1. Paula Chilvers GPST2 November 2017
Bronchiolitis
Paula Chilvers
GPST2
November 2017

2. 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

3. Presentation

4. 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

5. Indications for hospitalisation

6. 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

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

8. 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

9. 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

10. Differential diagnosis

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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(!)