Bronchiolitis Epidemiology, Testing, & Management

BronchiolitisBronchiolitisEpidemiology, Testing, & ManagementEpidemiology, Testing, & Management

Jesse Sturm, MDJesse Sturm, MDFellow, Pediatric Emergency MedicineFellow, Pediatric Emergency Medicine

Emory UniversityEmory UniversityNovember 5, 2008November 5, 2008

OutlineOutline

DefinitionsDefinitions

EpidemiologyEpidemiology

Clinical ManifestationsClinical Manifestations

Testing and DiagnosisTesting and Diagnosis

Non-pharmacologic managementNon-pharmacologic management

Pharmacologic options – what’s the evidence?Pharmacologic options – what’s the evidence?

GuidelinesGuidelines

Interesting StudiesInteresting Studies

DefinitionsDefinitions

Bronchiolitis – clinical descriptionBronchiolitis – clinical description– Acute respiratory illnessAcute respiratory illness– Inflammation of small airways Inflammation of small airways → wheezing→ wheezing– Typically: first episode of wheezing in child younger than Typically: first episode of wheezing in child younger than

2yo with signs of viral URI & no other explanation for 2yo with signs of viral URI & no other explanation for wheezing such as pneumonia or atopywheezing such as pneumonia or atopy

Respiratory syncytial virus (RSV) is principal agentRespiratory syncytial virus (RSV) is principal agent– Para influenza, human metapneumovirus, adenovirus, Para influenza, human metapneumovirus, adenovirus,

influenza, rhinovirus, coronavirus, mycoplasmainfluenza, rhinovirus, coronavirus, mycoplasma

RSV specificRSV specific

RNA virusRNA virusIn infants < 2yo, 60% of lower In infants < 2yo, 60% of lower respiratory tract infections due to respiratory tract infections due to RSVRSVInvades epithelial cells of Invades epithelial cells of nasopharynx to mucosa of lower nasopharynx to mucosa of lower airwayairway– Moves by cell to cell transferMoves by cell to cell transfer– RSV kills resident cellsRSV kills resident cells– Mononuclear cells, mucous, Mononuclear cells, mucous,

sloughed epithelium clump in airwaysloughed epithelium clump in airway– Causes turbulent airflow, wheezing, Causes turbulent airflow, wheezing,

hyperinflation, atelectasis, V/Q hyperinflation, atelectasis, V/Q mismatchmismatch

Infection of epithelial cells in respiratory tract. Recombinant RSV expressing green fluorescence.

RSV EpidemiologyRSV Epidemiology

Primarily between 2-8 monthsPrimarily between 2-8 months– 50% of all children during first 2y of life50% of all children during first 2y of life– 95% have seroconversion by 3yo95% have seroconversion by 3yo

Overall seasonal pattern Nov – MarchOverall seasonal pattern Nov – March– Peak in Jan-Feb, duration of 15-16 weeksPeak in Jan-Feb, duration of 15-16 weeks– Southern US slightly earlier onsetSouthern US slightly earlier onset– Year round illness in equatorial regionsYear round illness in equatorial regions

EpidemiologyEpidemiology

~ 5% of children with bronchiolitis require hospitalization~ 5% of children with bronchiolitis require hospitalizationInfants < 6 months account for 57% of hospitalizationsInfants < 6 months account for 57% of hospitalizations

Increasing hospitalization rateIncreasing hospitalization rate– Among children < 1yo bronchiolitis accounted for 16.4% of Among children < 1yo bronchiolitis accounted for 16.4% of

admission in 1996 (compared to 5.4% in 1980)admission in 1996 (compared to 5.4% in 1980)

Mortality rates 2/100,000 live births in USMortality rates 2/100,000 live births in US– Deaths 200-500 annuallyDeaths 200-500 annually– Unchanged mortality rate in last 20 yearsUnchanged mortality rate in last 20 years– Increased risk of death if low birthweight, congenital heart Increased risk of death if low birthweight, congenital heart

disease, large family, unmarried mother, tobacco use during disease, large family, unmarried mother, tobacco use during pregnancy, low Apgar score at 5minpregnancy, low Apgar score at 5min

Medical CostsMedical Costs

Annual hospitalizations < 2yo ~ 150,000Annual hospitalizations < 2yo ~ 150,000

Mean length of stay 3.3 daysMean length of stay 3.3 days– Mean cost/hospitalization = $3800Mean cost/hospitalization = $3800– Total direct costs = $543 million per yearTotal direct costs = $543 million per year

Pelletier AJ, Mansbach JM, Camargo CA. Direct medical costs of bronchiolitis hospitalizations in the United States. Pediatrics. 2006, 118(6): 2418-23.

