Rosen & Barkin's 5-Minute Emergency Medicine Consult (114 page)

• Pediatric advanced life support: Airway, ventilation, and fluid hydration
  
• Emergent intubation if recurrent apneas, impending respiratory failure
  

• Supplemental oxygen if oxygen saturation <90–92% (sea level)
  
• Parenteral hydration if dehydration or severe respiratory distress. Many children may improve their intake once respiratory status has improved.
  
• Many children with bronchiolitis do not benefit from pharmacotherapy.
  
• Bronchodilators (albuterol, racemic epinephrine, l-epinephrine, levalbuterol):
  
  • Should not routinely be used alone without determination of efficacy
    
  • Some clinicians administer on trial basis with 2–3 consecutive treatments in those with moderate to severe distress and continue as part of management if there is a clear decrease in the work of breathing.
    
  • Often utilized in significantly ill children
    
• Steroids:
  
  • On their own do not change clinical course or hospitalizations in the majority of patients without prior atopic or family history.
    
  • 2 doses of 1:1,000 l-epinephrine 30 min apart in the ED + 6 daily doses of oral dexamethasone may be useful in moderate to severe distress—reduces admissions by 35% by day 7, shortens time to discharge and duration of symptoms
    
  • Conflicting evidence with another recent dexamethasone trial showing no benefit when used alone—synergy between steroids and epinephrine likely critical for efficacy
    
  • Often used empirically in children with past or family history of atopy. Prednisolone common for this usage.
    
  • Albuterol–dexamethasone combination efficacy not confirmed in a big trial.
    
  • Bronchodilators alone after discharge not effective unless there was demonstrated effectiveness prior to discharge.
    
• Antibiotics:
  
  • Not generally indicated since viral etiology
    
  • Consider if associated signs of focal bacterial disease (otitis, focal pneumonia), radiographic evidence of isolated lobar consolidation without airway disease (usually bacterial pneumonia rather than bronchiolitis), significant toxicity, sepsis
    
• Ribavirin:
  
  • No role in ED management and rarely used in the inpatient setting
    

• Albuterol: 2.5 mg/3 mL, 2–3 doses via nebulizer or 400 mcg via MDI/spacer 20–30 min apart in the ED. A therapeutic trial can be considered but continue only if there is a clear improvement in the work of breathing. Does not change overall disease outcomes.
  
• Levalbuterol: 1.25 mg/dose, 2–3 doses via nebulizer, 20–30 min apart in the ED (see above).
  
• l-epinephrine: 3 mL (1:1,000 solution), 2 doses via nebulizer 30 min apart in the ED or with
  
• Dexamethasone: 1 mg/kg/dose PO in the ED, then 0.15 mg/kg daily for 5 days
  
• Prednisolone (15 mg/5 mL): 1–2 mg/kg/d PO BID/3–5 d
  
• Comment 1: Most children require no medications. Bronchodilators alone rarely change outcomes. Initial trial of albuterol should be extended only if clear clinical improvement. Epinephrine–dexamethasone combination shown to decrease hospitalizations by day 7 of illness and may warrant consideration.
  
• Comment 2: Although no trial to date has identified any pharmacotherapeutic agent to change the course of the disease, a recent meta-analysis found that (a) inhaled epinephrine alone and epinephrine + oral dexamethasone appear to have half the odds of hospitalization compared to placebo and (b) salbutamol does not reduce hospitalizations in bronchiolitis.
  

FOLLOW-UP

• Need for supplemental oxygen (oxygen saturation on room air is <90–92% at sea level)
  
  • Some institutions have developed protocols that allow full-term, stable children >6 months of age, who are well hydrated, have compliant parents, and good follow-up to be discharged on minimal oxygen after a prolonged period of observation in the ED.
    
