Bronchiolitis
Bronchiolitis
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
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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
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Risk factors
Risk factors for admission to hospital with a severe episode of bronchiolitis include:
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
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
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
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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
Differential diagnoses
Table 1. Differential diagnoses of bronchiolitis
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Differential diagnosis Features differentiating from bronchiolitis
Investigations
Children are diagnosed clinically with bronchiolitis if they present with coryzal symptoms
lasting up to 3 days, followed by:
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Bedside investigations
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
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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].
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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
Editor
Arunachalam Soma
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