Clinical ManifestationsClinical Manifestations

Constellation of symptoms beginning with Constellation of symptoms beginning with cough, coryza in children < 2yocough, coryza in children < 2yo– Progresses over 2-5 days to nasal flaring, wheezing, Progresses over 2-5 days to nasal flaring, wheezing,

grunting, retractionsgrunting, retractionsWheezing usually predominatesWheezing usually predominates

– Fever in 60%Fever in 60%– Typically present for medical care at day 3-6Typically present for medical care at day 3-6

Complications include apnea, dehydration, Complications include apnea, dehydration, respiratory failure, rarely bacterial superinfectionrespiratory failure, rarely bacterial superinfection

Differential DiagnosisDifferential Diagnosis

Infant with acute onset wheezing with URIInfant with acute onset wheezing with URI– Asthma – typically recurrent pattern, more Asthma – typically recurrent pattern, more

responsive to bronchodilatorsresponsive to bronchodilators– PneumoniaPneumonia– Congestive heart failureCongestive heart failure– Foreign body aspirationForeign body aspiration– Wheezing from GERDWheezing from GERD– Cystic FibrosisCystic Fibrosis

DiagnosisDiagnosis

CLINCAL DIAGNOSISCLINCAL DIAGNOSIS

Direct Immunoflouresence tests exists for Direct Immunoflouresence tests exists for RSV and other causative viruses.RSV and other causative viruses.– Sensitivity 80-90% on rapid tests from nasal Sensitivity 80-90% on rapid tests from nasal

washwash– May be useful if specific antiviral therapy May be useful if specific antiviral therapy

available (influenza), would help avoid available (influenza), would help avoid antibiotic therapy, or needed to cohort antibiotic therapy, or needed to cohort patients in hospitalpatients in hospital

Ancillary TestsAncillary Tests

Routine CXR, CBC, Viral antigen testing not Routine CXR, CBC, Viral antigen testing not necessary and often do not affect clinical necessary and often do not affect clinical outcomeoutcome– Metanalysis of 82 articles by Bordley et al. Metanalysis of 82 articles by Bordley et al.

No studies stated whether knowing causative agent affected No studies stated whether knowing causative agent affected clinical outcomesclinical outcomes

Randomization of children with bronchiolitis to CXR or not Randomization of children with bronchiolitis to CXR or not results in more Abx to those given CXR, mean recovery time results in more Abx to those given CXR, mean recovery time and outcomes were the sameand outcomes were the same

Routine use of CBC does not help guide therapy or affect Routine use of CBC does not help guide therapy or affect outcomesoutcomes

Bordley, WC, Viswanathan, M, King, VJ, et al. Diagnosis and testing in bronchiolitis: a systematic review. Arch

Pediatr Adolesc Med 2004; 158:119.

Ancillary TestsAncillary Tests

CXR indicatedCXR indicated– focal examfocal exam– cardiac murmurcardiac murmur– not responding not responding

to therapyto therapy

Determining Disease SeverityDetermining Disease Severity

Severe disease – signs/symptoms associated Severe disease – signs/symptoms associated with poor feeding, respiratory distress with poor feeding, respiratory distress characterized by tachypnea, nasal flaring, and characterized by tachypnea, nasal flaring, and hypoxemiahypoxemia– Substantial variability in severity assessment scoring, Substantial variability in severity assessment scoring,

even in research settingseven in research settings– Have higher likelihood of requiring IVF, supplemental Have higher likelihood of requiring IVF, supplemental

oxygen, and intubationoxygen, and intubation– Risk factors: oxygen sats < 95%, age < 3months, Risk factors: oxygen sats < 95%, age < 3months, RR > 70, atelectasis on CXRRR > 70, atelectasis on CXR

