thriving, up to date with imms, no regular prescribed meds Found to be tachypnoeic at 50 bpm, temp 37.9, Sats= 94% (oa), HR=144bpm Chest left basal crackles Assessed to be amber -> admitted for a short period of observation and supportive measures, discharged home later once feeding and observations improved

Referral options from Primary Care Contact and speak to the on call Paediatric Registrar via the Homerton Hospital switchboard on 0208 510 5555 bleep 007 For advice contact and speak to the on call Paediatric Consultant via the Paediatric advice hotline on 07795 390 715. The hotline is open every weekday 9am to 5pm.

Bronchiolitis at HUH  We did an audit regarding bronchiolitis referrals and admission last year There were about 400 A&E presentations 20% were admitted which includes admissions as well as observations.

References Bronchiolitis in children: diagnosis and management. NICE guideline [NG9] Published June 2015 Schuh et al. Efficacy of oral dexamethasone in outpateints with acute bronchiolitis. J Pediatr 2002; 140(1):27-32 Patel H et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev 2004;(3): CD004878 Corneli HM et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med. 2007 Jul 26;357(4):331-9

Q&A

Reminder Paediatric hotline – 07795390715 Paediatric advice and guidance – through the electronic referral system (e-RS) Urgent clinic – refer through the e-RS system