Background

<2yr old (peak 2-6mo age)

Respiratory syncytial virus (RSV) causes ~70% of cases [1]

Preemies, neonates, congenital heart disease are at risk for serious disease

Peaks in winter

Duration = 7-14d (worst during days 3-5)

Inflammation, edema, and epithelial necrosis of bronchioles

Clinical Features

Symptoms Rhinorrhea, cough, irritability, apnea (neonates)

Signs Tachypnea, cyanosis, wheezing, retractions Fever is usually low-grade or absent If high-grade fever consider otitis media, UTI

Assess for dehydration (tachypnea may interfere with feeding)

Differential Diagnosis

Pulmonary/airway

Cardiac

Other diseases with abnormal respiration

Evaluation

Consider rapid RSV testing However, RSV is NOT linked apnea or acute severity (compared to other causes of bronchiolitis) [2] [3] You should NOT use RSV status to drive admission decisions and admission locations (eg, ward, step-down unit, ICU) [4] </ref> [5]



CXR Not routinely necessary May lead to unnecessary use ofantibiotics (atelectasis mimics infiltrate) Consider if Diagnosis unclear Critically ill



Concurrent infection risk

Infants <60 days with RSV bronchiolitis and fever

Low risk of bacteremia and meningitis in RSV+, still appreciable UTI risk UTI 5.4% in RSV+, 10.1% RSV- Bacteremia 1.1% RSV+, 2.3% RSV- Meningitis 0% RSV+, 0.9% RSV-

Recommended to still obtain UA in cases of bronchiolitis w/ fever. BCx and CSF not necessary if >28 days old

Management

Hydration for all infants

It is reasonable to not perform continuous oximetry on infants and children with bronchiolitis[6]

O2 (maintain SaO2 >90%) oxygen saturation alone should not dictate admission [7]



High flow nasal cannula multicenter randomized trial showed infants with bronchiolitis and hypoxemia required less escalation of therapy than standard oxygen [8]



Suctioning

There is insufficient data to make an evidence-based recommendation about suctioning.

Nasopharyngeal suctioning may temporarily relieve symptoms

The use of routine “deep” suctioning may lead to increased length of stay based on one small study [6]

AAP recommends as a possible intervention, but 2014 SABRE trial found no change in discharge or adverse events with nebulised HS.[9]

No decrease in hospital admission using 3% HS in 2017 multi-center, RCT for moderate-severe bronchiolitis, with mild adverse events such as worsening of cough were significantly higher in the HS group [10]

Only consider administering to infants who require hospitalization [6] (Class B)) Suction nares / nasal saline drops

(Class B))

Not Indicated

Randomized controlled trials of bronchodilator or corticosteroid therapy have shown mixed results. Bronchodilators could aggravate the symptoms.[11][12][13]

Albuterol/bronchodilator (Class B) [6] May trial if strong family hx of asthma/atopy in older infants

Racemic Epinephrine (Class B) [6]

Steroids [6] [14] Consider dexamethasone .6-1mg/kg PO or IM x1 in severe cases



Disposition

Consider Admission

Age <3months

Preterm (<34wks)

Underlying heart/lung disease

Initial SaO2 <90% Sa02 alone should not be used as the only factor for admission [15]

Unable to tolerate PO

Tachypnea with accessory muscle use

See Also

References