Limited, conflicting evidence relating these to outcomesLimited, conflicting evidence relating these to outcomes

Disease CourseDisease Course

Respiratory status typically improves in 2-5 daysRespiratory status typically improves in 2-5 days

Wheezing can persist for up to 4-5 weeksWheezing can persist for up to 4-5 weeks

Telephone survey of 486 discharged patientsTelephone survey of 486 discharged patients– 60% difficulty feeding, sleeping on day of d/c60% difficulty feeding, sleeping on day of d/c– 20% persistent symptoms on day 5 after d/c20% persistent symptoms on day 5 after d/c– Coughing and wheezing persisted in 30% 4-6 days Coughing and wheezing persisted in 30% 4-6 days

after d/cafter d/c

Robbins, JM, Kotagal, UR, Kini, NM, et al. At-home recovery following hospitalization for bronchiolitis.

Ambul Pediatr 2006; 6:8.

Disease ComplicationsDisease Complications

Most common apnea, respiratory failure, Most common apnea, respiratory failure, secondary bacterial infectionsecondary bacterial infection

– 16% of all RSV bronchiolitis admissions need ICU 16% of all RSV bronchiolitis admissions need ICU carecare

– 25% if concurrent history of underlying CHD, BPD, 25% if concurrent history of underlying CHD, BPD, immunosupressionimmunosupression

Risk of ApneaRisk of Apnea

In study of 691 hospitalized infants 2.7% In study of 691 hospitalized infants 2.7% (n=19) infants developed apnea(n=19) infants developed apnea– 18 of 19 had at least one high risk criteria18 of 19 had at least one high risk criteria

Full term < 30 days of ageFull term < 30 days of age

Preterm birth <37 wks and < 48 wks Preterm birth <37 wks and < 48 wks postconceptionpostconception

Report of apnea at homeReport of apnea at home

Willwerth B, Harper MB, Greenes DS. Clincal Decision Rule to identify infants with bronchiolitis at low risk for apnea. Pediatric Res 2001; 49:83A.

Respiratory failureRespiratory failure

Occurs in 14% of infants < 1yoOccurs in 14% of infants < 1yo

If mechanical ventilation and RSV:If mechanical ventilation and RSV:– high rates of secondary bacterial pneumonias, high rates of secondary bacterial pneumonias,

40% by tracheal aspirates and cultures (50% 40% by tracheal aspirates and cultures (50% community acquired and 50% nosocomial) --- community acquired and 50% nosocomial) --- recommend empiric Abxrecommend empiric Abx

Willson, DF, Landrigan, CP, Horn, SD, Smout, RJ. Complications in infants hospitalized for bronchiolitis or respiratory syncytial virus pneumonia. J Pediatr 2003; 143:S142.

Concurrent bacterial infectionConcurrent bacterial infection

In prospective trial of 1248 patients with temp > In prospective trial of 1248 patients with temp > 38.0, < 60 days old38.0, < 60 days oldN = 269 of patients (22%) were RSV +N = 269 of patients (22%) were RSV +

Therefore – especially for UTI rate of serious Therefore – especially for UTI rate of serious bacterial infection are appreciablebacterial infection are appreciableTreat fever as normally would for age, +/- LPTreat fever as normally would for age, +/- LP

Levine, DA, Platt, SL, Dayan, PS, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics 2004; 113:1728.

RSV +RSV + RSV -RSV - P valueP value

Overall SBIOverall SBI 7%7% 12.5%12.5% <0.05<0.05

UTIUTI 5.4%5.4% 10.1%10.1% <0.05<0.05

BacteremiaBacteremia 1.1%1.1% 2.3%2.3% NSNS

MeningitisMeningitis -- 0.9%0.9% NSNS

Initial ManagementInitial Management

Primarily supportivePrimarily supportive

Adequate hydration, nasal saline drops Adequate hydration, nasal saline drops and bulb suctioningand bulb suctioning– Little evidence to support deep nasal Little evidence to support deep nasal

suctioning in the ER or inpatient settingsuctioning in the ER or inpatient setting– Supplemental oxygen?Supplemental oxygen?

What saturation is significant?What saturation is significant?

