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Bronchiolitis Clinical Practice: An
Evidence-Based Approach
William Schneider, DO, MA, FACEPMedical Director, Pediatric Emergency Services
Banner Thunderbird Medical CenterEPIP Conference November 3rd and 4th, 2011
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Case Presentation► 7 month old uncircumcised male gasping for air► Low grade fever, cough and rhinorrhea for 2 days► Now wheezing, grunting, with mod-severe retractions► Unable to feed since this afternoon► Hx of wheezing in past – parents are treated for asthma► UTD with immunizations, ex-premie at 34 weeks gestation► VS: BP 92/60, HR 132, RR 55, Temp 39.1 ̊C (R), POx 87% RA► Moderately irritable and difficult to console► Nasal flaring with intercostal and substernal retractions► Diffuse expiratory wheezing
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Work Up► Asthma vs. Bronchiolitis pathway?► Respiratory Score?► Suction vs. SVN?
Albuterol vs. Epinephrine SVN?► Oxygen?► Steroids?► CBC, BCx, UA, C&S, LP, CXR, viral studies?► Nasal CPAP vs. Heliox vs. both combined?► Risk factors?
Severe Bronchiolitis Apnea
What is Your Work Up?
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ObjectivesBronchiolitis
► Review the current literature and the AAP recommendations for the diagnosis and management of Bronchiolitis
► Become familiar with the Bronchiolitis respiratory scoring tool used in the assessment of the severity of Bronchiolitis
► Explore the risk factors for Severe Bronchiolitis and Apnea
► Discuss the new Bronchiolitis Protocol using the Respiratory Scoring Tool to be implemented within Banner Health
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Introduction Bronchiolitis
► Bronchiolitis is the most common lower respiratory tract infection in patients < 2 years of age Peak age: 2-8 months Male predominance (1.5:1)
► 200,000 visits to EDs annually
► 19% admission rate
► Cost $700 million annually
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Definition AAPBronchiolitis
► “…rhinitis, tachypnea,
wheezing, cough, crackles,
use of accessory muscles,
and/or nasal flaring in a child
younger than 24 months.”
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PathophysiologyBronchiolitis
► Virus invades the nasopharynx and spreads by cell to cell transfer to the lower tract within a few days Viral infection of the lower respiratory tract
► Increased mucous secretion, cell death and sloughing of the bronchial ciliated epithelial cells Clumps of necrotic epithelium and mucus decrease diameter of the
bronchiolar lumen causing turbulent air flow particularly on expiration► Peribronchiolar lymphocytic infiltrate and submucosal edema► Narrowing, air trapping, and obstruction of small airways:
Hyperinflation and atelectasis Ventilation/perfusion mismatch ↓ lung compliance and ↑ work of breathing
► Smooth muscle constriction has limited role
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RecoveryBronchiolitis
► Degree of obstruction may vary as some of the airways clear resulting in rapidly changing clinical severity
► Epithelial cells recover after 3 – 4 days► Cilia regenerate after 2 weeks► Median duration of illness ~ 12 days► Symptoms may persist for 3 (18%) to 4 (9%) weeks
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EtiologyBronchiolitis
► RSV (50 – 80%): November to March Nearly all children (95%) infected within first 2 years of life 4 to 6 day incubation period precedes URI symptoms Spread through direct contact with secretions
► Human Metapneumovirus (3 – 19%)► Parainfluenza Virus Type 3► Influenza► Adenovirus► Rhinovirus (common in asthma)
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Differential DiagnosisBronchiolitis
LIFE-THREATENING CAUSES
Infection: pneumonia, Chlamydia, Pertussis (apnea)Foreign body: aspirated or esophagealCardiac anomaly: congestive heart failure, vascular ringAllergic reactionBronchopulmonary disorder exacerbation (CLD)
NON-LIFE THREATENING CAUSES
Congenital anomaly: tracheoesophageal fistula, bronchogenic cyst, laryngotracheomalacia
Gastroesophageal reflux diseaseMediastinal massCystic fibrosis
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Risk Factors For Severe Illness In Hospitalized Patients
