Bronchiolitis

Download as pdf or txt
Download as pdf or txt
You are on page 1of 7

Bronchiolitis

geekymedics.com/bronchiolitis

August 1, 2020

Introduction
Bronchiolitis is characterised by narrowing of the lower respiratory tract due to inflammation
of the bronchioles and build-up of mucus. It is a common respiratory condition in infancy.
Around a third of infants develop bronchiolitis before the age of 1, with a peak incidence
around 3 to 6 months of age.1

The incidence of bronchiolitis is linked with the winter period. Typically, children present
during this time with episodes of bronchiolitis lasting for 7-10 days.2,3

You might also be interested in our medical flashcard collection which contains over 1000
flashcards that cover key medical topics.

Aetiology
Bronchiolitis is usually caused by a viral infection. About 80% of cases are caused by the
respiratory syncytial virus (RSV). The other less common viral causes of bronchiolitis
include:

Parainfluenza virus
Rhinovirus
Adenovirus
Influenza
Human metapneumovirus

You might also be interested in our medical flashcard collection which contains over 1000
flashcards that cover key medical topics.

1/7
Risk factors
Risk factors for admission to hospital with a severe episode of bronchiolitis include:

Chronic lung disease


Congenital heart disease
Younger than 3 months old
Prematurity
Down’s syndrome
Cystic fibrosis
Neuromuscular disease2,4

Clinical features

History
Typical symptoms of bronchiolitis include:

Persistent cough
Wheeze
Shortness of breath
A prodrome of upper respiratory tract features – fever, runny nose, cold
Symptoms typically worsen during the 2nd or 3rd night of illness

Other symptoms can include:

Apnoea – in infants younger than 6 weeks of age, also typically seen with RSV
Poor feeding – young children are obligate nasal breathers, making it difficult to feed
and breathe at the same time during bronchiolitis
Symptoms of dehydration in severe disease – reduced urine output or fewer wet
nappies

Other important areas to cover in the history include:

Past medical history including birth history – ask about known risk factors for severe
bronchiolitis, as listed above
Medications/allergies – this information may be useful if there are other possible
differentials
Family history – ask if anyone in the family has been unwell, this may point towards
other differentials. It is also essential to ask about any family history of atopic conditions

2/7
Social history – ask about parental smoking, as this will exacerbate symptoms of
bronchiolitis. Also ask about the child’s situation at home (e.g. where they live, who is
at home with them, the involvement of social services), as difficult social circumstances
will reduce the threshold for admission.

Clinical examination

Typical clinical findings in bronchiolitis include:

Bilateral polyphonic expiratory wheeze


Tachypnoea
Tachycardia
Low-grade fever (<39o)
Irritability

Other clinical findings can include:

Prolonged capillary refill time (>2 seconds)


Cyanosis
Signs of dehydration – dry mucous membranes, sunken fontanelle in young babies5
Reduced conscious level6
Recessions (intercostal, subcostal or sternal) – this is a result of children having a
compliant rib cage, which makes an increased work of breathing clearly visible
externally.

Figure 1. Intercostal recessions in a newborn with


breathing difficulties.7

Differential diagnoses
Table 1. Differential diagnoses of bronchiolitis

3/7
Differential diagnosis Features differentiating from bronchiolitis

Pneumonia Fever >39o


Focal crackles

Viral-induced wheeze Persistent wheeze without crackles


Recurrent wheeze associated with a viral illness
Personal or family history of atopy
>1-year-old
Responsive to salbutamol treatment

Early-onset asthma Persistent wheeze without crackles


Recurrent wheeze associated with triggers
Personal or family history of atopy
>1-year-old
Responsive to salbutamol treatment

Bordetella pertussis or Coryza


whooping cough Characteristic hacking cough followed by an
inspiratory ‘whoop’
Unvaccinated

Gastro-oesophageal reflux Chronic cough


Poor weight gain

Foreign body aspiration May have a history of choking


Monophonic wheeze.8

Chronic heart disease or failure Cyanosis


Shortness of breath
Hepatomegaly
Murmurs

Investigations
Children are diagnosed clinically with bronchiolitis if they present with coryzal symptoms
lasting up to 3 days, followed by:

1. Persistent cough and


2. Tachypnoea or chest recession and
3. Wheeze or crackles on chest auscultation.4

Investigations do not influence the treatment of bronchiolitis.

