Bronchiolitis

1. Definition
a. Obstructive
b. Inflammation in the bronchioles (instead of bronchi)
c. Clinical diagnosis
2. Epidemiology
a. Epidemic outbreaks: winter/ spring
b. Peak age 6 months of age, M > F
c. Most commonly affects newborns – 2 y/o
i. 15% of all children by age 2 have had it
3. Clinical Manifestations
a. Starts as Mild URI
b. Anorexia
c. Cough
d. Apnea
e. Fever
f. Irritability
g. Vomiting (children more likely to vomit than adults when get sick)
h. Respiratory Distress Signs = HOSPITALIZE
i. Dyspnea
ii. Wheezing
iii. Nasal flaring
iv. Grunting
v. Cyanosis
vi. Intercostal retractions: right at the base of the diaphragm
vii. Tachypnea
viii. Tachycardia
4. Etiology
a. RSV: 50-90%
b. Influenza virus
c. Adenovirus
d. Parainfluenza
e. Older Patients
i. Bacterial infection
ii. Chronic bronchitis
iii. Inhalation of toxic gases
iv. idiopathic
5. Risk Factors
a. Exposure to toxic fumes (elderly)
b. Connective tissue disease (elderly)
c. Contact with infected person: Daycare
i. Someone coughs/sneezes, then shakes your hand, etc
6. Differential Diagnosis
a. Asthma
b. Foreign Body (FB)
c. Heart Dz
d. Pneumonia
e. Reflux
f. Aspiration
g. Cystic Fibrosis (CF)
 h. Emphysema
7. Laboratory
a. Arteriole Blood Gases (ABG)
i. Hypoxemia
ii. Hypercarbia
iii. Acidemia
b. Test for RSV antigen
i. QuickVue
ii. Nasopharyngeal swab (way in the back of the throat), wash out with saline and catch and test,
etc.
8. Special Tests
a. Infant Pulmonary Function Tests
9. Imaging
a. CXR, AP and Lateral
b. r/o FB, CHF, PN
c. Righter Upper Lobe (RUL) atelectasis: opacification
i. fissure has moved up, air can’t get in up there
d. Air-Trapping: hyperinflation
i. Blockage in bronchioles: can’t see them, air trapped in there
e. Flattened diaphragm: larger AP diameter (1:1)
f. Get CXR only if
i. Suspect FB or something other than bronchiolitis
10. Appropriate Health Care
a. If notice getting worse: call, ER
b. Inpatient: isolated, negative pressure beds (air in there will stay in there)
i. Increased respiratory distress
ii. Cyanosis
iii. Dehydration
iv. Inability to feed
11. General Measures
a. Critical Phase (48-72)
b. Fluid (IV) and nutrition
c. Oxygen
i. Mechanical ventilation if in repiratory distress
d. Cardio-respiratory monitoring: can send pt home with portable monitor
e. Treat the symptoms
f. Isolation/avoid contact
12. Activity
a. REST: get lots of sleep
b. Avoid crowds: very contagious
c. Avoid other viral illnesses: for at least 2 months
d. Can go to work, might be off for a couple of weeks tho – depends on how bad they get it
13. Diet
a. Frequent small feedings of clear liquids
b. IV if hospitalized
14. Drugs of Choice
a. Albuterol
i. Inhaler
ii. Nebulizer: can be given to babies
b. Ribavirin
i. <6 wks old
ii. Severe RSV
c. Antibiotics (secondary bacterial infx – rare
15. Alternative Drugs
a. Corticosteroids: want to stay away from for babies, can give toddlers prednisone
i. Reactive airways dz
ii. Usually only use in adults
16. Patient F/U
a. Outpatient Care
i. Telephone call in 2-4 days to see how doing
b. Post-Hospital Care
i. Send home on Heart/lung monitor
c. Bronchiolitis associated with apnea
17. Prevention/Avoidance
a. Palivinumab (Synagis)
i. RSV prevention in high risk patients
b. RSV immune globulin
i. At risk patients
c. Both meds VERY expensive
d. If in home with recently diagnosed case, etc
18. Possible Complications
a. Bacterial superinfection
b. Respiratory failure
c. Death (1%)
19. Expected Course/Prognosis
a. Recovery in 7-10 days