► PICNIC network (Pediatric Investigators Collaborative Network on Infections in Canada 1995): 689 hospitalized children < 2 years:
6 out of 689 patients died (0.9%)4 out of 6 had underlying disease (congenital heart disease,
chronic lung disease, immunocompromised)2 were either premature or < 6 weeks old
None of 372 pts died if older than 6 weeks and without other risk factors for severe disease (95% CI 0-0.8%)
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Risk Factors for Severe BronchiolitisHistory
► Age < 6 - 12 weeks► Prematurity < 34 - 37 weeks gestation► Underlying chronic respiratory illness such as CF, CLD or BPD► Significant congenital heart disease► Immune deficiency including human immunodeficiency
virus, organ or bone marrow transplants, or congenital immune deficiencies
► Prior intubation► First 48 hours of illness
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Risk Factors for Severe BronchiolitisPhysical Examination
► General appearance: ill appearing► Oxygen saturation level < 92 - 94% on room air
5 fold increase in likelihood of hospitalization
► Respiratory rate > 60-70 breaths per minute► Increased work of breathing - moderate to severe retractions
and/or accessory muscle use► Dehydration► Male
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Risk Factors for Apnea
► Full-term birth and < 1 month of age
► Preterm birth (< 37 weeks gestation) and age < 2 months post conception
► History of Apnea of prematurity
► Emergency Department presentation with apnea
► Apnea witnessed by a caregiver
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Bronchiolitis Scoring Tool► Assist in clinical decision-making within a protocol
Objective and subjective reproducible clinical parameters► Be applicable to its particular pathophysiology (LRTI)
Validity: score relates to disease severity Good inter-rater reliability >80% Responsiveness: detect changes over time
► Apply to patients < 2 years of age► Easily adopted by the provider, RT, RN, started in the ED and
continued on the floor and/or PICU► Goals:
↓ LOS, ↓ cost & ↓admission rate ↑Consistency, ↑efficiency, and ↑quality
► Reflect AAP recommendations
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AAP Clinical Practice Guideline (Pediatrics 2006;118:1774)
► “Physical examination findings of importance include respiratory rate, increased work of breathing as evidenced by accessory muscle use or retractions, and ausculatory findings such as wheezes or crackles”
► “Pulse oximetry has been rapidly adopted into clinical assessment of children with Bronchiolitis on the basis of data suggesting that it can reliably detect hypoxemia that is not suspected on physical examination”
► “The lack of uniformity of scoring systems make comparison between studies difficult”
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Bronchiolitis Respiratory Score (Liu, 2004)
0 1 2 3Respiratory Rate 0-6 mo < 50
6mo – 1yr < 401 yr+ < 30
0-6 mo < 606mo – 1yr < 501 yr+ < 45
0-6 mo < 706mo – 1yr < 601 yr+ < 60
0-6 mo > 706mo – 1yr > 601 yr+ > 60
SaO2 ≥ 90 % > 88 % > 86 % ≤ 85 %General Appearance
CalmNo distress
Mildly irritable; easy to console
Moderately irritable; difficult to console
Extremely irritable; cannot be comforted
Retractions and nasal flaring (NF, SS, IC, SC)
None 1 of 4 2 of 4 3 or more
Auscultation Clear Scattered wheezes
Diffuse expiratory wheezing
Biphasic wheezing or very poor air movement
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Diagnostic Studies - CXRBronchiolitis
► Schuh S, Lalani A, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007; 150(4):429-433. Prospective Cohort study of 265 infants 2-23 months old Only 2 CXR inconsistent with bronchiolitis
Lobar consolidation More likely to treat with antibiotics
Pre-radiography: 7 infants (2.6%) identified for antibiotics Post-radiography: 39 infants (14.7%) identified for antibiotics
► Not routinely recommended► Reserved for clinical deterioration or unclear presentation
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Normal With Possible Hyperinflation
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RUL Atelectasis
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Mild RML Perihilar Markings With Peribronchial Cuffing
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Worse Bilateral Perihilar Infiltrates With Flattened Diaphragms
