Bronchiolitis

Question 1

What is bronchiolitis?

Answer 1

Viral LRTI generally affecting children under 12m. Most frequent cause of hospitalisation in children less than 6m. Consider overlap with asthma if 12m+

Question 2

What are the risk factors for severe bronchiolitis?

Answer 2

• Young (esp less 6w)
• Ex premi
• CHD
• Neurological conditions
• Chronic respiratory illness
• Pulmonary HTN

Question 3

Describe the time course of bronchiolitis

Answer 3

• Peak severity D2-3
• Illness resolution over 7 - 10d
• Cough may persist for weeks

Question 4

What are the PEx features of bronchiolitis?

Answer 4

• Increased WOB
• Widespread wheeze and creps
• +/- fever
• +/- dec SaO2
• Assess for dehydration

Question 5

What are the signs of moderately severe bronchiolitis?

Answer 5

• Irritable
• Inc RR, tracheal tug, nasal flaring
• Mod chest wall retraction
• Reduced feeding
• Mild hypoxemia (90-93%)
• +/- brief apnoeas

Question 6

What are the signs of severe bronchiolitis?

Answer 6

• Irritability / lethargy / fatigue
• Marked inc or dec in RR
• Marked chest wall retraction
• Reluctant or unable to feed
• Hypoxemia: less 90%
• May have more frequent or prolonged apnoeas

Question 7

What investigations are required in bronchiolitis?

Answer 7

Most children: NO investigations.

• NPA: not routine
• CXR: not routine unless diagnostic uncertainty / local signs.
• Blood gas: not routinely required

Question 8

What are the typical features of bronchiolitis on CXR?

Answer 8

• Hyperinflation
• Peribronchial thickening
• Patchy consolidation / collapse

Question 9

What is the general approach to acute management of bronchiolitis?

Answer 9

Supportive:

• oxygenation
• maintain fluids
• minimal handling

Question 10

How is mild bronchiolitis managed?

Answer 10

• Home Mx
• Advise parents of expected course, when to return
• Give info leaflet
• Smaller, frequent feeds
• Further Rv if:
• -early
• -RFx present
• -increasing signs of severity develop

Question 11

How is moderate bronchiolitis managed?

Answer 11

• Discuss with paeds for admission
• O2 maintain 92%+
• Consider limiting fluids to 2/3 maintenance
• 1-2h obs

Question 12

How is severe bronchiolitis managed?

Answer 12

• Cardioresp monitoring
• Close nursing
• Supplemental O2 and fluids
• Consider tertiary transfer with ICU facilities

Question 13

When should child be transferred to tertiary centre?

Answer 13

• Severe
• Comorbidities (e.g. premi)
• Apnoeas
• Children needing care above comfort of hospital
• O2 requirement 50%+

Question 14

Do bronchodilators have a role in bronchiolitis?

Answer 14

Do not alter course of acute bronchiolitis. Some evidence for neb saline but not standard therapy.

Question 15

Are ABx indicated for bronchiolitis?

Answer 15

Not for uncomplicated bronchiolitis.

Question 16

What are the CFx of bronchiolitis?

Answer 16

• Cough
• Tachypnoea
• Poor feeding
• Wheeze
• Crackles
• Apnoea
• Mucous production and inflammation causing obstruction at level of bronchioles.

Question 17

Hx features to elicit in bronchiolitis assessment?

Answer 17

• Age
• Duration (peak 3-5d)
• Hx prematurity
• PMHx
• Recent intake / output
• FHx atopy / asthma
• Apnoea: #, frequency, duration

Question 18

What must be assessed and documented in PEx for bronchiolitis admission?

Answer 18

• Temperature
• RR
• HR
• BP
• SPO2 and/or Oxygen requirements
• Pain
• Level of Respiratory Distress
• Central and Peripheral
• Capillary Refill Time
• Colour – i.e.: pink, pale, grey, cyanosed, flushed
  Feeding / Hydration Status / urine output
• Level of consciousness / irritable/ consolable etc

Question 19

What are the potential indications for NPA in bronchiolitis?

Answer 19

• Hx of apnoeas
• severe or atypical illness
• clinical suspicion of pertussis

Question 20

Which viruses are most commonly responsible for bronchiolitis?

Answer 20

• RSV

- Human metapneumovirus

Question 21

What is the only intervention demonstrated to improve the condition of children with bronchiolitis?

Answer 21

Supplemental oxygen.

Mx thus centres around symptomatic relief, hydration and oxygenations.

Question 22

What are the supportive care management strategies?

Answer 22

• Humidified oxygen
• Hydration maintenance
• Mechanical ventilation
• Nasal and oral suctioning
• Apnoea and cardiorespiratory monitoring
• Temp regulation in small infants

Question 23

What are bronchioles?

Answer 23

Small airways

Question 24

What is the bronchiolar lining comprised of?

Answer 24

• surfactant secreting Clara cells

- neuroendocrine cells (somatostatin, endothelin, serotonin)