Episode 33 - Acute Bronchiolitis: Assessment and Management in the Emergency Department (Pharmacology CME‪)‬ EMplify by EB Medicine

    • Medicine

Show Notes
Differentiating bronchiolitis from asthma and reactive airway disease in young children can be challenging, and a rapidly changing clinical presentation can confound accurate assessment of the severity of the illness. This episode reviews risk factors for apnea and severe bronchiolitis; discusses treatments/therapies and provides evidence-based recommendations for the management of pediatric patients with bronchiolitis.
Show More v (#showNotes)


Pathophysiology

* Bronchiolar narrowing and obstruction is caused by:

* Increased mucus secretion
* Cell death and sloughing
* Peri-bronchiolar lymphocytic infiltrate
* Submucosal edema


* Smooth muscle constriction seems to have a limited role, perhaps explaining the lack of response to bronchodilators.
* Median duration of illness is 12 days in children 2 yo.3

* Late fall epidemic peaking Nov-March, in the US.4


* Human Metapneumovirus (HMPV) accounts for 3-19% 5,6

* Similar seasonal variation to RSV.


* Parainfluenza, influenza, adenoviruses, coronaviruses, rhinoviruses, and enteroviruses are other causes.4-6
* Rhinoviruses have been shown to play a larger role in Asthma.7

Presentation

* The American Academy of Pediatrics defines it as any of the following in infants: 1

* Rhinitis
* Tachypnea
* Wheezing
* Cough
* Crackles
* Use of accessory muscles
* Nasal flaring



Differential Diagnosis

* Emergent Causes

* Infection: pneumonia, chlamydia, pertussis
* Foreign body: aspirated or esophageal
* Cardiac anomaly: congestive heart failure, vascular ring
* Allergic reaction
* Bronchopulmonary dysplasia exacerbation


* Non-acute Causes

* Congenital anomaly: tracheoesophageal fistula, bronchogenic cyst, laryngotracheomalacia
* Gastroesophageal reflux disease
* Mediastinal mass
* Cystic fibrosis


* Clinical Pearls

* Vomiting, wheezing, and coughing associated with feeding; consider GERD.
* Wheezing associated with position changes; consider tracheomalacia or great vessel anomalies.
* Wheezing exacerbated by flexion of neck and relieved by neck hyperextension; consider vascular ring.
* Multiple respiratory tract infections and failure to thrive; consider cystic fibrosis or immunodeficiency.
* Wheezing with heart murmur, cardiomegaly, cyanosis, exertion or sweating with feeding; consider cardiac disease.
* Sudden onset of wheezing and choking; consider foreign body.



Risk Factors for Severe Bronchiolitis

* Age 6-12 weeks11-13
* Prematurity 35-37 weeks’ gestation11-13
* Underlying respiratory illness such as bronchopulmonary dysplasia1
* Significant congenital heart disease; immune deficiency including HIV, organ or bone marrow transplants,

Show Notes
Differentiating bronchiolitis from asthma and reactive airway disease in young children can be challenging, and a rapidly changing clinical presentation can confound accurate assessment of the severity of the illness. This episode reviews risk factors for apnea and severe bronchiolitis; discusses treatments/therapies and provides evidence-based recommendations for the management of pediatric patients with bronchiolitis.
Show More v (#showNotes)


Pathophysiology

* Bronchiolar narrowing and obstruction is caused by:

* Increased mucus secretion
* Cell death and sloughing
* Peri-bronchiolar lymphocytic infiltrate
* Submucosal edema


* Smooth muscle constriction seems to have a limited role, perhaps explaining the lack of response to bronchodilators.
* Median duration of illness is 12 days in children 2 yo.3

* Late fall epidemic peaking Nov-March, in the US.4


* Human Metapneumovirus (HMPV) accounts for 3-19% 5,6

* Similar seasonal variation to RSV.


* Parainfluenza, influenza, adenoviruses, coronaviruses, rhinoviruses, and enteroviruses are other causes.4-6
* Rhinoviruses have been shown to play a larger role in Asthma.7

Presentation

* The American Academy of Pediatrics defines it as any of the following in infants: 1

* Rhinitis
* Tachypnea
* Wheezing
* Cough
* Crackles
* Use of accessory muscles
* Nasal flaring



Differential Diagnosis

* Emergent Causes

* Infection: pneumonia, chlamydia, pertussis
* Foreign body: aspirated or esophageal
* Cardiac anomaly: congestive heart failure, vascular ring
* Allergic reaction
* Bronchopulmonary dysplasia exacerbation


* Non-acute Causes

* Congenital anomaly: tracheoesophageal fistula, bronchogenic cyst, laryngotracheomalacia
* Gastroesophageal reflux disease
* Mediastinal mass
* Cystic fibrosis


* Clinical Pearls

* Vomiting, wheezing, and coughing associated with feeding; consider GERD.
* Wheezing associated with position changes; consider tracheomalacia or great vessel anomalies.
* Wheezing exacerbated by flexion of neck and relieved by neck hyperextension; consider vascular ring.
* Multiple respiratory tract infections and failure to thrive; consider cystic fibrosis or immunodeficiency.
* Wheezing with heart murmur, cardiomegaly, cyanosis, exertion or sweating with feeding; consider cardiac disease.
* Sudden onset of wheezing and choking; consider foreign body.



Risk Factors for Severe Bronchiolitis

* Age 6-12 weeks11-13
* Prematurity 35-37 weeks’ gestation11-13
* Underlying respiratory illness such as bronchopulmonary dysplasia1
* Significant congenital heart disease; immune deficiency including HIV, organ or bone marrow transplants,