Bronchiolitis

OVERVIEW

Goals:

• resuscitation
• severity and stability of disease
• assessment of possible differentials including cardiac disease, influenzae, pertussis
• stabilisation and possible transfer to neonatal/SCBU if required

Assessment takes place during simultaneous resuscitation and will involve history, examination, investigations and subsequent management.

HISTORY

A – allergies
M – medications
P – past medical history (birth gestation and weight, immunisation status, antenatal problems, mode of delivery, neonatal ventilation, other syndromes: trisomy 21)
L – last feed
E – events:

• how did illness start? -> presentation before day 3 is more severe.
• illness starts as a coryzal illness -> peak of respiratory distress @ 3 days and then settles over 7-10 days.
• URTI
• apnoea
• blue spells
• ability to feed
• respiratory function
• possible evidence of secondary bacterial infection (streptococcus or staphylococcus)

EXAMINATION

• general: temperature, P,
• respiratory: RR, WOB, grunting, nasal flaring, indrawing, retraction, apnoeas
• cardiovascular: perfusion, murmurs, pulses, heart failure

INVESTIGATIONS

• CXR
• naso-pharyngeal PCR for RSV
• ECHO

MANAGEMENT

• close liaison with paediatric team
• regular observation
• N/G tube to decompress stomach
• titrated O2
• NIV: via nasopharyngeal tube or bubble or high flow nasal prong O2 or BIPAP
• IV fluids
• N/G continuous feeding
• paracetamol
• chloral hydrate
• caffeine if apnoea (especially if premature), aminophyline is an alternative
• minimal handling
• antibiotics if superinfection suspected
• a few children require mechanical ventilation (particularly if retrieval required) -> this will prolong PICU course by 2-3 days.
• advance therapies: no proven benefit but some patients may respond

-> nebulised adrenaline
-> salbutamol
-> heliox
-> ribavirin

• Indications to call PICU:

-> commencing CPAP early in disease
-> if staff not confident in use of CPAP
-> need for intubation
-> not comfortable with plan

• indications to intubate:

-> increased WOB despite NIV
-> deterioration despite CPAP
-> not tolerating CPAP and continuing to desaturate
-> apnoea
-> transport

• precautions to take when intubating:

-> little respiratory reserve (become hypoxic quickly)
-> always preoxygenate
-> decompress stomach to allow for bagging
-> ensure can ventilate prior to intubating
-> have atropine and adrenaline drawn up
-> sedation: ketamine, morphine, fentanyl (beware of chest wall rigidity -> relax straight away)
-> relaxants: sux, rocuronium, atracurium

References and Links

• St Emlyns — Hypertonic saline for bronchiolitis (2013)