Bronchiolitis

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Bronchiolitis

• Beth Ballard
• October 4th, 2007

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Prevalence

• 2 of all children will be admitted for
  bronchiolitis in their lifetime
• Approximately 90,000 admissions a year
• Approximately 400 deaths a year (1999 data)
• 20 of all winter admission for children under 2
  years old are for bronchiolitis
• Most common between 2-5 months
• 50 of children will have RSV in the first years
  of life, almost 100 by two.
• Yearly re-infection is common

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Good trivia for rounds

• RSV is member of the paramyxovididae family and
  was initially identified in chimpanzees
• It was initially called chimpanzee coryza virus
• Incubation is 2 to 8 days
• Viral shedding occurs 2 days before symptoms and
  up to 2 weeks after

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RSV vs. bronchiolitis

• About 50 of bronchiolitis is caused by RSV
• Therefore 50 of bronchilitis is NOT caused by
  RSV - 0ther viruses include parainfluenza,
  adenovirus and influenza
• About 50 of children under 2 y.o. will develop
  bronchiolitis with their primary RSV infection
  RSV can also cause croup and routine URI symptoms.

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How to treat bronchiolitis
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What has been proven NOT to help (lots of things)

• RSV testing (50 bronchiolitis is not RSV)
• CXR (patchy atelectasis difficult to
  differentiate from pneumonia)
• CPT
• Cool mist
• Aerosolized saline
• Inhaled or systemic steroids
• Antibiotics, unless they have a secondary
  infection such as otitis or pneumonia. (some
  studies show up to 50 of kids with bronchiolitis
  will also develop otitis)

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What might help(a few things)

• Suctioning
• Albuterol is probably helpful in a subset of
  children with underlying asthma and can make a
  baby look better for an hour or so more on this
  later
• Inhaled Epinephrine has also shown to be somewhat
  effective in moderate to severe disease in a few
  studies

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What has been proven to help(very little)

• Supplemental hydration
• Supplemental oxygen
• THATS IT!

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Albuterol Abuse (its rampant)

• Multiple studies fail to show improvement with
  use of albuterol or improvement in only a small
  minority of patients, certainly less than 25).
• Studies also show that we continue to use
  albuterol in spite of documented of lack of
  effect. In one study 54 of children had
  documentation indicating no improvement, however,
  94 had medication continued during
  hospitalization and 54 of those non-responders
  were discharged home on albuterol

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When to try inhaled medications

• Baby with a history of wheezing
• Strong family history of asthma
• Moderate or severe distress
• Suction, evaluate, medication, evaluate !
• Use a respiratory score to evaluate
• Many studies show some short term improvement but
  very limited data showing earlier discharge,
  decreased hospitalization or shorter duration of
  symptoms

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2006 Clinical Practice Guidelines

• PEDIATRICS Vol. 118 No. 4 October 2006, pp.
  1774-1793

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• Clinicians should diagnose bronchiolitis and
  assess disease severity on the basis of history
  and physical examination. Clinicians should not
  routinely order laboratory and radiologic studies
  for diagnosis (recommendation).
• Clinicians should assess risk factors for severe
  disease such as age less than 12 weeks, a history
  of prematurity, underlying cardiopulmonary
  disease, or immunodeficiency when making
  decisions about evaluation and management of
  children with bronchiolitis (recommendation).

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• Bronchodilators should not be used routinely in
  the management of bronchiolitis (recommendation).
  
• A carefully monitored trial of -adrenergic or
  ß-adrenergic medication is an option. Inhaled
  bronchodilators should be continued only if there
  is a documented positive clinical response to the
  trial using an objective evaluation (option).
• Corticosteroid medications should not be used
  routinely in the management of bronchiolitis
  (recommendation).
• Ribavirin should not be used routinely in
  children with bronchiolitis (recommendation).
• Antibacterial medications should only be used in
  children with bronchiolitis who have specific
  indications of the coexistence of a bacterial
  infection. When present, bacterial infection
  should be treated in the same manner as in the
  absence of bronchiolitis (recommendation).