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Diagnostic Studies – Labs/Viral SwabBronchiolitis
► Rapid viral testing: Direct Fluorescent Antibody (DFA) is the Gold standard (99% sensitive)
More sensitive than Enzyme Immunoassay (EIA) and Cx (thermo labile virus) Most viruses have similar presentation Results have minimal effect on management May be considered in infants <3 months of age
Limit further lab testing Limit unnecessary antibiotics
Not routinely recommended
► Routine CBC, BMP and blood cultures are not recommended► Febrile neonate (> 38.0̊ C) with RSV and/or clinical bronchiolitis
Requires septic workup and admission
RSV in Febrile Infants Study InformationBronchiolitis
► Study: The Risk of Serious Bacterial Infections in Young Febrile Infants with RSV Infections
► Pediatric Emergency Medicine Collaborative Research Committee of the AAP
► Authors: D Levine, S Platt, P Dayan, C Macias, J Zorc, W Krief, J Schor, D Bank, K Shaw, M Stein, C Jacobstein, N Fefferman and N Kuppermann and The Multicenter RSV-SBI Study Group
► Pediatrics 2004; 113;1728
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Background: RSV in Febrile InfantsBronchiolitis
► Young febrile infants are at substantial risk of SBI
► Clinical assessment may be difficult
► Unclear whether viral infection alters the risk of bacterial disease in this age
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Methods: RSV in Febrile InfantsBronchiolitis
► Prospective, multi-center, cross sectional study: Eight Pediatric Emergency Departments October-March, 1998-2001 1,248 patients enrolled
► Inclusion: Age < 60 days Rectal temp > 38.0oC
► Exclusion: Received antibiotics w/in 48 hrs
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Evaluation: RSV in Febrile InfantsBronchiolitis
► Clinical: History and physical examination Yale Observation Scale and Pulmonary Score
► Diagnostic Testing: Rapid RSV antigen Fever evaluation: urine, blood, CSF Stool culture - if symptomatic Chest radiograph
► Treatment / Disposition at discretion of physician
► Telephone follow-up
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Categorization: RSV in Febrile InfantsBronchiolitis
► RSV Status: “Indeterminate” considered Negative
► Clinical Bronchiolitis: Wheezing or retractions with URI No lobar infiltrate on chest radiograph URI: history/presence of cough or Rhinorrhea
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RSV in Febrile InfantsPositive vs Negative NP Swab Results
Variable
RSV (+) N = 269
RSV (-) N = 979
RR (95% CI) p
Any SBI 17/244 7.0% (4.1,10.9%)
116/925 12.5% (10.5,14.8%)
0.5 (0.3,0.9) .013
UTI 14/261 5.4% (3.0, 8.8%)
98/966 10.1% (8.3,12.2%)
0.5 (0.3,0.9) .015
Bacteremia 3/267 1.1% (0.2, 3.2%)
22/968 2.3% (1.4, 3.4%)
0.5 (0.1,1.6) .33
Meningitis 0/251 (0, 1.2%)
8/938 0.9% (0.4, 1.7%) 0 .21
3 RSV (+) with Bacteremia were neonates29
RSV in Febrile InfantsClinical Bronchiolitis (CB) Results
Variable CB (+) N = 156
CB (-) N =1035
RR (95% CI) p
Any SBI 10/141 7.1% (3.5,12.7%)
122/976 12.5% (10.5,14.7%)
0.57 (0.3,1.1) .069
UTI 10/153 6.5% (3.2,11.7%)
102/1018 10% (8.2,12.0%)
0.65 (0.3,1.2) .19
Bacteremia 0/154 (0, 1.9%)
24/1026 2.3% (1.5, 3.5%) 0 .06
Meningitis 0/146 (0, 2.0%)
8/989 0.8% (.3, 1.6%) 0 .61
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Conclusion: RSV in Febrile InfantsBronchiolitis
► Young febrile infants with RSV or clinical Bronchiolitis are at lower risk of SBI than febrile infants without these findings Routine RSV testing not necessary
► Risk of UTI, however, remains significant
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TreatmentBronchiolitis
► Suctioning – First line therapy Nasal suction:
BBG nasal aspirator Age-appropriate bulb suction Use prior to:
– Feeds– SVN trials or therapy
Deep posterior nasal-pharyngeal suctioning: Reserved for mod-severe respiratory distress from significant airway
obstruction Data does not support routine use
– May induce bronchospasm from irritation and /or agitation
Normal saline nose drops may be used prior to suctioning
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TreatmentBronchiolitis
► Oxygen - First line therapy Supplemental oxygen administered if POx consistently < 90%:
After nasal suctioning, airway positioning and POx probe repositioning
Titrate 02 to keep POx > 90% while awake or > 88% while sleeping
