Bronchiolitis Part 1: Basics

Hello. I'm Michael Kissel A.

I'm one of the pediatric Hospitalist at Duke.

The title of this talk is to do or not.

To do the bronchiolitis questions.

This is a two part series that will focus on

acute viral bronchiolitis, specifically the basics of the disease and

the evidence based supporting current management.

Being one of the most common disease processes in pediatrics.

Pediatric hospitalist must not only be current in in patient

management strategies but must be able to counsel and educate

colleagues on appropriate evidence based outpatient management options.

Therefore, I will review the evidence across the pediatric care

continuum as outlined by the 2014 Ap guidelines on the

diagnosis, management and prevention of viral bronchiolitis.

First, a quick overview of this talk and bronchiolitis in

general. The objectives of this presentation are first and foremost

to review not only the basics, but also the evidence

as simply as possible.

Unlike many of the pediatric illnesses, there is a significant

existing body of literature regarding bronchiolitis with many very high

quality studies.

So I will try to sift out the most notable

and influential as I review the evidence it will become

evident which interventions have been shown to be effective or

ineffective as the case may be in the various clinical

settings. Finally, I'll touch on the many evolving potential prevention

and treatment strategies.

Acute viral bronchiolitis is the most common diagnosis managed by

pediatric hospitalists and is the leading cause of hospitalization in

infants bronchiolitis is a clinical diagnosis based on the presence

of a constellation of clinical symptoms, including an upper respiratory

pro drome followed by increased respiratory effort and wheezing in

Children less than two years of age.

The presence of this history paired with a non focal

on exam is enough to diagnose vasculitis.

Therefore, chest X ray or lab studies are not routinely

needed nor helpful respiratory syncytial virus or RSV accounts for

somewhere between 60 to 80% of cases with the remainder

caused by human rhinovirus, adenovirus, coronavirus influenza as well as

at no and para influenza.

However, co infection with more than one virus is an

increasingly recognized problem and contributes to more severe clinical disease.

A recent prospective multi center study published by potash at

at all in 2021 found a 55% incidence of co

infection in a cohort of over 700 Children evaluated in

an E.

D. Setting.

So this is quite common.

RSV is active throughout the world during cold months, with

incidents figuring from season to season depending on geographic location.

In the United States, infections typically begin in the south

around late september then spread north until the season tapers

off in late May, interestingly during the SARS could be

to pandemic RSV incidents was shifted to late spring and

summer months of 2021 in the northern hemisphere, likely due

to relaxation of public health measures that were put in

place during the pandemic.

Unfortunately, physical distancing and masking are not likely to be

effective. Long term prevention strategies.

So our search for optimal prevention measures goes on globally.

RSC accounts for 33 million lower respiratory tract infections, three

million hospitalizations and 60,000 deaths among Children less than five

years old, mostly in developing countries in the United States,

fortunately, mortality from RSV disease is rare and typically occurs

in high risk infants with comorbidities including broncho, pulmonary dysplasia

and congenital heart disease, socio economic factors associated with higher

disease burden include overcrowded living conditions and limited availability of

indoor plumbing.

Other risk factors include low birth weight, male gender, maternal

smoking, family history of 80 p and lack of breastfeeding.

As I mentioned earlier, the presence of co infection can

also influence the severity of infection, extending hospital length of

stay in the need for ICU admission.

This translates into roughly $1.7 billion Inpatient care alone in

terms of cost.

However, this may just be the tip of the iceberg

when considering cost more broadly.

Two studies looking at caregiver impacts noted parental distress lasting

up to 60 days after this, church reported downstream complications

included high parental anxiety levels, missed work, decreased work productivity,

disruption of sleep and strained finances and family relationships.

In addition to the short term effects RSV lower respiratory

tract illnesses associated with the development of recurrent wheezing and

asthma, with the associated substantial long term individual financial and

societal burdens there.

In While the vast majority patients can be managed in

the outpatient setting, infants younger than 12 months are at

higher risk of requiring inpatient admission due to poor feeding

or dehydration, hypoxia and increased work of breathing concerning for

potential respiratory failure.

Children with underlying chronic medical conditions are at higher risk

for severe disease.

Um these high risk conditions, in addition to the heart

disease and lung disease include immunodeficiency, congenital and genetic abnormalities

and in utero smoke exposure.

The presence of these conditions should prompt more conservative monitoring

and management.

Generally speaking, infants with ticket Nia or respiratory rates greater

than 60 are at higher risk of aspiration and hypoxic

respiratory failure.

infants less than two months are also at increased risk

of apnea, which often presents early in the course of

illness to further characterize apnea and bronchiolitis.

A 2013 retrospective study was conducted across 16 sites in

a cohort of 2200 patients over a three year period.

Abney was identified in 5% with similar risks seen among

the various viral ideologies, as well as between genders, white

versus non white race or birth weight.

This table is busy, but I highlight factors found to

be strongly positively associated with Apnea, including age less than

two weeks, with the highest odds ratio at 9.6, Age

2 to 7.9 weeks with an odds ratio of 4.7

Abney are reported by the caregiver or lower respiratory rate

at initial presentation.

So be particularly careful with those infants.

The second part of this bronchiolitis series will focus on

treatment and prevention of RSV.

But before delving into the data I should point out

the universal supportive treatment principles endorsed in the ap bronchiolitis

guideline for all Children with bronchiolitis regardless of clinical setting.

These include first Providing oxygen to keep saturation is greater

than 90%.

Um pulse ox has been shown to increase length of

hospitalization so emphasis is placed on transitioning from continuous to

intermittent pulse ox as soon as improvement is demonstrated by

the patient 2nd providing nasal suction only as needed particularly

prior to feeds if nasal congestion is interfering with feeding

ability. Routine deep suctioning has been shown in lengthen hospital

stay and should therefore be avoided as much as possible.

Third maintaining adequate hydration either through the frequent oral feedings

and tear it to feeding or supplemental I.

V. Fluids.

It's generally recommended to provide in G Tube feeding if

the patient has significantly increased work of breathing and or

a respiratory rate greater than 70.

To minimize the risk of aspiration.

Finally minimize stimulation of the infant given that agitation frequently

exacerbates symptoms when it comes to viral bronchiolitis literally Hundreds

of studies have been published over the past six decades

to determine the effectiveness of various proposed therapies.

So it's important for pediatric hospitals to clearly understand the

data as I discuss each modality.

You can use the accompanying table to track which treatment

to do or not do in each of the clinical

settings

Bronchiolitis Part 1: Basics

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