Pediatric Small Talk – Battling Bronchiolitis: Supportive Care and A Tincture of Time

Welcome back to Small Talk; a new monthly section from emDOCs.  Every first Wednesday of the month we will release high yield PEM content written by PEM talent from around the country.  We hope you enjoy these reviews. Comments, questions, accolades or concerns: feel free to reach out to Joe Ravera, MD (pemgemspod@gmail.com).


Authors: Tamara Casas, MD (EM Resident Physician, UC San Diego Health); Joe Ravera, MD (@pemuvm1, Director of Pediatric Emergency Medicine, UVM Medical Center, Assistant Professor of Surgery, UVM College of Medicine); Kristy Schwartz, MD, MPH (@kaynani32, Assistant Program Director Emergency Medicine, Assistant Health Sciences Clinical Professor, Departments of Pediatrics and Emergency Medicine, UC San Diego) // Reviewed by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)


Case

An 11-month-old female is presenting to the ED in January for evaluation of shortness of breath. Her mother, who is at bedside providing history, reports the patient had a runny nose, fever and cough for 2 days. For the last day, she noticed the patient working harder to breathe and breathing faster. She also noticed increased mucus in her nose and decreased feeding due to congestion. She is drinking less and only made one wet diaper today. The patient has an older sibling in school who had a runny nose and cough last week, but now is feeling better.

Vital signs include temperature 38.2 C, heart rate 142, respiratory rate 60, oxygenation saturation 89% room air. The child appears uncomfortable in moderate respiratory distress. She appears tired but is arousable and interactive with dry mucous membranes, with normal capillary refill. She has tachypnea, with subcostal and intercostal retractions, as well as nasal flaring. Diffuse wheezing and crackles are present through all lung fields.

The parent asks, “What is going on and how can you make it better?


Epidemiology and Seasonality

Bronchiolitis is a viral lower respiratory tract disease that occurs in children <2 years of age.  Classically, it was encountered in the winter months; to quote a PICU MD, “Think turkeys (November) to bunnies (April)”.  However, this summer had a large number of cases of bronchiolitis likely due to social distancing and restrictions during the winter. The most common causative agent identified is Respiratory Syncytial Virus (RSV), however other implicated viruses include human metapneumovirus and rhinovirus.1,2,3

Initial presentation typically involves upper respiratory tract symptoms (runny nose, cough, fever) and progresses to lower respiratory tract symptoms (increased work of breathing, tachypnea and wheezing).1,2,3

The clinical presentation of bronchiolitis stems from damage of epithelium in the bronchi, which leads to edema, mucus production and inflammation. This causes mucus plugging and obstruction of bronchioles, resulting in atelectasis and respiratory distress, which is commonly encountered in these patients. The spectrum of disease is broad and can span from mild symptoms to respiratory failure and death.1,2,3


Diagnosis

Bronchiolitis is a clinical diagnosis made based on history and physical examination findings. Viral swabs will often not change management but given the possibility of SARS-COV2 infection or co-infection, they are now routinely sent.

Laboratory studies are often not helpful in making the diagnosis but may help as a marker of dehydration in more advanced disease.

Routine chest X-ray (CXR) in bronchiolitis is discouraged as it can be difficult to interpret and may lead to over-treatment with antibiotics. CXR should be reserved for patients with persistent focal lung findings on repeated physical exam or lingering symptoms that suggest bronchiolitis mimics, such as myocarditis, CHF or pneumonia.4 If available, there is preliminary data to suggest that point of care ultrasound (POCUS) of the lungs may provide a useful data point in risk stratification of the patient’s disease.5

Lastly, the possibility of a concomitant bacterial infection, such as otitis media, should be considered. In terms of invasive infections (bacteremia and meningitis) there is robust data that the risk of concomitant infections is very small outside of the first month of life. On the other hand, other data suggests that the risk of concomitant urinary tract infection in neonates with bronchiolitis, while reduced, can still occur at an appreciable rate; In some reviews, as high as 13%. The clinical diagnosis of bronchiolitis is simply another data point that needs to be interpreted along with the patients age, biologic sex, duration of fever when making the determination if urine testing is warranted.6,7


Management

The history of bronchiolitis treatment is a legacy of futility. The following is a list of treatments that have not shown to be beneficial and should not be used routinely.1,2,3

–          Nebulized beta agonist agents (i.e. albuterol)

–          Nebulized epinephrine

–          Nebulized hypertonic saline

–          Steroids

–          Antibiotics

–          Heliox

All that is left is supportive care which is paramount in bronchiolitis treatment. Observational studies have shown improvement of SpO2 after suctioning as well as nasal irrigation with normal saline. Fever should also be treated with antipyretics if increased work of breathing or poor oral intake may be related to elevated temperature. Supplemental O2 is recommended in patients with SpO2 <90% (threshold SpO2 to begin supplemental O2 is controversial). IV fluids should be considered in patients with signs and symptoms of dehydration who are not tolerating oral intake.


Children who are Critically Ill with Bronchiolitis

As mentioned before, the spectrum of bronchiolitis includes children who present with overt or impending respiratory failure. These children warrant early recognition of respiratory distress leading to failure and aggressive respiratory support. Data supports early initiation of High Flow Nasal Cannula (HFNC) to hopefully prevent the need for further support including intubation and mechanical ventilation.8,9 Critically ill children require IV access for supplemental hydration, which can often be initiated while simultaneously coordinating respiratory support.

Children who require this level of respiratory support wll obviously also require admission. The disposition to intensive care, step down, or pediatric floor will depend on the specifics and capabilities of your institution.


Well-Appearing Children with Bronchiolitis

While these children do not require critical resuscitation, they are often more cognitively challenging to clinicians. After supportive care with nasal suction, antipyretics, and PO hydration, we are often left with the decision: “Can this kid go home or should they stay?”

