Pediatric Acute Bronchiolitis

By : DR Doaa Yusuf
Board Eligible family Medicine
 *Viral bronchiolitis is an acute viral infection
of the lower respiratory tract.

*Although it can affect individuals of any age,

Definition the term is most often used to refer to infection
in infancy.

*It is characterized by epithelial cell destruction,

cellular oedema, and airway obstruction by
inflammatory debris and mucus.
 *The early symptoms are similar to those of a
common cold, such as runny nose or cough.

* As bronchiolitis develops, it can cause: mild fever, dry

Etiology and and persistent cough, increased work of breathing,
presentation wheezing and difficulty feeding

*Respiratory syncytial virus (RSV) accounts for the

majority of cases(80%), although rhinovirus, human
metapneumovirus, bocavirus, influenza, parainfluenza,
and adenovirus can all cause bronchiolitis as well.
 *The condition is most common in infants aged 3-6 months old.
• By 2 years of age, almost all infants have been infected
with RSV and 40-50% will have had bronchiolitis.

• Around many 2–3 per cent of all infants are admitted each year
Epidemiology with RSV-positive bronchiolitis but many more are managed at
home

• Most cases of bronchiolitis occur during the winter months, from

November to March, when the viruses that cause bronchiolitis
are more common.
*It is possible to get bronchiolitis more than once during the same
winter season
 *It is a clinical diagnosis, based on typical history
and examination

• Peak severity is usually at around day two to three

of the illness with resolution over 7–10 days
Approach
• Usually self-limiting, often requiring no treatment
or interventions

• The cough may persist for weeks.

 ▪ Max is a 3-month-old boy seen in the
community by his GP.

-He developed a runny nose and bit of a cough 2

days ago but has become progressively more
chesty and has now gone off his feeds and is
having far fewer wet nappies.
Case 1 -He has two older siblings who also have colds.
He was born at 34 weeks’ gestation but had no
significant neonatal problems.

-Both parents smoke but not in the house. His

mother had asthma as a child.
 Examination

Max is miserable but alert. His airway is clear. He is

febrile (37.8C) and has copious clear nasal secretions
and a dry wheezy cough.

His respiratory rate is 56 breaths/min with intercostal

and subcostal recession.
Case 1 On auscultation, there are widespread fine crackles
and expiratory wheeze.

The remainder of the examination is unremarkable.

 • What is the most likely diagnosis?

• What is the commonest causative organism?

• What are the indications for referral to

hospital?

*What investigations would you order for this

Questions child?

• What is the management in hospital?

 • Apnoeic episodes (commonest in babies 2 months
and may be the presenting feature)

• Intake 50 per cent of normal in preceding 24 hours

• Cyanosis
Indications for
hospital referral • Severe respiratory distress

• Congenital heart disease, pre-existing lung disease or

immunodeficiency

• Significant hypotonia

• Survivor of extreme prematurity

• Social factors
 ▪ Investigations are rarely indicated.
▪ In hospital, a nasopharyngeal aspirate (NPA) may be sent for
viral immunofluorescence, polymerase chain reaction (PCR) or
culture. This is largely for infection control and epidemiology
and does not affect acute management.

▪ A chest X-ray is only needed if the clinical course is unusual and

Investigations often leads to unnecessary antibiotic prescriptions.

▪ Blood tests are only required if there is diagnostic uncertainty,

e.g. if the infant has a temperature 39C and a superadded
bacterial respiratory infection is suspected.

▪ Blood gas should be checked if the infant is deteriorating.

 *The main goal of treatment is to correct abnormalities in
oxygenation and hydration
-Therefore, treatment is primarily supportive.
Management *The majority of infants with bronchiolitis can be managed as
outpatients.
 Treatment is primarily supportive:
*Maintenance of adequate hydration
Management *Relief of nasal congestion/ obstruction
*Monitoring of Disease progression .
 ▪ Oxygen saturations should be kept at 90 per cent
▪ the infant should be nasogastrically fed if they cannot maintain 50
per cent of normal intake.

▪ Intravenous fluids are used in severe cases. All fluids are restricted
to two-thirds of maintenance.

Management ▪ Nasal and oral suction is helpful.

▪ There is no evidence that bronchodilators, oral or inhaled steroids
modify the clinical course or any important outcomes such as the
need for ventilation or the length of stay.

