Bronchiolitis

 

Bronchiolitis is the most common disease of the lower respiratory tract during the first year of life.  It usually presents with cough with increased work of breathing, and it often affects a child's ability to feed. In primary care, the condition may often be confused with a common cold, though the presence of lower respiratory tract signs (wheeze and/or crackles on auscultation) in an infant in mid-winter would be consistent with this clinical diagnosis. The symptoms are usually mild and may only last for a few days, but in some cases the disease can cause severe illness

There are several individual and environmental risk factors that can put children with bronchiolitis at increased risk of severe illness. These include congenital heart disease, neuromuscular disorders, immunodeficiency and chronic lung disease

The management of bronchiolitis depends on the severity of the illness. In most children bronchiolitis can be managed at home by parents or carers.  Approximately 1 in 3 infants will develop clinical bronchiolitis in the first year of life and 2–3% of all infants require hospitalization

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Assessment and diagnosis

When diagnosing bronchiolitis, take into account:

  • bronchiolitis is most common in the first year of life, peaking between 3 and 6 months
  • the following symptoms are common in children with this disease:
    • fever (in about 30% of cases, usually of < 39°C
    • poor feeding (typically after 3 to 5 days of illness)
  • symptoms usually peak between 3 and 5 days, and that cough resolves in 90% of infants within 3 weeks
  • young infants with this disease (particularly those under 6 weeks of age) may present with apnoea without other clinical signs

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Diagnose bronchiolitis if the child has a coryzal prodome lasting 1 to 3 days, followed by:

  • persistent cough and
  • either tachypnoea or chest recession (or both) and
  • either wheeze or crackles on chest auscultation (or both)

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Measure oxygen saturation in every child presenting with suspected bronchiolitis, if pulse oximetry is available and there are appropriately trained staff who are able to performenpulse oximetry on infants and young children

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Differential diagnoses

Consider a diagnosis of pneumonia if the child has:

  • high fever (over 39°C) and/or
  • persistently focal crackles

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Consider a diagnosis or viral-induced wheeze or early onset asthma rather than bronchiolitis in older infants and young children if they have:

  • persistent wheeze without crackles or
  • recurrent episodic wheeze or
  • a personal or family history of atopy

NOTE These conditions are unusual in children under 1 year of age

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Suspect impending respiratory failure, and take appropriate action as these children may need intensive care, if any of the following are present:

  • signs of exhaustion (e.g. listlessness or decreased respiratory effort)
  • recurrent apnoea
  • failure to maintain adequate oxygen saturation despite oxygen supplementation

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When to refer

Immediately refer children with bronchiolitis for emergency hospital care (usually 999 ambulance) if they have any of the following:

  • apnoea (observed or reported)
  • child looks seriously unwell to a healthcare professional
  • severe respiratory distress (e.g. grunting, marked chest recession, or a respiratory rate of > 70 breaths/minute
  • central cyanosis
  • persistent oxygen saturation of < 92% when breathing air

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Consider referring children with bronchiolitis to hospital if they have any of the following:

  • a respiratory rate of > 60 breaths/minute
  • difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume, taking account of risk factors
  • clinical dehydration

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Parental information on management

Provide key safety information for parents and carers when children will be looked after at home.  This should cover:

  1. How to recognise developing 'red flag' symptoms:
    1. worsening work of breathing (e.g. grunting, nasal flaring, marked chest recession)
    2. fluid intake is 50-75% of normal or no wet nappy for 12 hours
    3. apnoea or cyanosis
    4. exhaustion (e.g. not responding normally to social cues, wakes only with prolonged stimulation)
  2. That people should not smoking in the child's home because it increases the risk of more severe symptoms of bronchiolitis
  3. How to get immediate help from an appropriate professional if any red flag symptoms develop
  4. Arrangements for follow-up if necessary

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Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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