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.
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* 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
* The American Academy of Pediatrics defines it as any of the following in infants: 1
* Use of accessory muscles
* Nasal flaring
* 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,