▪ Response to conventional asthma treatment is variable. Leukotriene

antagonists may have a role. Exposure to tobacco smoke must be
avoided.
 ▪ Do not administer
• Beta 2 agonists, including infants with a personal or family
history of atopy
• Corticosteroids (nebulised, oral, intramuscular (IM) or IV)
• Adrenaline (nebulised, IM or IV) except in peri-arrest or
arrest situation
Management • Nebulised Hypertonic Saline
• Antibiotics, including Azithromycin
• Antivirals

▪ Chest physiotherapy
• Is not indicated
 ▪ Babies are discharged when they are well
enough to continue recovering at home

▪ but many continue to cough and wheeze for

weeks and get similar symptoms with
subsequent upper respiratory tract infections.
Discharge
 — Minimal clinical criteria for discharge from the hospital or
emergency department include :
●Respiratory rate <60 breaths per minute for age <6 months,

<55 breaths per minute for age 6 to 11 months, and

<45 breaths per minute for age ≥12 months
●Caretaker knows how to clear the infant's airway using bulb suctioning

●Patient is stable while breathing ambient air; discharge from the

Discharge hospital requires that the patient remain stable for

criteria at least 12 hours prior to discharge

●Patient has adequate oral intake to prevent dehydration

●Resources at home are adequate to support the use of any necessary

home therapies (eg, bronchodilator therapy if the trial was successful
and this therapy is to be continued)
●Caretakers are confident they can provide care at home
●Education of the caregivers is complete
 *Bridget, aged 12 weeks, admitted with
respiratory distress.
-He was admitted at 2am with fever and
respiratory distress, reduced feeding and low
SpO2 (90%).Medical Hx: ex-preterm (GA 32 WKS),
SVD, NICU admission with need for CPAP. .
-The infant was diagnosed to have acute
Case 2 bronchiolitis and kept on 1L O2 via nasal prongs.
IV access established and receiving half
maintenance fluids IV.
-Medical instructions are to monitor, provide O2
and maintain SpO2 >94%.
 1. What are the indications of antibiotics?
Questions
 • Viruses are the primary etiologic agents in bronchiolitis;
therefore, routine administration of antibiotics has not been
shown to influence the course of this disease.

What is the role of • In young, acutely ill infants, excluding the presence of
antibiotics for the secondary bacterial infection on clinical grounds may be
difficult.
treatment of
bronchiolitis? Thus, administration of broad-spectrum antibiotics in such
critically ill infants may be justified until bacterial culture
results prove negative .
*Studies have shown that the risk of concurrent serious
bacterial infections in nontoxic-appearing infants with
bronchiolitis is low.
Standard strategies to reduce the risk of bronchiolitis
and accompanying morbidity include
**hand hygiene (Alcohol-based hand solutions are
recommended )
**minimizing passive exposure to cigarette smoke,
**encouraging exclusive breastfeeding for at least six
months
** avoiding contact with individuals with respiratory tract
infections

--Immunoprophylaxis with palivizumab, a humanized

monoclonal antibody for special cases .
 ▪ Antimicrobial stewardship programs were
associated with increased likelihood of
discontinuing antimicrobial treatments in the PICU
Antimicrobial patients with viral bronchiolitis.
stewardship ▪ However, larger studies are needed to further
programs in acute determine the role of an antimicrobial stewardship
bronchiolitis programs in reducing unnecessary antimicrobial
use in this patient population.
 A 10-week-old boy presents to his family doctor in January
because his mother feels his breathing is laboured. His mother
smoked during pregnancy and continues to do so. The family
history is negative for asthma or allergy.
He developed rhinitis and a tactile fever 3 days prior to
presentation.
Over the next few days he developed increasing cough,
Case history increased work of breathing, and decreased oral intake.
On examination, his temperature is 38.0°C (100.4°F), his
respiratory rate is 42 breaths per minute, and his
oxyhaemoglobin saturation, measured by pulse oximetry, is
93% while breathing room air.
He has a wet cough.
His chest examination reveals mild intercostal and subcostal
retractions, scattered crackles bilaterally, and expiratory
wheezes bilaterally.
 The MOST LIKELY virus involved in this child’s illness is:
A) Rhinovirus

B) Adenovirus

Q1 C) Respiratory syncytial virus (RSV)

D) Parainfluenza

E) Human metapneumovirus
 RSV is usually diagnosed by:

A) Nasal wash using immunofluorescence, antigen

detection, or PCR

B) Baseline and convalescent antibody titers

Q2 C) Blood culture for RSV

D) Sputum Gram stain

E) Induced sputum culture

 Which of the following treatments has been unequivocally
shown to be effective in bronchiolitis?

A) Nebulized albuterol
B) Nebulized epinephrine
C) Corticosteroids such as prednisone or dexamethasone
Q3
D) All of the above

E) None of the above

 • Bronchiolitis is a clinical diagnosis

• No investigations should be routinely performed

Home Message • Management includes supporting feeding and oxygenation

as required

• No medication should be routinely administered