What is bronchiolitis and its definition, the age group, signs and symptoms and clinical presentation The clinical practice guidelines, how to diagnosis, clinical criteria, what are the severity degrees and How to assess the severity, what are the investigations that may be needed, Is there any diagnostic test, what is the prognosis
What is the management,
2. 1.Bronchiolitis is a clinical diagnosis
2.No investigations should be routinely
performed
3.Management is to support feeding
and oxygenation as required
4.No medication should be routinely
administered
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29/09/2019
Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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3. • Bronchiolitis is a viral lower respiratory
tract infection, generally affecting children
under 12 months of age
• Viral bronchiolitis is a clinical diagnosis,
based on typical history and examination.
• Peak severity is usually at around day two
to three of the illness with resolution over
7– 10 days.
• The cough may persist for weeks.
29/09/2019
Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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4. Bronchiolitis typically begins with an acute
upper respiratory tract infection followed by
onset of respiratory distress and fever and
one or more of:
• Cough
• Tachypnea
• Retractions
• Widespread crackles or wheeze
29/09/2019
Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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5. Risk factors for more serious illness
• Chronological age at presentation
less than 10 weeks
• Chronic lung disease
• Congenital heart disease
• Chronic neurological conditions
• Indigenous ethnicity
• Immunodeficiency
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Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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6. • Infants with any of these risk factors are more
likely to deteriorate rapidly and require
escalation of care.
• Consider hospital admission even if presenting
early in illness with mild symptoms.
• The more symptoms the infant has in the
moderate-severe categories, the more likely
they are to develop severe disease
29/09/2019
Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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8. Assessment of severity
29/09/2019
Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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MILD MODERATE SEVERE
Behaviour Normal Some / intermittent irritability Increasing irritability and /
or lethargy Fatigue
Respiratory rate Normal – mild
tachypnea
Increased respiratory rate Marked increase or decrease
in respiratory rate
Use of accessory
muscles
Nil to mild chest
wall retraction
Moderate chest wall
retractions
Suprasternal retraction
Nasal flaring
Marked chest wall
retractions
Marked suprasternal
retraction
Marked nasal flaring
Oxygen saturation/
oxygen requirement
O2 saturations
greater than 92%
(in room air)
O2 saturations 90 –92%
(in room air)
O2 saturations less than 90%
(in room air)
Hypoxemia, may not be
corrected by O2
Apneic episodes None May have brief apnoea May have increasingly
frequent or prolonged
apnoea
Feeding Normal May have difficulty with
feeding or reduced feeding
Reluctant or unable to feed
9. Management
• Investigations:
In most children with bronchiolitis no investigations
are required
– Chest X-ray (CXR)
• Is not routinely indicated and may lead to unnecessary treatment
with antibiotics
– Blood tests (including blood gas, full blood count (FBC),
blood cultures)
• Have no role in management
– Virological testing (nasopharyngeal swab or aspirate)
• Has no role in management of individual patients
29/09/2019
Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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10. Management
• Treatment:
• Children are often more settled if comfort
oral feeds are continued.
• Initial management
The main treatment of bronchiolitis is supportive.
This involves ensuring appropriate oxygenation and
fluid intake, and minimal handling
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Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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11. Initial management
MILD MODERATE SEVERE
Likelihood
of admission
Suitable for discharge
Consider risk factors
Likely admission, may
be able to be discharged
after a period of
observation
Management should be
discussed with a local
senior physician
Requires admission and
consider need for
transfer to an
appropriate children’s
facility/PICU
Threshold for referral
is
determined by local
capacity but should be
early
Observations
Vital signs
(respiratory rate,
heart rate,
O2 saturations,
temperature)
Adequate assessment in
ED prior to discharge
(minimum of two
recorded measurements
or every four hours)
One to two Hourly (not
continuous)
Once improving and
not requiring oxygen
for 2 hours discontinue
oxygen saturation
monitoring
Hourly with continuous
cardiorespiratory
(including oximetry)
monitoring and close
nursing observation
29/09/2019
Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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12. Initial management (Cont.)
