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
• 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
• 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
?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(!)
