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Bronchiolitis
Bronchiolitis is a viral lower
respiratory tract infection, generally
affecting children under 12 months of
age. After 12 months of age consider
overlap with asthma
Assessment
Is the child improving, stable, or
likely to deteriorate over the next
few days? Peak severity is usually at
around day 2-3 of the illness with
resolution over 7-10 days. The cough
may persist for weeks
Examination
Increasedwork of breathing
Widespread wheeze and crepitations
+/- fever
May have reduced oxygen saturation
Look for signs ofdehydration
Mild
Moderate
Severe
Behaviour
Normal
Some/intermitte Increasing
nt irritability
irritability and/or
lethargy
Tachypneu
Normal or
mildly increase
respiratory rate
Increased
respiratory rate
Increased or
markedly reduced
respiratory rate as
the child tires
Sign of increased
None or minimal Moderate
WoB
Retraction
- (intercostal,
suprasternal, costal
margin)
- Paradoxical
abdominal
breathing
Accessory muscle
use
- Nasal flaring
- Sternomastoid
contraction
- Forward posture
Marked increase in
accessorymuscle
use with prominent
chest retraction
Oxygenation
Cyanosis
SaO2 <85%
Assessment of Severity
Investigation
Nasopharyngeal aspirate NOT routinely
required for children with typical bronchiolitis
Chest X-ray NOT routinely required unless
diagnostic uncertainty eg localised signs on
auscultation, cardiac murmur with signs of
congestive cardiac failure. For children with
typical clinical picture of bronchiolitis X-ray
typically demonstrates hyperinflation,
peribronchial thickening, and often patchy areas
of consolidation and collapse.
Blood gas NOT routinely required
Acute Management
The main treatment of bronchiolitis is
supportive. This involves ensuring
oxygenation and fluid intake, as well
asminimal handling. Children are
often more settled if comfort oral
feeds are continued
Minimal Handling
-The sick child deteriorates with handling and distressing procedures.
-Increased distress in an unwell child can:
Increase heart rate, respiratory rate and blood pressure
Cause de-oxygenation (especially in neonates)
Tip a child's condition from moderate to severe
-Minimal handling is particularly important in:
Respiratory conditions, such as croup, asthma
Principles:
Keep the child with parent or care giver.
Try and keep the environment quiet and moderate lighting.
Allow the child comfort feeds if safe to do so.
Minimise interventions, including examination and investigations that are not going
to impact acute management
Group cares - eg observations and oral medications
Use comfort techniques for painful procedures such as intravenous catheters - EMLA
or Angel cream, distraction
Don't forcibly alter a child's posture - especially in respiratory conditions such as
croup. Children will naturally adopt the posture that facilitates the least airway
obstruction.
Management
Discharge requirement
Children can be discharged when they
are
-maintaining adequate oxygenation
-maintaining adequate oral intake
Additional Notes
Bronchodilators such as salbutamol have not shown to alter the
course of acute bronchiolitis
There is some evidence for the use of nebulised saline, however
this is not currently recommended as standard therapy.
Antibiotics are not indicated for uncomplicated bronchiolitis.
Although there has been some recent evidence regarding the use
of intravenous steroids in combination with nebulised adrenaline
in bronchiolitis, this data should be considered exploratory only.
Use of steroids should be judicial as their use may have neurodevelopmental consequences, especially in younger infants. They
may also have a negative impact on lung development.
Ribavirin (antiviral) treatment is not supported by evidence of
significant benefit.
Immunoglobulins have no evidence of benefit.