MILD MODERATE SEVERE
Hydration/nutrition Small frequent
feeds
If not feeding adequately
(less
than 50% over 12 hours),
administer NG hydration
If not feeding
adequately
(less than 50% over
12 hours),or unable
to feed, administer
NG hydration
Oxygen
saturation/oxygen
requirement
Nil requirement Administer O2 to
maintain
saturations greater than
or equal to 90%
Once improving and not
requiring oxygen for 2
hours discontinue oxygen
saturation monitoring
Administer O2 to
maintain
saturations greater
than
or equal to 90%
29/09/2019
Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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13. Initial management (cont.)
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Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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MILD MODERATE SEVERE
Respiratory
support
Begin with NPO2
HFNC to be used only if
NPO2 has failed
Consider HFNC or CPAP
Disposition/
escalation
Consider further
medical review if
early in the illness
and any risk
factors are present
or if child
develops
increasing severity
after discharge
Decision to admit
should be supported by
clinical assessment
(including risk factors),
social and geographical
factors, and phase of
illness
Consider escalation if severity
does not improve
Consider ICU review/
admission or transfer to local
centre with
paediatric HDU/ICU capacity
if:
• Severity does not improve
• Persistent desaturations
• Significant or recurrent
apnoea associated with
desaturations
• Has risk factors
14. Initial management (cont.)
29/09/2019
Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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MILD MODERATE SEVERE
Parental
education
Provide advice on the expected course of illness
Provide advice on when to
return (worsening symptoms and inability
to feed adequately)
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15. Management
• Oxygen therapy should be :
instituted when oxygen saturations are
persistently less than 90%
discontinued when oxygen saturations
are persistently greater than or equal
to 90%.
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Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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Respiratory
support
16. Management (Cont.)
• It is appreciated that infants with
bronchiolitis will have brief episodes
of mild/moderate desaturations to
levels less than 90%.
• These brief desaturations are not a
reason to commence oxygen therapy.
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Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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Respiratory
support
17. Management (Cont.)
• Heated humidified high flow oxygen/air
via nasal cannulae (HFNC) should only
be considered in the presence of hypoxia
(oxygen saturation less than 90%) and a
lack of response to nasal prong oxygen,
or where severe disease is present.
29/09/2019
Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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Respiratory
support
18. Management (Cont.)
• If oxygen has been required: Once
improving and not requiring oxygen for 2
hours discontinue oxygen saturation
monitoring.
• Continue other observations 2-4 hourly
and reinstate intermittent oxygen
monitoring if deterioration occurs.
29/09/2019
Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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Respiratory
support
19. Management (cont.)
• When non-oral hydration is required
nasogastric (NG) hydration is the route of
choice
• If IV fluid is used it should be isotonic
with added glucose.
• NG or IV fluids should be commenced at
two-thirds maintenance
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Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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Hydration
/nutrition
20. Management (cont.)
• Medications are not indicated in the
treatment of bronchiolitis
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Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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Medication
21. Management (cont.)
• Beta 2 agonists - (including in infants with a
personal or family history of atopy)
• Corticosteroids - (nebulised, oral, IM or IV )
• Adrenaline - (nebulised, IM or IV) except in
peri-arrest or arrest situation
• Nebulised Hypertonic Saline
• Antibiotics – (Including Azithromycin)
• Antivirals
29/09/2019
Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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Donot
administer
22. Management (cont.)
• Nasal suction is not routinely recommended.
• Superficial nasal suction may be considered
in those with moderate disease to assist
feeding
• Nasal saline drops may be considered at time
of feeding
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Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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Nasalsuction
23. Management (cont.)
• Is not indicated
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Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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Chest
physiotherapy
24. Management (cont.)
• Discharged prior to day 3 of illness
with other risk factors
• Abnormal oxygen saturations
• Less than half normal oral intake
or urine output
• Assessed as moderate or severe
bronchiolitis
29/09/2019
Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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Considerconsultationwith
localpaediatricteam
when:
25. Management (cont.)
• Severe bronchiolitis
• Risk factors for more severe illness
• Apnoea
• Children requiring care above the level of
comfort of the local hospital
• Children whose O2 requirement is >50%
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Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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Considertransfer
when:
26. Management (cont.)
• Children can be discharged when they are
–maintaining adequate oxygenation
–maintaining adequate oral intake
• Infants younger than 8 weeks of age are at
an increased risk of representation
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Bronchiolitis :Clinical Practice Guidelines
Prof.Dr. Saad S Al Ani
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Considerdischarge
when: