Pediatrics

Bronchiolitis

January 25, 2021 /

Preview Questions

  • What is the recommended management of bronchiolitis according to the American Academy of Pediatrics?
  • What is the most common pathogen responsible for bronchiolitis?
  • What happens to the airways in bronchiolitis?
  • Which patients require admission to hospital?
  • When is Palivizumab considered?

About Bronchiolitis

  • Bronchiolitis is the most common reason for infants to be hospitalized during the first year of life
  • Bronchiolitis is most often seen in infants 3 to 6 months old
  • Bronchiolitis

Pathogens causing Bronchiolitis

Bronchiolitis is most often due to viral infection of the lower respiratory tract. The most common virus responsible for bronchiolitis is respiratory syncytial virus (RSV). Other viruses that can cause bronchiolitis include human rhinovirus (second most common cause), influenza, human pneumovirus, adenovirus, coronavirus, parainfluenza virus.

The result of the infection is acute inflammation of the lower respiratory tract. The epithelial cells lining the small airways or bronchioles are damaged resulting in swelling and necrosis. There is also increased mucus production.

Presentation of Bronchiolitis

  • There is often a 1 to 3 day prodrome of upper respiratory tract infection symptoms
  • Look for a child 2 years old or younger with fever and cough
  • Suspect bronchiolitis especially during peak infection season – fall and winter
  • Disease is often more severe in infants who were born premature and in those with chronic lung disease or congenital heart disease
  • Look for signs of respiratory distress which can help determine disease severity and therefore the amount of supportive care required.
    • Tachypnea. Respiratory rate ≥60 breaths per minute is concerning because it can interfere with infant feeding and therefore lead to dehydration.
    • Hypoxemia. Pulse oximetry showing oxygen saturation (SaO2)

Management of Bronchiolitis

The following summary is based on the American Academy of Pediatrics guidelines. References are listed at the bottom of this article.

KEY POINTS

  • There is no single effective therapy for bronchiolitis
  • Treatment for bronchiolitis is supportive care

Many therapy options have been studied and not shown to be beneficial – this includes: steroids, nebulized epinephrine, nebulized hypertonic saline, and albuterol. Therefore, the mainstay of therapy for bronchiolitis is supportive care.

Important supportive measures include maintaining hydration and respiratory support if needed.

  • Nasal suctioning before feeding and after naps
    • However, deep suctioning is not recommended in the AAP guidelines, and suctioning in general does not have enough data to recommend it. (e1486 guideline PDF)
  • Supplemental oxygen via humidified, heated, high-flow nasal canula
    • high-flow nasal canula improves can generate continuous positive airway pressure in bronchiolitis and clinical evidence suggests it reduces work of breathing and may decrease need for intubation
    • Statement from AAP 2014 guidelines: “Clinicians may choose not to ad- minister supplemental oxygen if the oxyhemoglobin saturation exceeds 90% in infants and children with a diagnosis of bronchiolitis (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low-level evidence and reasoning from first principles]).”
  • What supportive measures should be avoided? i.e. not recommended by the AAP?
    • Chest physiotherapy: the AAP guidelines states “Clinicians should not use chest phys- iotherapy for infants and children with a diagnosis of bronchiolitis (Evi- dence Quality: B; Recommendation Strength: Moderate Recommendation)”

Palivizumab

SYNAGIS is supplied in single-dose vials containing either 50 mg or 100 mg of product.
Palivizumab (Synagis®) – Prophylactic monoclonal antibody against RSV
  • Palivizumab sold under the trade name Synagis® is a monoclonal antibody against respiratory syncytial virus (RSV) that is used as prophylaxis, to prevent infection in infants ≤2 years who are at high risk. It requires cold storage and is an intramuscular injectable solution. Infants are typically given several doses over the infectious season (fall, winter) – given typically once a month.
  • The American Academy of Pediatrics did a review of Palivizumab recommendations in the 2014 guidelines and has not changed its guideline recommendation – which is to recommend Palivizumab for
    • infants born < 29 weeks gestation
    • infants born < 32 weeks gestation with chronic lung disease of prematurity (defined as need for >21% oxygen for at least 28 days after birth)
    • See the complete list of recommendations here.
  • The Canadian Paediatric Society (CPS) no longer recommends routine use of Palivizumab for infants who were born after 30 weeks unless they have chronic lung disease or congenital heart disease. Source: CPS.ca 2015 update. Position statement reaffirmed Jan 1, 2021.

References and Resources

Summary notes for Bronchiolitis

DIAGNOSIS

  • Diagnosis and assessment of severity of bronchiolitis should be based on history and physical examination.
    • Since diagnosis is made based on history and physical exam, then labs and imaging should not be routinely obtained
  • Assess for risk factors for severe diease before making decisions about evaluation or management. Risk factors include: age <12 weeks, premature birth, underlying cardiopulmonary disease, or immunodeficiency.

TREATMENT

  • Do not give the following therapies for bronchiolitis, treatment is supportive only:
    • Albuterol or salbutamol
    • Epinephrine
    • Nebulized hypertonic saline *(may be given if hospitalized but recommendation has weak strength)
    • Systemic corticosteroids
    • antibacterial agents *(unless there is concomitant bacterial infection or strong suspicion of one)
  • Supportive Care is the mainstay of therapy
    • Supplemental oxygen if needed (oxygen saturation <90% on pulse oximetry) via high-flow, heated, nasal canula
    • Continuous pulse oximetry may be used
    • Nasogastric or IV fluids to maintain hydration
  • Chest physiotherapy is not recommended by the AAP

PREVENTION

  • Palivzumab. Dosing for palivizumab is 15 mg/kg/dose with a maximum of 5 doses given monthly during the first year of life for infants who qualify:
    • Do not give if healthy infant born at >29 weeks gestation
    • Qualifying infants include those with hemodynamically significant heart disease or chronic lung disease of prematurity (defined as preterm infants <32 weeks gestation who require >21% oxygen for at least the first 28 days of life)
  • Hand Hygiene. Disinfect hands before and after direct contact with patients and after contact with objects near the patient and after removing gloves. Alcohol based rubs (or soap and water hand washing when alcohol rubs aren’t available) should be used by anyone caring for the sick child.
  • Tobacco Smoke. Ask about exposure to tobacco smoke during initial assessment of bronchiolitis and give advice about environmental tobacco smoke and smoking cessation.
  • Breastfeeding. Encourage exclusive breastfeeding for at least 6 months to help reduce morbidity or respiratory infections.
  • Education. Educate family members and caregivers on the evidence-based diagnosis, treatment and prevention of bronchiolitis.