EMERGENCY MANAGEMENT OF

ACUTE BRONCHIOLITIS

PETHUEL AGYIN, MD
 CONTENT
• CASE PRESENTATION
• INTRODUCTION
• BRIEF PATHOPHYSIOLOGY
• DISEASE SEVERITY
CLASSIFICATIONS
• CLINICAL PRESENTATIONS
• INVESTIGATIONS
• TREATMENT
• COMPLICATIONS
• REFERENCES
 CASE PRESENTATION
• 11 month old male infant was seen at the CEW around 1: 00am on the 27 th
of November 2022.
• PC: Difficulty breathing of a day’s duration
• Vitals on arrival: Temp: 36.2*c, Spo2: 88% on RA, RR: 70cpm, PR: 136bpm
WT: 6kg
• Primary survey: Airway: patent, Breathing: spontaneous and labored,
Circulation: crt < 2 secs, GCS: 15/15
• Primary intervention: Child was given INO at 1l/min and was also
nebulized with 2.5 mg of salbutamol back to back .
 CASE PRESENTATION
• HPC: Infant was apparently well until few hours prior to presentation when
mother noticed that his respiratory rate was faster than usual and for that
reason she decided to bring the child to TTH CEW for expert management
• ODQ: Fever+, Cough+, Dyspnea+, Runny nose+, Ear tugging+, Poor
Feeding+, Chills-, Rigors-, Nasal congestion-, Vomiting-, Diarrhea-, Crying on
micturition-
• O/E: Respiratory System: patient was in distress evidenced by scr, air entry
was reduced in all lung zones, breath sounds were versicular and there
were wheezes auscultated. other parts of the exam were unremarkable
including an otoscopy.
• Impression: Acute bronchiolitis w/ dx of bronchopneumonia.
 CASE PRESENTATION
• Plan:
Admit to the CEW, continue INO 1L/min, nebulize with salbutamol 2.5 mg 4
hourly, monitor vitals every 30 minutes and inform sc if there’s any change,
to ease nasal congestion with saline nasal drops
To do a CXR, fbc, bf for mps
• After reviewing the next morning: Patient was weaned off oxygen (spo2
was 97% on RA), RR was 37 cpm, patient wasn’t in distress.
Plan: Discharge home and review in 3 days at the OPD
 INTRODUCTION
• Bronchiolitis, part of the spectrum of lower
respiratory tract diseases is a major cause of
illness and hospitalization in infants and
children less than 2 years.
• Peek incidence usually between 2-6 months
• It is characterized by upper respiratory
presentations (eg. rhinorrhea) followed by
lower respiratory tract presentations (eg.
wheezing, rales)
 INTRODUCTION

• Usually caused by RSV but other known

pathogens include influenza virus, adenovirus,
parainfluenza virus.
• Risk factors include age <12 wks, preterm
birth, immunodeficiency, chd, exposure to
tobacco smoke.
• Children with the above risk factors are likely
to deteriorate rapidly and require escalation of
care.
 PATHOPHYSIOLO
GY

• Infection of the ciliated epithelial cells of

the bronchiolar mucosa results in
increased mucosal secretion, cell death
and lymphocytic infiltration causing
submucosal edema.
• This leads to distal airway obstruction
and distal air trapping.
 PATHOPHYSIOLO
GY
• The effort of breathing is increased due to
increased expiratory lung volumes and
decreased lung compliance.
• Recovery of the epithelial cells occurs in 3-4
days but the cilia do not regenerate until
approximately 2 weeks.
• The debris is then cleared by macrophages.
CLINICAL PRESENTATION

Signs Include:
• Tachypnea
• Intercostal Recessions
• Subcostal Recession
• Nasal Flaring
• Cyanosis
• Rhonchi Or Wheezes On
Auscultation
• Irritability
 CLASSIFICATION OF DISEASE
SEVERITY

