Bronchiolitis

What is bronchiolitis and its definition, the age group, signs and symptoms and clinical presentation The clinical practice guidelines, how to diagnosis, clinical criteria, what are the severity degrees and How to assess the severity, what are the investigations that may be needed, Is there any diagnostic test, what is the prognosis
What is the management,

1. Bronchiolitis Clinical Practice Guideline Prof. Dr. Saad S Al Ani Senior Pediatric Consultant Head of Pediatric Department Khorfakkan Hospital Sharjah, UAE [email protected]

2. Bronchiolitis is a clinical diagnosis No investigations should be routinely performed Management is to support feeding and oxygenation as required No medication should be routinely administered http://allaboutwindowsphone.com 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 2

3. Bronchiolitis is a viral lower respiratory tract infection, generally affecting children under 12 months of age Viral bronchiolitis is a clinical diagnosis, based on typical history and examination. Peak severity is usually at around day two to three of the illness with resolution over 7– 10 days. The cough may persist for weeks. 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 3 https://blog.mymusictaste.com/blog

4. Bronchiolitis typically begins with an acute upper respiratory tract infection followed by onset of respiratory distress and fever and one or more of: Cough Tachypnea Retractions Widespread crackles or wheeze   29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 4 https://www.hiclipart.com

5. Risk factors for more serious illness Chronological age at presentation less than 10 weeks Chronic lung disease Congenital heart disease Chronic neurological conditions Indigenous ethnicity Immunodeficiency 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 5 http://clipart-library.com

6. Infants with any of these risk factors are more likely to deteriorate rapidly and require escalation of care. Consider hospital admission even if presenting early in illness with mild symptoms.  The more symptoms the infant has in the moderate-severe categories, the more likely they are to develop severe disease       29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 6 https://www.dreamstime.com

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8. Assessment of severity 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 8 MILD MODERATE SEVERE Behaviour    Normal Some / intermittent irritability Increasing irritability and / or lethargy Fatigue Respiratory rate    Normal – mild tachypnea Increased respiratory rate Marked increase or decrease in respiratory rate Use of accessory muscles   Nil to mild chest wall retraction Moderate chest wall retractions   Suprasternal retraction    Nasal flaring   Marked chest wall retractions  Marked suprasternal retraction   Marked nasal flaring Oxygen saturation/ oxygen requirement   O2 saturations greater than 92% (in room air)   O2 saturations 90 –92% (in room air)   O2 saturations less than 90% (in room air)   Hypoxemia, may not be corrected by O2 Apneic episodes    None May have brief apnoea May have increasingly frequent or prolonged apnoea Feeding Normal May have difficulty with feeding or reduced feeding Reluctant or unable to feed

9. Management Investigations: In most children with bronchiolitis no investigations are required Chest X-ray (CXR) Is not routinely indicated and may lead to unnecessary treatment with antibiotics  Blood tests (including blood gas, full blood count (FBC), blood cultures) Have no role in management Virological testing (nasopharyngeal swab or aspirate) Has no role in management of individual patients 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 9

10. Management Treatment: Children are often more settled if comfort oral feeds are continued. Initial management The main treatment of bronchiolitis is supportive. This involves ensuring appropriate oxygenation and fluid intake, and minimal handling   29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 10 https://www.vitalisphagetherapy.com

11. Initial management MILD MODERATE SEVERE Likelihood of admission   Suitable for discharge  Consider risk factors   Likely admission, may be able to be discharged after a period of observation  Management should be discussed with a local senior physician   Requires admission and consider need for transfer to an appropriate children’s facility/PICU  Threshold for referral is determined by local capacity but should be early Observations Vital signs (respiratory rate, heart rate, O2 saturations, temperature) Adequate assessment in ED prior to discharge (minimum of two recorded measurements or every four hours) One to two Hourly (not continuous)  Once improving and not requiring oxygen for 2 hours discontinue oxygen saturation monitoring Hourly with continuous cardiorespiratory (including oximetry) monitoring and close nursing observation 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 11