Shaw K et al. demonstrated that sats <95% Shaw K et al. demonstrated that sats <95% may predict disease severity, n= 213may predict disease severity, n= 213

Prospective study of 689 patients, Prospective study of 689 patients, prolonged hypoxia <90% was risk factor for:prolonged hypoxia <90% was risk factor for:– Prolonged hospitalization > 5day: OR 1.3 (1.2-1.5)Prolonged hospitalization > 5day: OR 1.3 (1.2-1.5)– ICU admission: OR 3.7 (1.9-6.9)ICU admission: OR 3.7 (1.9-6.9)– Ventilation: OR 3.9 (1.6-9.5)Ventilation: OR 3.9 (1.6-9.5)

Shaw K et al. Outpatient assessment of infants with bronchiolitis. Am J Dis Child, 145: 151-155, 1991.

Wang EE. Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) prospective study of risk factors and outcomes in patients hospitalized with respiratory syncytial viral lower respiratory tract infection. Jounral Pediatrics, 126: 212-0, 1995.

Supplemental OxygenSupplemental Oxygen

Some evidence from clinical studies that Some evidence from clinical studies that intermittent or chronic hypoxia 90-94% intermittent or chronic hypoxia 90-94% may have long term cognitive effectsmay have long term cognitive effects

If PCO2 >55 even if normal saturations If PCO2 >55 even if normal saturations may require mechanical ventilationmay require mechanical ventilation

Bass, JL, Gozal, D. Oxygen therapy for bronchiolitis. Pediatrics 2007; 119:611. Bass, JL, Corwin M, Gozal D, et al.The effectof chronic or intermittent hypoxia on cognition in childhood: a review of the

evidence. Pediatrics 2004; 114:805.

Supplemental OxygenSupplemental Oxygen

Oxygen as needed for Oxygen as needed for Pox < 90% by AAP Pox < 90% by AAP guidelinesguidelines– OxyHgb dissociation curve: OxyHgb dissociation curve:

“in absence of resp “in absence of resp distress and feeding distress and feeding difficulties gain little benefit difficulties gain little benefit from increasing PaO2 with from increasing PaO2 with supplemental oxygen supplemental oxygen above 90%”above 90%”

– Fever, acidosis raise Fever, acidosis raise threshold as larger threshold as larger ↓↓ in in PaO2 for same PaO2 for same ↓↓ sats sats

Bass, JL, Gozal, D. Oxygen therapy for bronchiolitis. Pediatrics 2007; 119:611. Bass, JL, Corwin M, Gozal D, et al.The effect of chronic or intermittent hypoxia on cognition in childhood: a review of the

evidence. Pediatrics 2004; 114:805.

Pharmacologic OptionsPharmacologic Options

BronchodilatorsBronchodilators

EpinephrineEpinephrine

GlucocorticoidsGlucocorticoids

Antivirals Antivirals

Advanced TherapiesAdvanced Therapies– Heliox, Surfactant, 3% saline nebs, synagisHeliox, Surfactant, 3% saline nebs, synagis

Nebulized BronchodilatorsNebulized Bronchodilators

Difficult to determine which pts predisposed to Difficult to determine which pts predisposed to airway hyper reactivity vs isolated bronchiolitisairway hyper reactivity vs isolated bronchiolitisCochrane review of 8 RCT of 394 childrenCochrane review of 8 RCT of 394 children– At most 1 in 4 children treated have transient At most 1 in 4 children treated have transient

improvementimprovement– No effect on overall course of illness or avoidance of No effect on overall course of illness or avoidance of

hospitalizationhospitalization

AAP recommends trial and evaluation before AAP recommends trial and evaluation before and after treatment to assess responseand after treatment to assess response– Weigh cost benefit, but reasonable to treat Weigh cost benefit, but reasonable to treat

respondersresponders

Zorc, JJ. Bronchiolitis trial and tribulation. Acad Emerg Med 2008; 15:375.

Diagnosis and management of bronchiolitis. Pediatrics 2006; 118:1774.

Gadomski, AM, Bhasale, AL. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev 2006; 3:CD001266.







