– Signs of severity: • Significant deterioration in general condition, toxic appearance (pallor, greyish colouration) • Apnoea, cyanosis (check lips, buccal mucosa, fingernails) • Respiratory distress (nasal fla… Palivizumab immunoprophylaxis effectiveness in children with cystic fibrosis. Physiologic Effects of Nasal Aspiration and Nasopharyngeal Suctioning on Infants With Viral Bronchiolitis, Paediatric critical illness associated with respiratory infection: a single-centre, retrospective cohort study, Nebulised hypertonic saline in moderate-to-severe bronchiolitis: a randomised clinical trial, Bedside clinical assessment predicts recurrence after hospitalization due to viral lower respiratory tract infection in young children, Hospitalizations associated with respiratory syncytial virus (RSV) and influenza in children, including children having a diagnosis of asthma. Although many infants with bronchiolitis have abnormalities on chest radiography, data are insufficient to demonstrate that chest radiography correlates well with disease severity. Racemic adrenaline and inhalation strategies in acute bronchiolitis. The group of patients who received epinephrine concomitantly with corticosteroids had a lower likelihood of hospitalization by day 7 than the double placebo group, although this effect was no longer statistically significant after adjusting for multiple comparisons. Bronchiolitis is a common lower respiratory tract infection in infants and young children, and respiratory syncytial virus (RSV) is the most common cause of this infection. C. Adams, MD 3. Clinicians should educate personnel and family on hand sanitation. Off-label drug prescriptions in French general practice: a cross-sectional study, Canadian and UK/Ireland practice patterns in lumbar puncture performance in febrile neonates with bronchiolitis, Monoclonal Antibody Treatment of RSV Bronchiolitis in Young Infants: A Randomized Trial, Use of Social Psychology to Improve Adherence to National Bronchiolitis Guidelines, Practical Guidance for Clinical Microbiology Laboratories: Viruses Causing Acute Respiratory Tract Infections, Overcoming the Bronchiolitis Blues: Embracing Global Collaboration and Disease Heterogeneity, Predicting Escalated Care in Infants With Bronchiolitis, High-Flow Oxygen Reduces Escalation of Bronchiolitis Care, Interventions to Reduce Over-Utilized Tests and Treatments in Bronchiolitis, Minimizing Alarm Fatigue: Pediatric Perspective, Intermittent versus continuous oxygen saturation monitoring for infants hospitalised with bronchiolitis: study protocol for a pragmatic randomised controlled trial, Helmet Versus Nasal-Prong CPAP in Infants With Acute Bronchiolitis, Multisite Emergency Department Inpatient Collaborative to Reduce Unnecessary Bronchiolitis Care, Protocol for a randomised pilot multiple centre trial of conservative versus liberal oxygenation targets in critically ill children (Oxy-PICU), Practice Variation in Acute Bronchiolitis: A Pediatric Emergency Research Networks Study, Choosing Wisely Campaign: Report Card and Achievable Benchmarks of Care for Childrens Hospitals, Retrospective audit of guidelines for investigation and treatment of bronchiolitis: a French perspective, Corticosteroids for Children With Bronchiolitis and Asthma, Breastfeeding disruption during hospitalisation for bronchiolitis in children: a telephone survey, Hyponatremia in Children With Bronchiolitis Receiving Intravenous Fluids, Pediatric Oxygen Therapy: A Review and Update, Burden of disease and change in practice in critically ill infants with bronchiolitis, Oxygen Therapy for Bronchiolitis: Effectiveness of High Flow, Association of Bronchiolitis Clinical Pathway Adherence With Length of Stay and Costs, The treatment of acute bronchiolitis: past, present and future, Efficacy of High-Dose Meropenem (Six Grams per Day) in Treatment of Experimental Murine Pneumonia Induced by Meropenem-Resistant Pseudomonas aeruginosa, Nebulized epinephrine for young children with bronchiolitis, Variation in Diagnostic Testing and Hospitalization Rates in Children With Acute Gastroenteritis, Nebulisation depinephrine chez les jeunes enfants atteints de bronchiolite, Use of Low-Value Pediatric Services Among the Commercially Insured, Association of nasopharyngeal microbiota profiles with bronchiolitis severity in infants hospitalised for bronchiolitis, Pulmonary air leak syndrome associated with traumatic nasopharyngeal suctioning, A Framework