Bronchiolitis in Pediatric Emergency

This is an acute viral lower respiratory infection. Varying definitions throughout the world cause confusion when doctors are assessing useful treatments. The etiological agent is usually respiratory syncytial virus but can also be adenovirus or parainfluenza 3.

The infection usually affects children under 1 year old. It occurs in about 10% of all infants and 2–3% are admitted to hospital. Younger infants are usually more seriously affected. The illness usually peaks on day 2–3 with resolution of wheeze and respiratory difficulty over 7–10 days. The cough may persist for weeks and postbronchiolitic respiratory symptoms may cause much concern. Management involves a primary assessment of severity and initiation of resuscitation and treatment. Assessment and management are illustrated in Table of Primary assessment and initial management of bronchiolitis in below.

Primary assessment and initial management of bronchiolitis

History

The child presents with cough and wheezing. A lethargic, exhausted child may feed poorly, be hypoxemic, and is at risk of respiratory failure. Risk factors include age, infants with bronchopulmonary dysplasia or congenital heart disease. The time course is important. Is the child improving, stable, or likely to deteriorate over the next few days? Peak severity is usually at around day 2–3 of the illness. If the child is early on in the illness, consider admission to hospital.

Examination

Clinical signs include cough, tachypnea and hyperinflation. There may be audible wheeze. Auscultation reveals widespread crepitations and wheeze and signs of accessory muscle use. Cyanosis always indicates severe disease. Acyanotic infants may also be hypoxemic. If O2 saturation is less than 90%, the infant should receive supplementary O2 during the examination.

Investigations

A routine NPA (nasopharyngeal aspirate) or chest X-ray is not required for children with a typical clinical picture of bronchiolitis. If a chest Xray is taken it may demonstrate hyperinflation, peribronchial thickening, and often patchy areas of consolidation and collapse.

Consider whether this may be early asthma. Nebulized salbutamol may help in the older infant. Currently there is little evidence supporting the use of bronchodilators or antibiotics in bronchiolitis. Steroids were not thought to be of benefit, although some recent work from Toronto suggests that they may help.