Consider using continuous pulse oximetry Significant respiratory distress
– First 12 to 24 hours
High risk infants < 2 months of age Hx of prematurity RS > 10 Until patient is clinically improving
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TreatmentBronchiolitis
► Albuterol nebulized therapy: Controversial Inconsistent results in studies Gadomski, et al. Bronchodilators for bronchiolitis. Cochrane
Collaboration Database Syst rev. 2006;(3):CD001266: Small short term clinical improvements at best (14%) Do not affect rate of hospitalization or length of hospital stay Slightly more effective in those patients with history of wheezing or Atopy Routine use not recommended:
– Consider SVN trial to determine effectiveness in individual patients
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TreatmentBronchiolitis
► Epinephrine nebulized therapy: Hartling L, et al. Epinephrine for Bronchiolitis. Cochrane Collaboration
Database Syst Rev. 2004;(1): CD003123: Slightly better clinical effect when compared with placebo or Albuterol Short-term improvements in clinical scores, POx, and respiratory rates The improvements possibly related to the alpha effect of vasoconstriction Should be reserved for mod-severe disease No reduction in the admission rates or length of hospital stay
► Anticholinergic agents (Ipratropium): Everad M, et al. Anticholinergic drugs for wheeze in children under the
age of two years. Cochrane Collaboration Database Syst Rev. 2009: Review of 6 trials involving 321 infants No significant clinical improvement Not justified if used alone or in combination with B-adrenergic agents
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AAP Treatment RecommendationBronchiolitis
► “Bronchodilators should not be used routinely in the management of Bronchiolitis”
► “A carefully monitored trial of alpha-adrenergic or beta-adrenergic medication is an option. Inhaled Bronchodilators should be continued only if there is a documented positive clinical response to the trial using an objective means of evaluation.”
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Treatment - Corticosteroids:Bronchiolitis
► Patel H. et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Collaboration Database syst rev. 2004;(3):CD004878. 13 studies with 1,198 patients No significant difference between steroid & placebo treatment
groups:Clinical scoresOxygen satsAdmission rates Length of stay Return visits
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Corticosteroids Treatment Bronchiolitis
► Corneli HM, et al. A Multicenter Randomized, Controlled Trial of Dexamethasone for Bronchiolitis. N Engl J Med. 2007;357:331-339 (Bronchiolitis study group of the Pediatric Emergency Care Applied Research Network): 600 patients with first episode of bronchiolitis 2 – 12 months of age with mod-severe disease 2004 – 2006 / 20 medical center Eds Dexamethasone 1 mg/kg vs. placebo: Measure outcome at 4 hours:
No significant difference in clinical respiratory scores No difference in admit rates (39.7% vs. 41%) No difference in readmission rates or hospital LOS Conclusion: Did not improve outcomes
– ED– Hospital
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► “Corticosteroid medications should not be used routinely
in the management of Bronchiolitis.”
Corticosteroids Treatment AAP Recommendation
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TreatmentBronchiolitis
► Inhaled steroids: 2 small studies Showed no benefit in the course of the acute disease
► Nebulized Hypertonic 3% Saline: Improves mucociliary clearance in cystic fibrosis Kuzik, et al. Nebulized hypertonic saline in the treatment of viral
bronchiolitis in infants. J Pediatr 2007; 151:266-270. Multi-center trial of 96 patients admitted 3% saline vs. normal saline SVN 26% reduction in hospital length of stay (2.6 vs. 3.5 days)
Chaudhry K, Sinert R. Is nebulized hypertonic saline solution an effective treatment for bronchiolitis in infants? Annals of Emerg. Med. 2010; 55 (1): 120-12122:
No significant clinical outcome in ED or admission rate
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TreatmentBronchiolitis
► Nasal Continuous Positive Airway Pressure (CPAP): Noninvasive humidified high flow nasal cannula (1L/kg/min) Decreases inspiratory muscle work load Relieves atelectasis Prevents airway collapse Improves ventilation Bridge to intubation