for Evaluating Value of New Clinical Recommendations, Point-of-care lung ultrasound in young children with respiratory tract infections and wheeze, A clustering approach to identify severe bronchiolitis profiles in children, Observed Effectiveness of Palivizumab for 29-36-Week Gestation Infants, Does pulse oximeter use impact health outcomes? Bronchiolitis is a general term used to describe a nonspecific inflammatory injury that primarily affects the small airways (eg, 2 mm or less in diameter without cartilage) (), often sparing a considerable portion of the interstitium [].. An overview of bronchiolar disorders in adults is provided here. Clinicians should not administer antibacterial medications to infants and children with a diagnosis of bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one. The report makes recommendations regarding effective ways to eliminate or reduce secondhand smoke exposure, including education of parents.226. In some cases there may be infection with more than one virus. Prepare for the ABFM exam with the AAFP’s Family Medicine Board Review Express Livestream, February 18-21 and get the same in-depth Board review but with all the conveniences of your home or office. This guideline is a revision of the clinical practice guideline, “Diagnosis and Management of Bronchiolitis,” published by the American Academy of Pediatrics in 2006. Suctioning and length of stay in infants hospitalized with bronchiolitis. The potential adverse effects (tachycardia and tremors) and cost of these agents outweigh any potential benefits. Risk of acute otitis media in relation to acute bronchiolitis in children. Most studies addressing this issue have enrolled children when presenting to hospital settings, including a large, prospective, multicenter study that assessed a variety of outcomes from the emergency department (ED) and varied inpatient settings.18,32,33 Severe adverse events, such as ICU admission and need for mechanical ventilation, are uncommon among children with bronchiolitis and limit the power of these studies to detect clinically important risk factors associated with disease progression.16,34,35 Tachypnea, defined as a respiratory rate ≥70 per minute, has been associated with increased risk of severe disease in some studies35–37 but not others.38 Many scoring systems have been developed in an attempt to objectively quantify respiratory distress, although none has achieved widespread acceptance and few have demonstrated any predictive validity, likely because of the substantial temporal variability in physical findings in infants with bronchiolitis.39, Pulse oximetry has been rapidly adopted into clinical assessment of children with bronchiolitis on the basis of data suggesting that it reliably detects hypoxemia not suspected on physical examination36,40; however, few studies have assessed the effectiveness of pulse oximetry to predict clinical outcomes. Further, although there is no evidence of short-term adverse effects from corticosteroid therapy, other than prolonged viral shedding, in infants and children with bronchiolitis, there is inadequate evidence to be certain of safety. Randomized, double-blind, placebo-controlled trial of oral albuterol in infants with mild-to-moderate acute viral bronchiolitis. Clinicians should inquire about the exposure of the infant or child to tobacco smoke when assessing infants and children for bronchiolitis (Evidence Quality: C; Recommendation Strength: Moderate Recommendation). Pediatric Investigators Collaborative Network on Infections in Canada. 3. Strachan and Cook220 first delineated the effects of environmental tobacco smoke on rates of lower respiratory tract disease in infants in a meta-analysis including 40 studies. Intravenous fluids versus gastric-tube feeding in hospitalized infants with viral bronchiolitis: a randomized, prospective pilot study. Treatment of acute otitis media in children under 2 years of age. An evaluation of chest physiotherapy in the management of acute bronchiolitis: changing clinical practice. How is bronchiolitis treated? Short acting beta2-agonists for recurrent wheeze in children under two years of age. Other possible viral causative agents include human metapneumovirus (hMPV), adenovirus, rhinovirus, and parainfluenza and influenza viruses. Prospective multicenter study of the viral etiology of bronchiolitis in the emergency department. Physiologic evidence suggests that hypertonic saline increases mucociliary