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• Clinicians should assess hydration and ability to
  take fluids orally (strong recommendation).
• Chest physiotherapy should not be used routinely
  in the management of bronchiolitis
  (recommendation).
• Supplemental oxygen is indicated if SpO2 falls
  persistently below 90 in previously healthy
  infants. If the SpO2 does persistently fall below
  90, supplemental oxygen should be used to
  maintain an SpO2 at or above 90. Oxygen may be
  discontinued if SpO2 is at or above 90 and the
  infant is feeding well and has minimal
  respiratory distress (option).
• As the child's clinical course improves,
  continuous measurement of SpO2 is not routinely
  needed (option).
• Infants with a known history of hemodynamically
  significant heart or lung disease and premature
  infants require close monitoring as oxygen is
  weaned (strong recommendation).

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• Clinicians may administer palivizumab prophylaxis
  for selected infants and children with CLD or a
  history of prematurity (less than 35 weeks'
  gestation) or with congenital heart disease
  (recommendation).
• When given, prophylaxis with palivizumab should
  be given in 5 monthly doses, usually beginning in
  November or December, at a dose of 15 mg/kg per
  dose administered intramuscularly
  (recommendation).

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• Hand decontamination is the most important step
  in preventing nosocomial spread of RSV. Hands
  should be decontaminated before and after contact
  with patients, after contact with inanimate
  objects in the direct vicinity of the patient,
  and after removing gloves (strong
  recommendation).
• Alcohol-based rubs are preferred for hand
  decontamination. An alternative is hand-washing
  with antimicrobial soap (recommendation).
• Clinicians should educate personnel and family
  members on hand sanitation (recommendation).
• Infants should not be exposed to passive smoking
  (strong recommendation).
• Breastfeeding is recommended to decrease a
  child's risk of having LRTD (recommendation).
• Clinicians should inquire about use of CAM
  (option).

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Admission criteria

• Admission for bronchiolitis has increased 250
  since 1980s, while incidence has remained the
  same (likely largely due to increased
  availability of pulse oximetry)
• Hypoxia (? What number hypoxia)
• Dehydration
• Early in illness with neonate at risk for apnea
• At risk for more severe disease

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Who is at risk for more severe disease?

• Males
• Not breast fed
• Time period of 48 to 72 hours after onset of
  illness
• Less than 6 weeks old

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Use of evidence based guidelines

• Routine testing not recommended
• Routine CXR not recommended
• Blood gases only as needed for selected patients
• CPT not recommended
• Cool mist not recommended
• Aerosolized saline not recommended
• Use of steroids not recommended
• Inhaled epinephrine considered in selected
  patients
• In, within 60 minutes of trial inhalation
  therapy, there is no significant improvement,
  therapy is not recommended

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Impact of using guidelines

• Use of the following guidelines reduced
• Admissions by 29
• LOS by 17
• RSV testing by 52
• CXRs by 20
• Any use of albuterol by 30
• Repeated use of albuterol by 51
• Overall cost of hospitalization by 37

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Discharge Criteria

• Respiratory rate less than 80
• Able to adequately suction with a bulb
• On room air or stable on lt ½ liter for greater
  than 24 hours
• Taking adequate oral intake

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Does RVS cause asthma?

• Studies do support the idea that children with
  moderate or severe bronchiolitis in the first
  year of life are more likely to having subsequent
  wheezing episodes.

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Preventing RSV

• Synagis only helps prevents bronchiolitis caused
  by RSV
• Very expensive (5,000 to 7,000 to treat one baby
  for one season)
• Indicated for less than 32 weeks and less than 6
  months or less than 28 weeks and less than one
  year or under 2 with chronic lung disease
  requiring treatment in the past 6 months.
• Vaccines in different trial stages but none
  coming soon
• Handwashing!