Severe respiratory distress Apnea spells
Heliox alone or in addition to nasal CPAP: Helium + 21% oxygen mixed gas 1/3 as dense as air Reduces gaseous flow resistance Improves gaseous exchange and alveolar ventilation Increases C02 elimination Response seen within first hour
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Ineffective Treatments
► Ribavirin: No role (Randolph 1996 Arch Ped Adoles Med)
► Antibiotics: < 2% have concurrent bacterial infection
(Purcell 2002 Arch Ped Adoles Med)
No difference in hospitalization with or without antibiotics(Friis 1984 Arch Dis Child)
► Antihistamines, Decongestants, Singulair► Inhaled Interferon -2a► Nebulized Furosemide► Chest Physiotherapy
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Criteria for HospitalizationBronchiolitis
► Persistent respiratory distress after treatment (RS > 5)► POx consistently < 92% ► Dehydration with inadequate po intake► Significant risk factors for Apnea:
< 1-2 month old with hx of prematurity < 35 weeks gestation► Unreliable caretaker► Witnessed Apnea by caretaker or ED personnel► Febrile neonate► Respiratory rate > 60 breaths per minute after treatment► Continual need for deep NP suctioning► Physician discretion
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Criteria for PICU AdmissionBronchiolitis
► Intubation► Nasal CPAP (HHNC/Heliox)► Apnea► RS > 10► Sepsis► Frequent bronchodilator SVN less than 2 hours apart► Physician discretion
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Criteria for DischargeBronchiolitis
► Oxygen sats consistently > 92%► No respiratory distress (RS < 5) ► No apnea or significant risk factors► Respiratory rate < 60 breaths per minute► Adequate oral intake► Family education complete► Adequate bulb suctioning► Physician discretion► Caretaker comfortable and reliable
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Risk Factors for ED Return VisitBronchiolitis
► 17 - 20% ED return rate: 65% within 2 days
► Norwood A, Mansbach JM, Clark S, et al. Prospective multi-center study of bronchiolitis: predictors of an unscheduled visit after discharge from the emergency department. Acad. Emerg Med. 2010 Apr;17(4):376-82. [722 patients younger than 2 years of age]:
OR p-value < 2 months of age: 2.1 0.03 Sex: male: 1.7 0.02 History of hospitalizations: 1.7 0.02 Prematurity (< 35 weeks): 1.6 0.16
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ConclusionBronchiolitis
► Bronchiolitis is mainly a clinical diagnosis
► Diagnostic laboratory and radiographic tests play a limited role
► Bronchodilators and steroids lack significant clinical effectiveness
► Supplemental oxygen indicated if POx < 90% consistently
► Assess patients for risk factors when making final disposition decisions
► Respiratory tool and protocol aid in treatment and disposition decisions
► Most patients recover with suction, O2 & fluids only
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Bronchiolitis Protocol
Process Flow
ED and Inpatient
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History of wheezing, atopy, or FH of asthma?
Patient meets
Discharge Criteria?
Yes
Yes
Trial of Racemic Epinephrine SVN
<5kg: 5.63mg (0.25ml)>5kg: 11.25mg (0.5ml)
Trial of Albuterol Nebulizer (2.5 mg/3cc) or MDI 4 puffs
No Yes
RS > 5 (AFTER Suction)
No
No Score improved >3 points?
Classified as Epi Responder Classified as
Non-Bronchodilator Responder
No
Yes
Patient meets
Discharge Criteria?
Classified as Albuterol Responder
Yes
Supportive Care Orders
■ Albuterol Responder: • Supportive Care • Alb MDI or Neb Q4 hours
■ Epi Responder: • Before D/C: Monitor for Minimum of 60 minutes
post treatment for rebound (RS>5)• Supportive Care
■ Non Bronchodilator Responder: • Supportive Care • Family Education
Bronchiolitis Protocol Process Flow
(ED and Inpatient)
No
Yes
■ Albuterol Responder: • Supportive Care Orders• Alb MDI or Neb Q4 hours prn for RS >5
– ED: Q1 hour prn• Alb MDI or Neb Q2 hours prn for RS >7
– ED: Q30 minutes prn• Notify MD if on Q2 hours
■ Epi Responder: • Supportive Care Orders• Racemic Epi Q4 hours prn for RS >5
– ED: Q1 hour prn• Racemic Epi Q2 hours prn for RS >7
– ED: Q30 minutes prn• Notify MD if on Q2 hours
■ Non Bronchodilator Responder: • Supportive Care Orders• Notify MD for RS >7
Score improved >3 points?
