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)
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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