12. Initial management (Cont.) MILD MODERATE SEVERE Hydration/nutrition   Small frequent feeds If not feeding adequately (less than 50% over 12 hours), administer NG hydration If not feeding adequately (less than 50% over 12 hours),or unable to feed, administer NG hydration Oxygen saturation/oxygen requirement   Nil requirement Administer O2 to maintain saturations greater than or equal to 90%  Once improving and not requiring oxygen for 2 hours discontinue oxygen saturation monitoring Administer O2 to maintain saturations greater than or equal to 90% 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 12

13. Initial management (cont.) MILD MODERATE SEVERE Likelihood of admission   Suitable for discharge  Consider risk factors   Likely admission, may be able to be discharged after a period of observation  Management should be discussed with a local senior physician   Requires admission and consider need for transfer to an appropriate children’s facility/PICU  Threshold for referral is determined by local capacity but should be early Observations Vital signs (respiratory rate, heart rate, O2 saturations, temperature) Adequate assessment in ED prior to discharge (minimum of two recorded measurements or every four hours) One to two Hourly (not continuous)  Once improving and not requiring oxygen for 2 hours discontinue oxygen saturation monitoring Hourly with continuous cardiorespiratory (including oximetry) monitoring and close nursing observation Hydration/nutrition   Small frequent feeds If not feeding adequately (less than 50% over 12 hours), administer NG hydration If not feeding adequately (less than 50% over 12 hours),or unable to feed, administer NG hydration Oxygen saturation/oxygen requirement   Nil requirement Administer O2 to maintain saturations greater than or equal to 90%  Once improving and not requiring oxygen for 2 hours discontinue oxygen saturation monitoring Administer O2 to maintain saturations greater than or equal to 90% Respiratory support     Begin with NPO2  HFNC to be used only if NPO2 has failed Consider HFNC or CPAP Disposition/ escalation   Consider further medical review if early in the illness and any risk factors are present or if child develops increasing severity after discharge   Decision to admit should be supported by clinical assessment (including risk factors), social and geographical factors, and phase of illness   Consider escalation if severity does not improve  Consider ICU review/ admission or transfer to local centre with paediatric HDU/ICU capacity if: • Severity does not improve • Persistent desaturations • Significant or recurrent apnoea associated with desaturations Has risk factors Parental education     Provide advice on the expected course of illness and when to return (worsening symptoms and inability to feed adequately)  Provide  Parent information sheet Provide advice on the expected course of illness and when to return (worsening symptoms and inability to feed adequately)  Provide  Parent information sheet Provide advice on the expected course of illness  Provide  Parent information sheet 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 13 MILD MODERATE SEVERE Respiratory support   Begin with NPO2  HFNC to be used only if NPO2 has failed Consider HFNC or CPAP Disposition/ escalation   Consider further medical review if early in the illness and any risk factors are present or if child develops increasing severity after discharge   Decision to admit should be supported by clinical assessment (including risk factors), social and geographical factors, and phase of illness Consider escalation if severity does not improve  Consider ICU review/ admission or transfer to local centre with paediatric HDU/ICU capacity if: • Severity does not improve • Persistent desaturations • Significant or recurrent apnoea associated with desaturations Has risk factors

14. Initial management (cont.) MILD MODERATE SEVERE Likelihood of admission   Suitable for discharge  Consider risk factors   Likely admission, may be able to be discharged after a period of observation  Management should be discussed with a local senior physician   Requires admission and consider need for transfer to an appropriate children’s facility/PICU  Threshold for referral is determined by local capacity but should be early Observations Vital signs (respiratory rate, heart rate, O2 saturations, temperature) Adequate assessment in ED prior to discharge (minimum of two recorded measurements or every four hours) One to two Hourly (not continuous)  Once improving and not requiring oxygen for 2 hours discontinue oxygen saturation monitoring Hourly with continuous cardiorespiratory (including oximetry) monitoring and close nursing observation Hydration/nutrition   Small frequent feeds If not feeding adequately (less than 50% over 12 hours), administer NG hydration If not feeding adequately (less than 50% over 12 hours),or unable to feed, administer NG hydration Oxygen saturation/oxygen requirement   Nil requirement Administer O2 to maintain saturations greater than or equal to 90%  Once improving and not requiring oxygen for 2 hours discontinue oxygen saturation monitoring Administer O2 to maintain saturations greater than or equal to 90% Respiratory support     Begin with NPO2  HFNC to be used only if NPO2 has failed Consider HFNC or CPAP Disposition/ escalation   Consider further medical review if early in the illness and any risk factors are present or if child develops increasing severity after discharge   Decision to admit should be supported by clinical assessment (including risk factors), social and geographical factors, and phase of illness   Consider escalation if severity does not improve  Consider ICU review/ admission or transfer to local centre with paediatric HDU/ICU capacity if: • Severity does not improve • Persistent desaturations • Significant or recurrent apnoea associated with desaturations Has risk factors Parental education     Provide advice on the expected course of illness and when to return (worsening symptoms and inability to feed adequately)  Provide  Parent information sheet Provide advice on the expected course of illness and when to return (worsening symptoms and inability to feed adequately)  Provide  Parent information sheet Provide advice on the expected course of illness  Provide  Parent information sheet 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 14 MILD MODERATE SEVERE Parental education   Provide advice on the expected course of illness   Provide advice on when to return (worsening symptoms and inability to feed adequately) samsung.com