Observation or Admit if admission criteria
met
NoASSESS & SCORE using Respiratory
Scoring Tool (“Assess –
Suction – Assess” process)
AD
MIT
DIS
CHA
RG
E
Discharge with Supportive Care and
Family Education
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Bronchiolitis Protocol
► Inclusion criteria: Diagnosis of bronchiolitis Less than 2 years of age
► Exclusion criteria: Hx of cystic fibrosis (CF) Hx of Bronchopulmonary dysplasia (BPD) Significant or cyanotic congenital heart disease Immunocompromised On home oxygen Has significant comorbid conditions complicating care
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Bronchiolitis Protocol► Does the patient meet eligibility criteria?
► Use Banner Health System (BHS) Bronchiolitis Order Set/RT Bronchiolitis Protocol
► Assess & Score using BHS Sheet (Always score before and after intervention): Allow 10-15 minutes after each intervention before reassessment and
scoring
► Document patient past medical history of Atopy, allergies, or wheezing
► Document family medical history of asthma: First degree relatives treated for asthma (parents, siblings)
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ED and Inpatient Supportive Care Orders► Oral or nasopharyngeal suctioning prn by RT/RN :
Age appropriate suction bulb or BBG nasal aspirator Reserve deep suction for airway obstruction causing significant respiratory compromise
► Scheduled spot check pulse oximetry Q4 hrs (Q1 hrs in ED) and prn: Consider continuous pulse oximetry in pts in ED or with significant respiratory distress (first 12-24 hrs),
high risk infants <1-2 months of age, hx of prematurity, RS >10)
► Begin Oxygen Protocol: Supplemental O2 begins ONLY when pulse Ox consistently < 90% after suction/repositioning O2 weaning starts when O2 consistently > 90% while awake or > 88% asleep comfortably
► Bronchiolitis assessment: Scoring to be done PRE & POST intervention primarily by the RT (RN if RT not available): (Q 30-60 minutes and prn in ED) PRN if post score 0 - 4 Q4 hrs and prn if post score is > 5 Q2 hrs and prn if post score is > 7
► Begin family education upon hospital admission or complete at discharge► Notify physician if score > 10, clinical deterioration, or new O2 requirements
► Consider nasal CPAP (HHNC/Heliox) if severe respiratory distress or apnea spells► Notify physician when discharge criteria are met
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Bronchiolitis Protocol Process Flow
History of wheezing, Atopy,
or first degree relative treated for
asthma?
Patient meets
Discharge Criteria?
Yes
Yes
Trial of Racemic Epinephrine SVN
<5kg: 5.63mg (0.25ml)>5kg: 11.25mg (0.5ml)
Trial of Albuterol Nebulizer (2.5 mg / 3cc)
or MDI 4 puffs
No Yes
DISCHARGE CRITERIA:■ O2 Sats consistently >92%■ No respiratory distress (RS <5)■ Feeding adequately■ Family comfortable & reliable■ Family education complete■ Respiratory rate <60■ No Apnea or significant risk■ Bulb suction adequate■ Physician discretion
RS > 5 (AFTER Suction)
No
NoScore
improved >3 points?
Score improved >3 points?
Include: 0-24 months; Dx BronchiolitisExclude: hx BPD, CHD, home O2, or
significant comorbid conditions
Supportive Care Orders
No
ASSESS & SCORE using Respiratory Scoring
Tool (“Assess – Suction – Assess” process)
Observation or Admit if admission
criteria met
D/C with Supportive Care & Family
Education
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Bronchiolitis Protocol Process Flow continued
Trial of Racemic Epinephrine SVN
<5kg: 5.63mg (0.25ml)>5kg: 11.25mg (0.5ml)
Trial of Albuterol Nebulizer (2.5 mg/ 3cc)
or MDI 4 puffs
NoScore
improved >3 points?
Score improved >3 points?
Classified as Epi Responder
Classified as Non-Bronchodilator
Responder
No
Yes
Patient meets
Discharge Criteria?
Classified as Albuterol
Responder
Yes
ADMISSION CRITERIA:■ O2 Sats consistently <92%■ RS >5■ Feeding poorly or dehydrated■ Family unreliable■ Respiratory rate >60■ Apnea witnessed■ Significant risk factors for apnea■ Neonatal fever■ Bulb suction inadequate■ Physician discretion
PICU CRITERIA:■ Intubation■ Nasal CPAP (HHNC/Heliox)■ RS > 10■ Apnea■ Frequent bronchodilator <2 hrs■ Sepsis■ Physician discretion
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Patient meets
Discharge Criteria?
