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Jassam: Bronchiolitis in the community in children aged between 2 months and 2 years

Bronchiolitis in the community

Jack’s case

Jack is an 11-month-old boy brought to hospital by his mother, Sandy, for the third time in 6 months with cough, wheezy chest and rattling sounds when he breathes. I saw Jack, who is healthy otherwise, 6 months ago with low-grade fever, runny nose, cough, difficulty breathing and decreased appetite.

The examination at that time revealed a healthy 5-month-old with slightly distressed but audible wheezes, not cyanotic, with a temperature of 38.5°C, respiratory rate of 34 breaths/minute, heart rate of 116 beats/minute, O2 saturation of 96% and a normal weight for his age.

Ear, nose and throat examination was normal. Respiratory examination revealed no intercostal recession and scattered wheeze and crackles. Cardiovascular and abdomen were normal.

I advised Sandy of my diagnosis, which was bronchiolitis, and gave her management instructions and advised when to return to the clinic or go to the emergency department.

I saw Jack 3 months later with cough, wheezy chest and rattling sounds, mainly at night, with no fever. I discussed the findings and the plan with Sandy, who admitted that she took Jack to the emergency department and was given the same diagnosis and instructions and was advised to follow up with myself.

So, if you were in my position, how would you treat Jack on his most recent visit?

Bronchiolitis

Bronchiolitis is a major cause of respiratory morbidity in young children and usually affects children younger than 2 years; the peak age is in infants between 3 and 6 months. The peak season is usually between November and March, but also between March and July.

Bronchiolitis is the most common cause of hospital visits in infancy, leading to significant morbidity, and even mortality, putting pressure on paediatric wards, emergency rooms and intensive care units.1

In Canada, between 1980 and 2000, the rate of hospitalization for bronchiolitis increased, especially among children younger than 6 months of age.2

Of all cases of bronchiolitis, 1–2% may need hospital admission; 1% of hospitalized infants may die because of it.

If community physicians are able to diagnose bronchiolitis with certainty, are aware of the referral criteria and are able to educate the parents, bronchiolitis can be managed at home, which may help decrease pressure on hospitals.

Causes of bronchiolitis

Causes of bronchiolitis include:

  • respiratory syncytial virus (RSV; accounts for up to 80% of cases)

  • metapneumovirus

  • adenovirus

  • influenza

  • parainfluenza

  • coronavirus

  • enterovirus

  • human bocavirus.

Almost all children have serological evidence of RSV infection by 3 years of age.

Unlike asthma, the inflammation is neutrophilic rather than eosinophilic. This subsequently leads to plugging of the small bronchioles, which eventually leads to ventilation–perfusion mismatch, causing hypoxemia. This is more pronounced in treated and untreated premature infants.1

Presentation and diagnosis

When bronchiolitis affects young infants, clinical manifestations may be subtle, which may include:

  • increasing fussiness and difficult feeding during the first 2 to 5 days of the illness;

  • low-grade fever (usually < 38.6°C); temperature of ≥ 40°C is rare and should prompt a search for an alternative diagnosis;

  • infants less than 1 month old may become hypothermic;

  • congestion and a runny nose that can become worse;

  • apnoea, which may be the only presenting symptom.

In severe cases of bronchiolitis infants may become irritable, distressed with tachypnoea with nasal flaring, tachycardia and respiratory retraction and, in more severe cases, may become cyanotic.

The diagnosis of bronchiolitis is based on clinical presentation, the infant’s age, the season and findings from the physical examination, which may reveal the following additional signs:

  • fine crackles, diffuse, fine wheezing

  • hypoxia

  • otitis media.3

Investigations

Bronchiolitis is a clinical diagnosis.

Pulse oximetry should be performed in infants when hypoxia is suspected, which may direct the physician to send the child either home or to the hospital.

Temperature and weight should be checked.

Non-distressed infants with typical bronchiolitis symptoms require no investigations, especially not a chest radiography, which has been proven to be not useful and may lead to the use of unnecessary antibiotics.4

If the decision was made to refer the infant to the hospital based on the referral criteria below, tests may be conducted in the hospital, which is outwith the scope of this report.

Management of bronchiolitis

Since there is no cure for bronchiolitis the treatment is mainly symptomatic. The parent will need to be educated regarding this and instructed about home treatment and when to come back to the clinic, go to the hospital or call an emergency number.

  • Monitoring – observing the child regularly for signs or symptoms of worsening bronchiolitis, which may include increased respiratory rate and heart rate, worsening chest retractions, nasal flaring, cyanosis and a decreased oral intake or urine output.

  • Fever control – acetaminophens 10 to 15 mg/kg every 4 to 6 hours, not to exceed five doses (50–75 mg/kg) in 24 hours and, for infants older than 6 months, ibuprofen 5–10 mg/kg every 6–8 hours as needed, and not to exceed 40 mg/kg/day, can be given for comfort, which may improve the infant’s appetite. Avoid aspirin in children with fever.

  • Nasal drops or spray – saline nasal drops can be used in young infants followed by bulb suction to clean the nose of secretions. Saline nasal spray can be used in older infants.5

  • Encourage adequate but not extra fluids.

  • Bronchodilators should not be routinely used.