• The severity of acute

bronchiolitis can be classified as
mild, moderate and severe.
• Children with mild disease can
usually be treated on out-
patient basis but children with
moderate and severe disease
require in-patient treatment as
well as continuous monitoring.
CLASSIFICATION OF DISEASE
SEVERITY
 INVESTIGATIONS
Acute bronchiolitis is a clinical diagnosis.
however, certain investigations are
recommended. these include:
• CBC
• Chest x-ray (findings usually non-specific,
usually done to rule out other co-existing chest
diseases)
• Virological testing (respiratory viral panel)
• ABGS
DIFFERENTIAL DIAGNOSIS

• Bacterial pneumonia
• Asthma
• Pertussis
• Foreign body aspiration
• Congenital heart disease
 APPROACH TO MANAGEMENT BASED ON DISEASE
SEVERITY
MILD BRONCHIOLITIS
• Supportive care and anticipatory guidance are
the mainstay of management of mild
bronchiolitis.
• This includes adequate hydration, relief of nasal
congestion and monitoring for disease
progression.
• Patients under this category can be treated on
out-patient basis but should be placed on contact
precautions.
 APPROACH TO MANAGEMENT BASED ON DISEASE
SEVERITY

MILD BRONCHIOLITIS
• Randomized trials, systemic reviews and even
guidelines from the American Academy of
Pediatrics does not support the routine use of
bronchodilators, steroids and antibiotics
(unless there is an evidence of superimposed
infection) in non-sever bronchiolitis.
 APPROACH TO MANAGEMENT BASED ON DISEASE
SEVERITY

MODERATE-SEVERE BRONCHIOLITIS
Children with moderate-severe bronchiolitis
require assessment in the emergency
department and usually require supportive care
together with medical interventions while on
admission.
 APPROACH TO MANAGEMENT BASED ON
DISEASE SEVERITY
MODERATE- SEVERE BRONCHIOLITIS
Supportive treatment include:
• Giving adequate maintenance iv fluids.
• Providing respiratory support by giving:
 Free flow oxygen
 CPAP
 HFNC
 Endotracheal oxygenation
 APPROACH TO MANAGEMENT BASED ON
DISEASE SEVERITY

MODERATE-SEVERE BRONCHIOLITIS
Medical interventions not routinely recommended
because therapeutic benefits not so significant according
to papers we referenced for this presentation.
These interventions include:
• nebulization with hypertonic saline.
• nebulization with bronchodilators (salbutamol,
epinephrine).
 APPROACH TO MANAGEMENT BASED ON DISEASE
SEVERITY

ROLE OF CORTICOSTEROIDS IN THE MANAGEMENT OF SEVERE

BRONCHIOLITIS.
• Steroids are not routinely used in the management
of severe bronchiolitis but however, risk factors for
asthma such as family history and atopy prompt
some practitioners to prescribe corticosteroids.
• This however has no benefits in reducing the risk of
developing asthma in the future according to
research.
 COMPLICATIONS

• Dehydration
• Aspiration pneumonia
• Apnea
• Respiratory failure
• Secondary bacterial infection
94%
 DISCHARGE COUNSELING

• Counsel caregivers to seek prompt medical care

when child presents with episodes of wheezing
and respiratory difficulty.
• Counsel caregivers on the need for immunization
particularly influenza and pneumococcal
• Avoid exposing the child to smoke.
• Encourage good nutrition.
 REFERENCES
• Aherne W, Bird T, Court SD, et al. Pathological changes in virus infections of the
lowerrespiratory tract in children. J Clin Pathol 1970; 23:7.
• Wohl ME, Chernick V. State of the art: bronchiolitis. Am Rev Respir Dis 1978;
118:759.
• Midulla F, Scagnolari C, Bonci E, et al. Respiratory syncytial virus, human
bocavirusand rhinovirus bronchiolitis in infants. Arch Dis Child 2010; 95:35.
• Meissner HC. Viral Bronchiolitis in Children. N Engl J Med 2016; 374:62.
• Skjerven HO, Megremis S, Papadopoulos NG, et al. Virus Type and Genomic
Load inAcute Bronchiolitis: Severity and Treatment Response With Inhaled
Adrenaline. JInfect Dis 2016; 213:915.
• AMBOSS
THANK YOU