■ Albuterol Responder: • Supportive Care • Alb MDI or Neb Q4 hours prn
■Epi Responder: • Before D/C: Monitor for Minimum of 60
minutes post treatment for rebound (RS >5)• Supportive Care
■Non Bronchodilator Responder: • Supportive Care • Family Education
Yes
■Albuterol Responder: • Supportive Care Orders• Alb MDI or Neb Q4 hours prn for RS >5
– ED: Q1 hour prn• Alb MDI or Neb Q2 hours prn for RS >7
– ED: Q30 minutes prn• Notify MD if on Q2 hours
■Epi Responder: • Supportive Care Orders• Racemic Epi Q4 hours prn for RS >5
– ED: Q1 hour prn• Racemic Epi Q2 hours prn for RS >7
– ED: Q30 minutes prn• Notify MD if on Q2 hours
■Non Bronchodilator Responder: • Supportive Care Orders• Notify MD for RS >7
No
Bronchiolitis Protocol Process Flow continued
AD
MIT
DIS
CHA
RG
E
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Case Conclusion► 7 month old male gasping for air:
low grade fever cough and rhinorrhea for 2 days now wheezing, grunting, with mod-
severe retractions unable to feed since this afternoon hx of wheezing in past parents treated for asthma UTD with immunizations, uncircumcised ex-premie at 34 weeks gestation VS: BP 92/60, HR 132,RR 55, T 39.1 ̊C (R),
POx 87% RA moderately irritable and difficult to
console nasal flaring with intercostal and
substernal retractions diffuse expiratory wheezing
■ Asthma vs. Bronchiolitis pathway?■ Respiratory Score?■ Suction vs. SVN?
– Albuterol vs. Epinephrine SVN?■ Oxygen?■ Steroids?■ CBC, BCx, UA, C&S, LP, CXR, viral
studies?■ Nasal CPAP vs. Heliox vs. both?■ Risk factors?
– Severe Bronchiolitis– Apnea
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References► Bronchiolitis Guideline Team, Cincinnati Chi8ldren’s Hospital Medical Center. Evidence-based care guideline for
management of cronchiolitis in infants 1 year of age or less with a first time episode. Guideline 1. http:/www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-base/bronchiolitis. Htm. Revised November 16, 2010. (Clinical guideline).
► Cambonie G, Melesi C, Fournier-Favre S, Counil F, Jaber S, Picaud J, and Matecki S. Clinical effects of heliox administration for acute bronchiolitis in young infants. Chest (2006) Vol. 129(3): pp 676-682.
► Corneli HM, et. al. A multicenter, randomized, controlled trial of Dexamethasone for Bronchiolitis. New England Journal of Med. (2007) Vol. 357. No. 4: pp 331-339.
► Everad M, Bara A, Kurian M, N’Diaye T, Ducharme F, and Mayowe V. Anticholinergic drugs for wheeze in children under the age of two years (review). The Cochrane Collaboration (2009), John Wiley and Sons, LTD.
► Harling L, Wiebe N, Russell K, Patel H, and Klassen TP, A meta-analysis of randomized controlled trials evaluating the efficacy of epinephrine for the treatment of acute viral bronchiolitis. Arch Ped Adolesc Med. (2003) Vol. 157: pp 957-964.
► Johnson DW, Adair C, Brant R, Holmwood J, and Mitchell I, Differences in admission rates of children with bronchiolitis by pediatric and general emergency departments. Pediatrics (2002) Vol. 110. No. 4: pp 1-7.
► Joseph M. Evidence-based assessment and management of acute bronchiolitis in the emergency department. EB Medicine Ped Em Med Practice. (2011) Vol 8. No. 3: pp 1-20.
► Levine D, Shari L, et al. Risk of Serious Infection in Young Febrile Infants With Respiratory Syncytial Virus Infections. Pediatrics 2004;113;1728.
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References► Kuzik BA, et. al. Nebulized Hypertonic Saline in the treatment of viral bronchiolitis in infants. Journal of Pediatrics.
(2007) pp 266-270.
► Liu LL, Gallaher MM, et al. Use of Respiratory Clinical Score Among Different Providers. Pediatr Pulmonol 2004; 37:243-48
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