4/7
Bedside investigations

Pulse oximetry: children should be admitted if oxygen saturation is <92% 4

Laboratory investigations

Blood tests (including arterial blood gases): these are not routinely performed

Imaging

Chest X-ray: not routinely performed, but if there is an area of the lung with reduced air
entry or focal crackles, this can be used to rule out pneumonia or pneumothorax.2

Management
Bronchiolitis is typically self-limiting. Not all children with bronchiolitis will require admission
to hospital. If a child does not require admission, it is important to provide safety netting to
the parents or guardians to return if symptoms get worse.

The criteria for admission to secondary care depends on several factors including:

Apnoea
Reduced oxygen saturation: <92%
Reduced oral intake: <50-75% of normal
Persistent respiratory distress: significant chest recessions, grunting
Presence of risk factors for severe disease, as mentioned earlier
Difficult social factors: living very far from the hospital, lack of parental confidence4

The management of bronchiolitis is supportive:

Oxygen supplementation if saturations are persistently <92%.


Positive pressure such as high flow oxygen or CPAP may be required for respiratory
distress. If these fail to work, intubation and ventilation may be required.
Nutritional and fluid supplementation – oral, nasogastric (NG) tube or intravenous (IV).
Depending on the severity of the bronchiolitis, a stepwise approach may be
considered:
Small and frequent oral feeds,
NG tube placement with small and frequent NG bolus feeds,
Continuous NG feeds,
IV fluids
Support parents/guardians with smoking cessation.

Important points to note:

5/7
Bronchodilators are not effective as respiratory tract narrowing is due to increased
secretions, not bronchoconstriction.
Antibiotics are also not effective due to the viral aetiology of bronchiolitis. 4,5

Complications
If bronchiolitis is not diagnosed and treated, complications can include:

Clinical dehydration
Syndrome of inappropriate antidiuretic hormone (SIADH) and subsequent
hyponatraemia. Because of the risk of SIADH, some guidelines will advocate for 2/3
maintenance NG/IV fluids, please refer to local guidelines.
Apnoea and respiratory failure requiring intubation and ventilation.6

Key points
Bronchiolitis is characterised by narrowing of the lower respiratory tract due
to inflammation of the bronchioles and build-up of mucus.
Bronchiolitis is usually caused by a viral infection. About 80% of cases are caused by
the respiratory syncytial virus (RSV).
The diagnosis is clinical, with investigations rarely indicated.
Bronchiolitis is typically self-limiting. Not all children with bronchiolitis will require
admission to hospital.
Management is supportive: oxygen supplementation, high flow oxygen and treatment
of dehydration.
Complications can include dehydration, SIADH, apnoea and respiratory failure.

References
1. Patient. Bronchiolitis. Published in 2018. Available from: [LINK].
2. Goldstein H. Published in 2013. Available from: [LINK].
3. Spottingthesickchild. Symptoms: Difficulty in Breathing. Published in 2020. Available
from: [LINK].
4. NICE Guidelines. Bronchiolitis in children: diagnosis and management. Published in
2015. Available from: [LINK].
5. Bronchiolitis (and RSV) in infants and children (Beyond the Basics). Published in 2019.
Available from: [LINK].
6. West Sussex Children & Young People’s Urgent Care Network. Bronchiolitis Pathway
and Assessment in Acute Settings for Children 0-2 years. Published in 2011. Available
from: [LINK].

6/7
7. Wikimedia Commons. Intercostal recessions in a newborn with breathing difficulties.
License: [CC BY-SA]. Available from: [LINK].
8. Bronchiolitis in Infants and Children: Clinical Features and Diagnosis. Published in
2020. Available from: [LINK].

Reviewer

Dr Hannah Murch

Paediatric Emergency Medicine Consultant

Editor

Arunachalam Soma

Copyright © Geeky Medics

7/7

You might also like