Nebulized EpinephrineNebulized Epinephrine

Demonstrated slightly better clinical effect than albuterol in Demonstrated slightly better clinical effect than albuterol in side by side RCTside by side RCT– Cochrane review: “Some evidence to suggest that Cochrane review: “Some evidence to suggest that

epinephrine may be favorable to albuterol and placebo in epinephrine may be favorable to albuterol and placebo in outpatient setting”outpatient setting”

– Does not affect hospitalization rates or ER length of stayDoes not affect hospitalization rates or ER length of stay– AAP guidelines state “epinephrine may be the preferred AAP guidelines state “epinephrine may be the preferred

bronchodilator for trial in the ER and hospitalized bronchodilator for trial in the ER and hospitalized patients”patients”

– No data on home use, safetyNo data on home use, safety

Hartling, L, Wiebe, N, Russell, K, et al. Epinephrine for bronchiolitis. Cochrane Database Syst Rev 2004; :CD003123.

Diagnosis and management of bronchiolitis. Pediatrics 2006; 118:1774.








Cochrane review of 1200 patients in 13 trials Cochrane review of 1200 patients in 13 trials showed no significant difference in length of showed no significant difference in length of stay, admission rates, or readmission ratestay, admission rates, or readmission rateNo data to suggest efficacy in first episode of No data to suggest efficacy in first episode of wheezingwheezingMay be of benefit in patients with CLDz or May be of benefit in patients with CLDz or previous episodes of wheezing (at risk for previous episodes of wheezing (at risk for asthma)asthma)

Corneli, HM, Zorc, JJ, Majahan, P, et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med 2007; 357:331.

Patel, H, Platt, R, Lozano, J, Wang, E. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev 2004; 3:CD004878.





AntiviralsAntivirals


AntiviralsAntivirals

Ribavirin inhibits replication of RNA and DNA Ribavirin inhibits replication of RNA and DNA viruses, nucleoside analogviruses, nucleoside analog– 11 RCT’s: 7 show modest benefit in oxygenation, 11 RCT’s: 7 show modest benefit in oxygenation,

length of stay, 4 show no benefitlength of stay, 4 show no benefit– No utility in otherwise healthy childrenNo utility in otherwise healthy children– Minimal benefit in children with immunosupression or Minimal benefit in children with immunosupression or

signif cardiopulmonary diseasesignif cardiopulmonary diseaseCost for therapy ~ $1000/day up to 7 daysCost for therapy ~ $1000/day up to 7 days

Mutagenic, gonadotoxic, potentially tumor producing so a Mutagenic, gonadotoxic, potentially tumor producing so a significant risk for healthcare workers in aerosolized formsignificant risk for healthcare workers in aerosolized form







Advanced TherapiesAdvanced Therapies

Heliox: mixed results in several RCT’s, but does decrease Heliox: mixed results in several RCT’s, but does decrease duration of ICU stay (5.4 to 3.5 days)duration of ICU stay (5.4 to 3.5 days)

RSV-specific IVIG (synagis): no benefit in acute phaseRSV-specific IVIG (synagis): no benefit in acute phase

Surfactant: may shorten duration of ventilation & ICU staySurfactant: may shorten duration of ventilation & ICU stay

Hypertonic saline: in hospitalized patients NS vs 3% saline Hypertonic saline: in hospitalized patients NS vs 3% saline nebs q2hr x 3, decreased length of stay in 3% group (2.6 nebs q2hr x 3, decreased length of stay in 3% group (2.6 vs 3.5 days) (n=96)vs 3.5 days) (n=96)– Facilitates removal of inspissated mucus through osmotic Facilitates removal of inspissated mucus through osmotic

hydration, disrupts mucus strand cross-linking, & reduces edemahydration, disrupts mucus strand cross-linking, & reduces edema Tibby, SM, Hatherill, M, Wright, SM, et al. Exogenous surfactant supplementation in infants with respiratory syncytial virus bronchiolitis. Am J Respir Crit Care Med 2000; 162:1251. Luchetti, M, Casiraghi, G, Valsecchi, R, et al. Porcine-derived surfactant treatment of severe bronchiolitis. Acta Anaesthesiol Scand 1998; 42:805. Vos, GD, Rijtema, MN, Blanco, CE. Treatment of respiratory failure due to respiratory syncytial virus pneumonia with natural surfactant. Pediatr Pulmonol 1996; 22:412. Mandelberg, A, Tal, G, Witzling, M, et al. Nebulized 3% hypertonic saline solution treatment in hospitalized infants with viral bronchiolitis. Chest 2003; 123:481. Sarrell, EM, Tal, G, Witzling, M, et al. Nebulized 3% hypertonic saline solution treatment in ambulatory children with viral bronchiolitis decreases symptoms. Chest 2002; 122:2015. Kuzik, BA, Al-Qadhi, SA, Kent, S, et al. Nebulized hypertonic saline in the treatment of viral bronchiolitis in infants. J Pediatr 2007; 151:266. Calogero, C, Sly, PD. Acute viral bronchiolitis: to treat or not to treat-that is the question. J Pediatr 2007; 151:235.

