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

3. 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

4. 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

5. Wheezing asthma

6. Wheezing asthma Distal Wheezing Airway obstruction

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

8. Asthma= extra-luminal compression

9. Bronchiolitis=intra-luminal obstruction

10. Foreign Body=intra-luminal obstruction

11. Pulmonary Edema=intra and extra luminal obstruction

12. Wheezing asthma Distal Wheezing Airway obstruction

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

14. 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

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

16. 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

17. 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

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

19. 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

20. 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

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

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

23. 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

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

25. 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

26. 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

27. Treatment

28. Asthma= extra-luminal compression

29. Bronchiolitis=intra-luminal obstruction

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

31. EPI

32. Pred
RCT with placebo
No effects

33. Chest Physiotherapy

34. 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

35. 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

36. 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

37. 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

38. 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 ;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.

39. Bronchiolitis treatment
Isotonic

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

41. 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

42. UNMH
Cohorting!

43. 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

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

45. 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. 

46. UNM

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

48. 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

50. Questions?????

51. 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