Bronchiolitis

Objectives:

1. Define bronchiolitis and describe the pathophysiology
2. Understand the epidemiology and presentation of bronchiolitis
3. Define treatment options and general management (and be aware of things that don't work, too!)
4. Understand clinical red flags (e.g. apnea, respiratory fatigue, persistent hypoxemia) that signal the need for escalation of care and/or intensive therapy

Articles:

• Peds in Review 2019 Review Article
• AAP Clinical Practice Guideline, 2014: The Diagnosis, Management, and Prevention of Bronchiolitis
• Not sure when to be worried about bronchiolitis induced apnea? It's a tough question. Ponder away with these papers:
  • Prospective, Multicenter Study by Schroeder et al 2013 in Pediatrics
  • Systematic Review from the Journal of Pediatrics 2009
• The age old question: does bronchiolitis increase risk of developing RAD/Asthma?
  • The classic Tuscon Children's Respiratory Study has provided interesting longitudinal data that continues to stimulate research. Here's a bit of a review written in 2002. It comes down to understanding different asthma phenotypes. For a deep dive, head over to the Pulmonology Rotation page and find great info on this topic in the Asthma teaching toward the bottom.
• A bit of the evidence regarding use of albuterol and steroids in bronchiolitis
  • 2014 Cochrane Review of Bronchodilators in Bronchiolitis
  • 2013 Cochrane Review of Glucocorticoids in Bronchiolitis

Additional Resources:

• OpenPediatrics Bronchiolitis video: learn the epidemiology, pathophysiology, and clinical presentation of bronchiolitis, and how to diagnose and care for affected children
• OpenPediatrics Common Intubation Scenarios including Bronchiolitis case
• CHOP Clinical Pathways
  • Bronchiolitis, Inpatient
  • Bronchiolitis, Emergency
• Seattle Children’s Clinical Pathway on Bronchiolitis
• Khan Academy’s article on pathophysiology of respiratory distress and retractions
• Check out Cribsiders podcast Episode #2 Go with the High Flow: Bronchiolitis with Dr. Brian Alverson

Self-Assessment:

1. (PREP 2018, q62) A 4-month-old female infant who was well until 3 days ago is brought to the urgent care center by her parents for increasing difficulty breathing and a cough. She has been breastfeeding less than usual and her urine output is decreased. On physical examination, the infant is awake and fussy but consolable. She is afebrile, with a respiratory rate of 66 breaths/min and pulse oximetry of 92% on room air. She has scattered wheezing and rhonchi bilaterally on auscultation of her lungs, with subcostal and suprasternal retractions. You diagnose her with viral bronchiolitis.

Of the following, the BEST next management step for this infant is to

1. administer nasogastric or intravenous fluids
2. administer nebulized albuterol 
3. administer supplemental oxygen 
4. perform polymerase chain reaction for specific viral etiologies
5. perform chest radiography​

2. (PREP 2019, q179) A 1-month-old female infant is brought to the emergency department by ambulance because her mother found her to be dusky and not breathing when asleep. She responded to stimulation by waking up and breathing but is now tachypneic and wheezing. There was no abnormal movement associated with the event, and her tone remained normal throughout the event. She was born at 36 weeks’ gestation, had no problems in the newborn nursery, and went home with her mother. She has an oxygen saturation of 83% on room air, temperature of 37°C, respiratory rate of 60 breaths/min, and heart rate of 140 beats/min. The physical examination findings are notable only for tachypnea and diffuse expiratory wheezes with mild intercostal retraction. She is admitted to the hospital and placed on supplemental oxygen.

Of the following, the MOST appropriate next intervention for this infant is

1. Barium swallow radiograph
2. Intravenous ceftriaxone
3. Nebulized albuterol solution
4. Telemetric cardiorespiratory monitoring