Decision to HospitalizeDecision to Hospitalize

Severe diseaseSevere disease– Toxic appearance, poor feeding, lethargy, dehydrationToxic appearance, poor feeding, lethargy, dehydration– Moderate to severe respiratory distressModerate to severe respiratory distress

Nasal flaring, retractions, RR>70, dyspnea, cyanosisNasal flaring, retractions, RR>70, dyspnea, cyanosis

– Apnea in ER or report at homeApnea in ER or report at home– Hypoxemia <90% on RA with or without pCO2 > 45Hypoxemia <90% on RA with or without pCO2 > 45

AAP guideline do not recommend supplemental oxygen unless AAP guideline do not recommend supplemental oxygen unless < 90% but give no guidelines on hospitalization threshold< 90% but give no guidelines on hospitalization threshold

– Poor home environmentPoor home environmentAs indicated by multiple ER/MD visitsAs indicated by multiple ER/MD visits

– Significant underlying medical condition (CLDz, CHDz)Significant underlying medical condition (CLDz, CHDz)– Age < 30 days, especially if prematurityAge < 30 days, especially if prematurity

Discharge CriteriaDischarge Criteria

No established guidelinesNo established guidelines

Consensus opinion at Cincinnati Children’s HospitalConsensus opinion at Cincinnati Children’s Hospital– RR < 70RR < 70– Caretaker can perform effective bulb suctioningCaretaker can perform effective bulb suctioning– Stable without supplemental oxygen, >90%Stable without supplemental oxygen, >90%– No need for IVFNo need for IVF– Resources adequate at homeResources adequate at home– PCP notified, identified and able to followupPCP notified, identified and able to followup

Cincinnati GuidelinesCincinnati Guidelines

EducationEducation

Expected clinical course:Expected clinical course:– Median 12 days illnessMedian 12 days illness– 20% symptomatic at 3 wks20% symptomatic at 3 wks– 10% symptomatic at 4 weeks10% symptomatic at 4 weeks

Proper technique to suction noseProper technique to suction nose

Prevention StrategiesPrevention Strategies

SynagisSynagis– monoclonal Ab against RSV F glycoproteinmonoclonal Ab against RSV F glycoprotein– Given monthly IM from Nov for 5 monthsGiven monthly IM from Nov for 5 months

Infants < 24 months with CLDz, prematurity or required Infants < 24 months with CLDz, prematurity or required diuretics, home oxygen in 6 months prior to start of seasondiuretics, home oxygen in 6 months prior to start of season

Infants < 32 weeks gestationInfants < 32 weeks gestation

Children < 2yo with clinically significant CHDzChildren < 2yo with clinically significant CHDz

– Reduction in hospitalization 39-79% in large RCT’sReduction in hospitalization 39-79% in large RCT’s– Most cost studies do not show cost effectivenessMost cost studies do not show cost effectiveness

Other interesting studiesOther interesting studies

Influence of pulseox and RR on admission rateInfluence of pulseox and RR on admission rate

A randomized trial of home oxygen therapy from A randomized trial of home oxygen therapy from the emergency department for acute bronchiolitisthe emergency department for acute bronchiolitis

Determining Severity of Bronchiolitis in PED: A Determining Severity of Bronchiolitis in PED: A Clinical Decision RuleClinical Decision Rule

Bronchiolitis management preferences and the influence of pulse oximetry and respiratory rate on the decision to admit, Mallory MD et al.

