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Emergency Medicine/Pediatrics Residency
Originally Published: Modern Resident December 2014/January 2015
It’s that time of year again. Snow is starting to fall, holiday lights are going up and little babies are showing up wheezing in your emergency department. While babies sometimes make emergency physicians nervous, the treatment for bronchiolitis just got a little easier. The American Academy of Pediatrics recently updated their clinical practice guidelines; the last update prior to this was in 2006. These guidelines were updated to provide clinicians with the most recent evidence based management strategies.
Bronchiolitis is a viral illness caused by multiple viruses and occurs in 90% of children before the age of two. Bronchiolitis is a clinical diagnosis and as such, it does not require any testing to confirm diagnosis. Illness usually starts with rhinitis and cough, but can progress to respiratory distress.1 Exam frequently reveals tachypnea, mild retractions and expiratory wheezing. Patients with more severe disease can have grunting, nasal flaring or severe retractions. Assessment of these patients should include evaluation of hydration status, respiratory status, history of apnea, behavior changes and history of cyanosis.
The new bronchiolitis management guidelines apply to patients aged one month through 23 months. They do not apply to immunocompromised patients, those with neonatal lung disease, cystic fibrosis, neuromuscular disease or congenital heart disease. Based on the new guidelines, clinicians should diagnose bronchiolitis based on history and physical examination, and assess risk factors for severe disease. These include less than 12 weeks of age, history of prematurity, comorbid conditions and immunodeficiency. If the diagnosis is made on a clinical basis, radiographic studies and laboratory studies should not be obtained.
The new guidelines state that clinicians should not administer albuterol to infants with bronchiolitis nor should they administer nebulized epinephrine. Nebulized hypertonic saline can be administered in an inpatient setting, but should not be used in the emergency department. The use of systemic corticosteroids is also not recommended for clinical bronchiolitis.
In general, antibiotics should not be given to these infants, unless there is a strong suspicion of concomitant bacterial infection, which is rare. The risk of bacteremia or meningitis in febrile children with bronchiolitis is less than one percent.
Supplemental oxygen is indicated if SpO2 is persistently below 90%. If SpO2 remains above 90%, and the child is able to feed, supplemental oxygen is not necessary. Nasal suctioning can provide temporary relief for these patients and allow them to feed properly. When making the decision to send these children home, teaching parents to perform saline nasal suctioning can be beneficial.
Disposition decisions should take into account the child’s age, parent’s ability to care for the child, fluid status, ability to feed and respiratory status. If the child is able to go home, care return precautions and anticipatory guidance should be given. They should also be counseled on tobacco smoke exposure, which can increase the risk of severe disease.
- Ralston SL, et al. “Clinical Practice Guideline: The diagnosis, management, and prevention of bronchiolitis.” Pediatrics. 2014;134:e1474-e1502.
- Piedra PA, Stark AR. “Bronchiolitis in infants and children: Clinical features and diagnosis.” Up to date. 2014. Accessed on 13 November 2014. Available from: http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis?source=search_result&search=bronchiolitis&selectedTitle=2~150.
- Piedra PA, Stark AR. “Bronchiolitis in infants and children: treatment, outcome, and prevention.” Up to date. 2014. Access on 14 November 2014. Available from: http://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-treatment-outcome-and-prevention?source=search_result&search=bronchiolitis&selectedTitle=1~150.