15. Management Oxygen therapy should be : instituted when oxygen saturations are persistently less than 90% discontinued when oxygen saturations are persistently greater than or equal to 90 %. 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 15 Respiratory support

16. Management (Cont.) It is appreciated that infants with bronchiolitis will have brief episodes of mild/moderate desaturations to levels less than 90%. These brief desaturations are not a reason to commence oxygen therapy . 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 16 Respiratory support

17. Management (Cont.) Heated humidified high flow oxygen/air via nasal cannulae ( HFNC ) should only be considered in the presence of hypoxia (oxygen saturation less than 90%)  and a lack of response  to nasal prong oxygen, or where severe disease is present . 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 17 Respiratory support

18. Management (Cont.) If oxygen has been required: Once improving and not requiring oxygen for 2 hours discontinue oxygen saturation monitoring.  Continue other observations 2-4 hourly and reinstate intermittent oxygen monitoring if deterioration occurs.   29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 18 Respiratory support

19. Management (cont.) When non-oral hydration is required nasogastric (NG) hydration is the route of choice If IV fluid is used it should be isotonic with added glucose. NG or IV fluids should be commenced at two-thirds maintenance   29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 19 Hydration/nutrition

20. Management (cont.) Medications are not indicated in the treatment of bronchiolitis 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 20 Medication

21. Management (cont.) Beta 2 agonists  - (including in infants with a personal or family history of atopy) Corticosteroids  - (nebulised, oral, IM or IV ) Adrenaline   - (nebulised, IM or IV) except in peri-arrest or arrest situation Nebulised Hypertonic Saline Antibiotics  – (Including Azithromycin) Antivirals   29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 21 Do not administer

22. Management (cont.) Nasal suction is not routinely recommended. Superficial nasal suction may be considered in those with moderate disease to assist feeding Nasal saline drops may be considered at time of feeding   29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 22 Nasal suction

23. Management (cont.) Is not indicated 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 23 Chest physiotherapy

24. Management (cont.) Discharged prior to day 3 of illness with other risk factors Abnormal oxygen saturations Less than half normal oral intake or urine output Assessed as moderate or severe bronchiolitis  29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 24 Consider consultation with local paediatric team when:

25. Management (cont.) Severe bronchiolitis Risk factors for more severe illness Apnoea Children requiring care above the level of comfort of the local hospital Children whose O2 requirement is >50% 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 25 Consider transfer when:

26. Management (cont.) Children can be discharged when they are maintaining adequate oxygenation maintaining adequate oral intake Infants younger than 8 weeks of age are at an increased risk of representation   29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 26 Consider discharge when:

27. https ://www.rch.org.au/clinicalguide/guideline_index/Bronchiolitis/# medication https:// www.nice.org.uk/guidance/ng9/chapter/1-Recommendations#assessment-and-diagnosis https:// www.mayoclinic.org/diseases-conditions/bronchiolitis/diagnosis-treatmen https:// emedicine.medscape.com/article/961963-overview https:// www.health.harvard.edu/blog/bronchiolitis-what-parents-of-infants-need-to-kno w https:// www.msdmanuals.com/home/children-s-health-issues/respiratory-disorders-in-infants-and-children/bronchiolitis 29/09/2019 Bronchiolitis :Clinical Practice Guidelines Prof.Dr. Saad S Al Ani 27

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