- AAP section of EM survey n = 519 PEM physicians- AAP section of EM survey n = 519 PEM physicians- Identical clinical vignettes given with variation in SpO2 - Identical clinical vignettes given with variation in SpO2 and RR, not dehydrated, non toxic, 6 month old, temp 101and RR, not dehydrated, non toxic, 6 month old, temp 101- Would you admit patient?- Would you admit patient?

-Pulseox stronger predictor of admission than RR (not signif in RR)-Pulseox stronger predictor of admission than RR (not signif in RR)- Perhaps increased hospitalization rates in last 20 years reflects over-- Perhaps increased hospitalization rates in last 20 years reflects over-

reliance on pulseox datareliance on pulseox data

Mallory, MD, Shay, DK, Garrett, J, Bordley, WC. Bronchiolitis management preferences and the influence of pulse

oximetry and respiratory rate on the decision to admit. Pediatrics 2003; 111:e45.

Sp02 = 94%Sp02 = 94% Sp02 = 92%Sp02 = 92%

RR = 50RR = 50 RR = 65RR = 65 RR = 50RR = 50 RR = 65RR = 65

43%43% 58%58% 83%83% 85%85%

A randomized trial of home oxygen therapy A randomized trial of home oxygen therapy from the emergency department for acute from the emergency department for acute bronchiolitis, Bajaj L et al.bronchiolitis, Bajaj L et al.

Children 2-24 mo with bronchiolitis and hypoxia Children 2-24 mo with bronchiolitis and hypoxia <=87% oxygen sat after 8 hrs obs in the ER<=87% oxygen sat after 8 hrs obs in the ER– Randomized to home oxygen or admissionRandomized to home oxygen or admission– N = 53 to home, N = 39 to admissionN = 53 to home, N = 39 to admission– Only 1 discharged patient returned (cyanotic Only 1 discharged patient returned (cyanotic

spell at 36hrs post discharge)spell at 36hrs post discharge)– Low complication rate cannot determine Low complication rate cannot determine

safety, but satisfaction was highsafety, but satisfaction was high

•Pediatrics. 2006 Mar;117(3):633-40

Platform Presentation PAS 2008Platform Presentation PAS 2008Determining Severity of Bronchiolitis in PED: A Determining Severity of Bronchiolitis in PED: A

Clinical Decision RuleClinical Decision Rule8 sites in Canada over 3 years8 sites in Canada over 3 yearsInclusion: bronchiolitis and < 1 yoInclusion: bronchiolitis and < 1 yoExcluded if previous wheezing or albuterol useExcluded if previous wheezing or albuterol use– Predictors: Age, sex, environmental factors, respiratory distress index, Predictors: Age, sex, environmental factors, respiratory distress index,

PMHx and others (22 variables)PMHx and others (22 variables)– Severe bronchiolitis = intubation, apnea, death, ICU admissionSevere bronchiolitis = intubation, apnea, death, ICU admission

ResultsResults: : – 1554 enrolled, mean age 22 wks, 80% white, 4% previously intubated,1554 enrolled, mean age 22 wks, 80% white, 4% previously intubated,– 27% febrile, mean resp index 8.2, sats <92% in 9%27% febrile, mean resp index 8.2, sats <92% in 9%– 31% admitted, 2.3% with severe bronchiolitis31% admitted, 2.3% with severe bronchiolitis– 18 to ICU from PED, 5 to ICU from floor18 to ICU from PED, 5 to ICU from floor

Severe bronchiolitis more likely if HR>180, RR>80, Sats<88%Severe bronchiolitis more likely if HR>180, RR>80, Sats<88%– Sens to detect severe bronchiolitis 100%, Spec 81%Sens to detect severe bronchiolitis 100%, Spec 81%

SummarySummary

Bronchiolitis has a high disease burdenBronchiolitis has a high disease burden

Self limited disease with few effective management optionsSelf limited disease with few effective management options– Reasonable to trial albuterol or epinephrine and continue if respondsReasonable to trial albuterol or epinephrine and continue if responds

Treatment algorithms and admission criteria often dictated Treatment algorithms and admission criteria often dictated by consensus opinionby consensus opinion

Large ongoing studies needed to further define risk factors Large ongoing studies needed to further define risk factors for progressionfor progression– Oxygen sats, RR, AgeOxygen sats, RR, Age

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Bronchiolitis Epidemiology, Testing, & Management

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