  • Corticosteroids should not be routinely used.

  • Antibiotics are not suggested unless bacterial infection is possible.

  • Hand decontamination is advised to prevent spread.

  • Avoid any exposure to second-hand smoke.

  • Breastfeeding is recommended.3

  • Racemic epinephrine is not superior to inhaled saline.6

  • No day care while the child is ill.

When to refer

The guidelines should not override the physician’s decision; if the physician is unsure or vitals are normal but the infant looks unwell the infant should be referred to hospital.

Absolute indications for hospital referral

  • Cyanosis

  • Oxygen saturation less than 94%

  • Age less than 1 month

  • Severe respiratory distress (respiratory rate > 70 breaths/minute, nasal flaring, grunting, chest wall recession)

  • Severe lethargy and poor feeding (< 50% of usual intake in past 24 hours)

  • Episodic apnoea

  • Uncertain diagnosis (infant looks unwell, temperature ≥ 40°C).4

Relative indications for hospital referral

  • Congenital heart disease

  • Age younger than 3 months but older than 1 month, when severe disease is most common

  • Prematurity

  • Pre-existing lung disease or immunodeficiency

  • Down syndrome

  • Social factors: lack of education, low socioeconomic classes.4

What next?

Many children, whether admitted or sent home, will have cough and wheeze lasting several weeks after bronchiolitis (post-bronchiolitis syndrome). The majority will recover completely; however, some of them may have intermittent symptoms which may continue for several years, more so with subsequent viral infections.

The treatment of post-bronchiolitis syndrome is difficult. No evidence has shown that inhaled steroids are an effective treatment; a leukotriene receptor antagonist may be effective for a few days to weeks but is not recommended for long-term treatment.

Episodic wheezing may respond to standard bronchodilator therapy.4

Whether the infant was treated by the community doctor or in the hospital, parents usually expect their doctor to explain to them what the expectations and the outcome of their child’s condition are. In my opinion, giving ample time to the parents is crucial in the management of bronchiolitis.

The most common questions community physicians face is whether or not the child has asthma and if bronchiolitis increases the risk of asthma.

Usually, bronchiolitis does not necessarily cause asthma and, specifically, RCV does not cause asthma.3

Children who are predisposed to asthma (because of atopic family history) will wheeze more when they are exposed to RSV or allergens.4

When to seek emergency treatment

The parent should seek immediate medical attention if, at any time, the symptoms of bronchiolitis become worse. These symptoms include:

  • respiratory distress

  • pale skin

  • cyanosis

  • severe coughing spells

  • severe respiratory retractions

  • apnoea

  • no oral intake

  • high fever > 39°C.

Parents should not attempt to drive their child to the hospital if the child is severely agitated, cyanotic, distressed, apnoeic or severely lethargic. In particular, an emergency number should be called if the infant is less than 3 months old, more specifically less than 1 month.5

Back to Jack’s case

Clearly Jack has post-bronchiolitis syndrome. Apart from salbutamol (Ventolin®, GlaxoSmithKline, Brentford, UK) as needed, reassurance and home remedy – with clear instructions on when to seek medical help – was determined to be the best treatment. In Jack’s case, more medication was unnecessary, but it is possible to try a leukotriene receptor antagonist for 4–6 weeks, which may give some relief of symptoms.

Summary points

  • RSV bronchiolitis is an important cause of respiratory morbidity in young infants.

  • Investigations are unnecessary and should be avoided.

  • Unproven treatment should be avoided.

  • Supportive management should be offered because of ineffective preventative and therapeutic measurements.

  • Bronchiolitis can be managed at home with clear instructions to the parent, and close observation should be assured.

  • If the infant is severely ill, an emergency phone number should be contacted rather than driving the child to the hospital.

  • Complicated cases or infants with pre-existing disease(s) should be recognized and referral should be made.

  • Post-bronchiolitis symptoms should not be confused with asthma, as they do not respond to current asthma treatments.

References

1. 

Nagakumar P, Bush A. Clinical review – bronchiolitis in children. GPOnline; 2010. URL: http://www.gponline.com/Clinical/article/985138/Clinical-Review---Bronchiolitis-children/ (accessed March 2014).

2. 

Worrall G. Bronchiolitis. Can Fam Physician 2008; 54:742–3.

3. 

DeNicola LK. Bronchiolitis. Medscape; 2014. URL: http://emedicine.medscape.com/article/961963-overview#aw2aab6b2b6 (accessed July 2014).

4. 

Bush A, Thomson AH. Acute bronchiolitis. Br Med J 2007; 335:1037–41. http://dx.doi.org/10.1136/bmj.39374.600081.AD

5. 

Piedra PA, Stark AR. Patient information: bronchiolitis (and RSV) in infants and children (Beyond the Basics). UpToDate; 2015. URL: http://www.uptodate.com/contents/bronchiolitis-and-rsv-in-infants-and-children-beyond-the-basics (accessed April 2015).

6. 

Skjerven HO, Hunderi JO, Brügmann-Pieper SK, et al. Racemic adrenaline and inhalation strategies in acute bronchiolitis. New Engl J Med 2013; 368:2286–93. http://dx.doi.org/10.1056/NEJMoa1301839




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