• Inability to self-hydrate
  
• Marked increase work of breathing (tachypnea with retractions or accessory muscle use)
  
• Apnea
  
• Severe underlying chronic lung disease or cardiac disease
  
• Persistent marked respiratory distress 4 hr after a trial of epinephrine and dexamethasone
  
• Significant comorbidity/suspicion of alternative diagnosis/underlying systemic disease/immunodeficiency or immunosuppressive therapy
  
• Strongly consider in infants <7 wk, weight <4 kg, respiratory rate >80/min, heart rate >180/min, comorbidities, or prematurity
  
• Caretaker noncompliant or unable to monitor child closely
  

• Feeding reasonably well
  
• Acceptable room air saturation (see above)
  
• Absence of significant respiratory distress
  
• Follow-up available within 24 hr
  
• Compliant home environment
  
• Discharge instructions:
  
  • Symptoms may persist for 2–3 wk
    
  • Frequent small feeds
    
  • Bronchodilators after discharge not uniformly beneficial
    

Because of the progressive nature of bronchiolitis close follow-up is required, particularly early in the illness alerting parents to the likelihood of worsening respiratory distress, dehydration, and apnea.

Infants with bronchiolitis often present with respiratory distress associated with hypoxia, dehydration, and/or apnea. Aggressive monitoring may be warranted.

• American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis.
  Pediatrics
  . 2006;118:1774–1793.
  
• Corneli HM, Zorc JJ, Mahajan P, et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis.
  N Engl J Med
  . 2007;357:331–339. [Erratum,
  N Engl J Med.
  2008;359:1972.]
  
• Hartling L, Bialy LM, Vandermeer B, et al. Epinephrine for bronchiolitis.
  Cochrane Database Syst Rev.
  2011;15(6):CD003123.
  
• Hartling L, Fernandes RM, Bialy L, et al. Steroids and bronchodilators for acute bronchiolitis in the first two years of life: Systematic review and meta-analysis.
  BMJ.
  2011;342:d1714.
  
• Kellner JD, Ohlsson A, Gadomski AM, et al. Bronchodilators for bronchiolitis.
  Cochrane Database Syst Rev
  . 2000;(2):CD001266.
  
• Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections.
  Pediatrics
  . 2004;113:1728–1734.
  
• Plint AC, Johnson DW, Patel H, et al. Epinephrine and dexamethasone in children with bronchiolitis.
  N Engl J Med
  . 2009;360:2079–2089.
  
• Ralston S, Hill V, Waters A. Occult serious bacterial infection in infants younger than 60 to days with bronchiolitis: A systemic review.
  Arch Pediatr Adolesc Med
  . 2011;165:951–956.
  
• Schuh S, Coates AL, Binnie R, et al. Efficacy of oral dexamethasone in outpatients with acute bronchiolitis.
  J Pediatr.
  2002;140:27–32.
  
• Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis.
  J Pediatr.
  2007;150:429–433.
  

See Also (Topic, Algorithm, Electronic Media Element)

Asthma, Pediatric

CODES

• 466.1 Acute bronchiolitis
  
• 466.11 Acute bronchiolitis due to respiratory syncytial virus (RSV)
  
• 466.19 Acute bronchiolitis due to other infectious organisms
  

BASICS

• Hyperemia and edema of the mucous membranes
  
• Production of mucopurulent exudates
  
• Impairment of the productive function of the cilia, lymphatics, and phagocytes
  
• Airway obstruction from:
  
  • Edema
    
  • Secretions
    
  • Bronchial muscle spasm
    

• Viral infections are the primary cause of bronchitis:
  
  • Parainfluenza
    
  • Influenza A and B
    
  • Respiratory syncytial virus
    
  • Human metapneumovirus
    
  • Echovirus
    
  • Coronavirus
    
  • Adenovirus
    
  • Coxsackievirus
    
  • Rhinovirus
    
  • Measles and herpes viruses (can cause severe viral bronchitis)
    
• Particularly severe or long-lasting bronchitis:
  
  • Mycoplasma pneumoniae
    
  • Chlamydia pneumoniae
    
  • Bordetella pertussis
    :
    
    • Rates of pertussis are increasing, even in the fully immunized population (little protection remains after 10 yr).
      
• Other bacteria have not been conclusively proven to cause bronchitis except in those with chronic lung disease.
  

DIAGNOSIS