Like all pediatric admissions we have to consider the disease process (bronchiolitis is classically worse on day 3 or 4), the age and physiologic reserve of the child (8 months is very different than 8 weeks) and other non medical factors such as the ability of the family to return to the emergency room or follow up with their pediatrician.


With these factors in mind, there are five main indications for admission in the non critically ill child with bronchiolitis.

Hypoxemia: This seems straightforward, if the child needs oxygen, they need admission to the hospital.  While most people in the PEM community will initiate supplemental 02 at 92%, the most recent AAP guidelines suggest 90% as a cut off for the initiation of therapy.2 In children who are otherwise well and only require a small amount of oxygen there are even a few pilot protocols looking at discharging hypoxemic babies with supplemental oxygen. Currently, these protocols have not yet been standardized and often it is difficult to titrate, but may be something on the horizon.10

Increased Work Of Breathing: Even without hypoxemia, children who have signs of moderate to severe respiratory distress such as abdominal retractions or grunting should be admitted for monitoring. HFNC can be helpful in these children even in the absence of hypoxemia, as it may provide some airway stenting with positive pressure. While there are scoring systems to quantify the degree of respiratory distress11, some of the most difficult babies are the “happy retractors.”  This is the child who is at baseline, tolerating PO, but still has residual intercostal retractions.  Oftentimes, it is best to have a discussion with the family, with specific focus on their ability to recognize clinical deterioration, return to ED, and access outpatient care.

Inability to Tolerate PO: This is another standard of PEM and EM in general. If the kid is unable to keep up with their baseline PO intake, combined with increased insensible losses from the illness, then they require admission for IV fluids.

Complex Medical Disease: Bronchiolitis disproportionately affects children with chronic medical problems.12 Even well appearing children can become critically ill as the disease progresses. While there are no hard and fast rules, these authors recommend admission (or consultation with specialists) for all children with complex cardiac, pulmonary, or neuromuscular disease who present with even mild bronchiolitis.

Apnea: While apnea with bronchiolitis has been reported in older babies, the vast majority and highest risk are in the first month of life with occurrence estimates ranging from 1-5%.  History of prematurity, younger age (<2 weeks), or babies with a witnessed apnic episode by the parents are at even higher risk. It is important to note that apnea in these young babies can occur in the absence of severe respiratory disease. While this is an ongoing debate with inpatient pediatrics, it is our recommendation that all children under a month (in particular under 2 weeks and/or a history of prematurity), with RSV or clinical bronchiolitis be discussed with inpatient pediatrics for admission.13


Case Concluded:

The child received antipyretics, nasal suction, and was able to tolerate oral fluids in the ED.  However, despite aggressive supportive care, the patient had persistent 02 saturations of 89% and required supplemental oxygen by nasal cannula. The child was admitted to the pediatric ward and spent two uneventful days hanging out on oxygen. She was eventually discharged without complication.


References:

  1. Florin TA, Plint AC, Zorc JJ. Viral bronchiolitis. Lancet. 2017 Jan 14;389(10065):211-224. doi: 10.1016/S0140-6736(16)30951-5. Epub 2016 Aug 20.
  2. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014;134(5):e1474–e1502.
  3. Joseph MM, Edwards A. Acute bronchiolitis: assessment and management in the emergency department. Pediatr Emerg Med Pract. 2019 Oct;16(10):1-24.
  4. Chao JH, Lin RC, Marneni S, et al. Predictors of Airspace Disease on Chest X-ray in Emergency Department Patients With Clinical Bronchiolitis: A Systematic Review and Meta-analysis. Acad Emerg Med. 2016 Oct;23(10):1107-1118.
  5. San Sebastian Ruiz N, Rodríguez Albarrán I, Gorostiza I, et al. Point-of-care lung ultrasound in children with bronchiolitis in a pediatric emergency department. Arch Pediatr. 2021 Jan;28(1):64-68.
  6. Bonadio W, Huang F, Nateson S, et al. Meta-analysis to Determine Risk for Serious Bacterial Infection in Febrile Outpatient Neonates With RSV Infection. Pediatr Emerg Care. 2016 May;32(5):286-9.
  7. Levine DA, Platt SL, Dayan PS, et al; Multicenter RSV-SBI Study Group of the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics. 2004 Jun;113(6):1728-34
  8. Franklin D, Babl FE, Schlapbach LJ, et al. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018 Mar 22;378(12):1121-1131
  9. Kelly GS, Simon HK, Sturm JJ. High-flow nasal cannula use in children with respiratory distress in the emergency department: predicting the need for subsequent intubation. Pediatr Emerg Care. 2013 Aug;29(8):888-92.
  10. Watkins T, Keller S. Home oxygen therapy criteria, guidelines and protocols for hypoxia management in pediatric patients with acute bronchiolitis: a scoping review protocol. JBI Database System Rev Implement Rep. 2018 Aug;16(8):1606-1612.
  11. Duarte-Dorado DM, Madero-Orostegui DS, Rodriguez-Martinez CE, et al. Validation of a scale to assess the severity of bronchiolitis in a population of hospitalized infants. J Asthma. 2013;50(10):1056-1061.
  12. Fujiogi M, Goto T, Yasunaga H, et al. Trends in Bronchiolitis Hospitalizations in the United States: 2000-2016. Pediatrics. 2019 Dec;144(6):e20192614.
  13. Schroeder AR, Mansbach JM, et al. Apnea in children hospitalized with bronchiolitis. Pediatrics. 2013 Nov;132(5):e1194-201. doi: 10.1542/peds.2013-1501. Epub 2013 Oct 7. PMID: 24101759; PMCID: PMC3813402.

 

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