With thanks to Amutha for this article….
As winter approaches, most of us are very well aware that the bronchiolitis season is in full swing. Bronchiolitis is a lower respiratory tract infection – in the under 1s predominantly – that can cause fever, dry cough, nasal discharge and bilateral fine inspiratory creps ± wheeze. Most cases of bronchiolitis occur from November to March, when the viruses that can cause bronchiolitis are more common. It is also possible to get bronchiolitis more than once during the same winter season (1).
Treatment is largely supportive and many infants are managed at home if they are feeding adequately and do not have significant respiratory difficulty. Patients at high risk are ex-premature babies, those with congenital cardiac or respiratory diseases, immunodeficiency and babies < 3months of age (2). When seeing a child, we should focus our history and examination on risk factors, signs of dehydration and respiratory distress. This podcast provides an example of respiratory distress:
http://empem.org/2010/09/bronchiolitis-part-1-of-2/comment-page-1/#comment-294
3% of children will present with severe illness and require admission (2). Map of Medicine (http://healthguides.mapofmedicine.com/choices/map/bronchiolitis1.html) defines “severe” as those with:
- poor feeding – less than half normal intake
- lethargy
- history of apnoea
- respiratory rate above 70breaths/minute
- presence of nasal flare and/or grunting
- severe chest wall recession
- cyanosis
- marked use of accessory muscles
- marked intercostal and subcostal recession
- oxygen saturation (SaO2) 94% or less
There have been no therapies that have been consistently effective enough to change the current supportive management of bronchiolitis. The majority of trials show that bronchodilators do not provide benefit and their routine use is not recommended (3).
1.http://www.nhs.uk/conditions/Bronchiolitis/Pages/Introduction.aspx
2. Scottish Intercollegiate Guidelines Network (SIGN). Bronchiolitis in children. A national clinical guideline. Edinburgh: SIGN; 2006. http://www.sign.ac.uk/pdf/sign91.pdf
3. Petruzella FD, Gorelick MH. Current therapies in bronchiolitis. Pediatr Emerg Care 2010 Apr;26(4):302-7
There is a parent information leaflet at http://www.sign.ac.uk/pdf/sign91parent.pdf which could be a useful resource for parents of babies in the initial stage of the illness as we know that they may get clinically worse over the first 72 hours of the infection before plateauing out on about day 4 or 5.
Zorc et al have published a recent update on the diagnosis and management of bronchiolitis. It also talks of the relevance of investigating bronchiolitic children using imaging and rapid antigen tests, and presents to us a handy table correlating risk factors and potential outcomes in bronchiolitic children. There still doesn’t seem to be adequate evidence to suggest the benefit of using steroids or nebulised adrenaline in these children, and it seems that clinical assessment is still at the forefront for diagnosis rather than the use of investigations. It’s also important to note that in American papers, such as this one, the patient population addressed is different to here in the UK. In the States, a specific finding of wheeze is included in the diagnosis of bronchiolitis, as well as the inclusion of children under the age of 2, as opposed to under 1 in the UK. I’ve copied a link of the paper below for your reading pleasure:
http://pediatrics.aappublications.org/content/125/2/342.full.pdf+html
Dr Avaleen Singh
FY2 Paediatrics