Podcast #123 - The ABCs of Bronchiolitis

Acute bronchiolitis is another condition that will start showing more this time of year.  In some parts of the country, it is already being diagnosed.  It is important to know the current recommendations for this common and potentially dangerous condition.

Like many respiratory conditions, bronchiolitis is a spectrum.  It is the most common lower respiratory tract infection affecting the first year of life.  Along with some recent literature, we will review key components of the NICE and AAP guidelines regarding bronchiolitis.

Diagnosis:
The diagnosis of bronchiolitis is clinical.  This usually consists of rhinorrhea, cough, tachypnea, retractions, wheezing, grunting, and nasal flaring.  In the very young (often under six weeks), the only symptom may be apnea. 

Concerning Findings:
A recent study has tried to help identify which of these variables would be high risk.  To help simply the key variable, JournalFeed developed a mnemonic (SCARY):

• S - Saturation <90%
• C - Can't Tolerate PO (Poor Feedings or Dehydration)
• A - Apnea (Reported or Observed)
• R - Retractions (Also Nasal Flaring or Grunting)
• Y - Younger than 2 Months

Children with any of these risk factors should be considered for admission as they are at increased risk for needing escalated care such as high-flow nasal cannula, noninvasive or invasive ventilation, or ICU admission.  It is worth noting that this has not been prospectively tested as a risk score, but can still help us identify the patients we  should exercise additional caution.

Treatment:
In general, treatment is supportive like the measures above.  Both NICE and AAP have outlined certain treatments that should NOT be used:

• Antibiotics
• Hypertonic Saline
• Racemic Epinephrine
• Albuterol (or Salbutamol)
• Ipratropium Bromide
• Montelukast
• Systemic or Inhaled Corticosteroids
• Chest Physiotherapy

However, there are exceptions to these medications depending on concomitant problems.   Treatments that are routinely recommended are as follows:

• Oxygen administration if oxygen saturation is persistently <92%
• High flow canal cannula in children with respiratory distress not improving with regular oxygen
• Continuous positive airway pressure (CPAP) in children with impending respiratory failure
• Fluids (nasogastric, orogastric, or IV) for those unable to tolerate PO

Discharge:
Patients that are improving without the SCARY findings and not requiring escalation of care should be able to be discharged home.  Consider social circumstances, skill and confidence of caregivers, and distance to an appropriate facility should there be deterioration.  Additionally, patients should have the following prior to discharge:

• Clinically stable
• Able to take adequate oral fluids
• Maintaining oxygen saturations over 92% on room air including a period of sleep (if applicable)

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