clearance in both normal and diseased lungs.69–71 Because the pathology in bronchiolitis involves airway inflammation and resultant mucus plugging, improved mucociliary clearance should be beneficial, although there is only indirect evidence to support such an assertion. Utility of sepsis evaluation in infants 90 days of age or younger with fever and clinical bronchiolitis. Acute viral bronchiolitis in children—a very common condition with few therapeutic options. Long-acting beta2-adrenoceptor agonists synergistically enhance glucocorticoid-dependent transcription in human airway epithelial and smooth muscle cells. Bronchiolitis is a viral lower respiratory tract infection, generally affecting children under 12 months of age It 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 OR oxygen saturation.mp. In a large prospective study in Australia, Oddy et al235 showed that breastfeeding for less than 6 months was associated with an increased risk for 2 or more medical visits and hospital admission for wheezing lower respiratory illness. Severe viral respiratory infections in infants with cystic fibrosis. Joint commission warns of alarm fatigue: multitude of alarms from monitoring devices problematic. A recent Cochrane meta-analysis by Hartling et al64 systematically evaluated the evidence on this topic and found no evidence for utility in the inpatient setting. Today's Lancet Seminar on viral bronchiolitis brings together evidence of the diagnosis, management, and treatment of viral bronchiolitis, and addresses some of the issues in the field. When diagnosing bronchiolitis, take into account that it occurs in children under 2 years of age and most commonly in the first year of life, peaking between 3 and 6 months. North American synagis prophylaxis survey. The diagnosis of bronchiolitis and assessment of disease severity should be based on history and physical examination. Although bronchiolitis is a condition commonly encountered in pediatrics, there is no single effective therapeutic agent; therefore, with an aim to provide high-value and high-quality care, clinicians should be aware that the main treatment plan for bronchiolitis is supportive care. It aims to help healthcare professionals diagnose bronchiolitis and identify if children should be cared for at home or in hospital. Tests and X-rays are not usually needed to diagnose bronchiolitis. The risk of RSV hospitalization is not well defined in children with pulmonary abnormalities or neuromuscular disease that impairs ability to clear secretions from the lower airway because of ineffective cough, recurrent gastroesophageal tract reflux, pulmonary malformations, tracheoesophageal fistula, upper airway conditions, or conditions requiring tracheostomy. Pneumothorax is a reported complication. It describes treatments and interventions that can be used to help with the symptoms of bronchiolitis. All people should use alcohol-based rubs for hand decontamination when caring for children with bronchiolitis. Guidelines on hand hygiene in health care. Nebulized hypertonic saline without adjunctive bronchodilators for children with bronchiolitis. Although there is good evidence of benefit from corticosteroids in other respiratory diseases, such as asthma and croup,82–84 the evidence on corticosteroid use in bronchiolitis is negative. Although bronchiolitis is a condition commonly encountered in pediatrics, there is no single effective therapeutic agent; therefore, with an aim to provide high-value and high-quality care, clinicians should be aware that the main treatment plan for bronchiolitis is supportive care. Failure of oxygen saturation and clinical assessment to predict which patients with bronchiolitis discharged from the emergency department will return requiring admission. Early emergency department treatment of acute asthma with systemic corticosteroids. Clinical practice guidelines for bronchiolitis should ensure that they use appropriate development and reporting frameworks, such as the AGREE II criteria or the RIGHT (Essential Reporting Items for Practice Guidelines in Health) checklist, in formulating guidelines [9, 43]. In guidelines published in 2009, the World Health Organization also recommended alcohol-based hand-rubs as the standard for hand hygiene in health care.217 Specifically, systematic reviews show them to remove organisms more effectively, require less time, and irritate skin less often than hand washing with soap or other antiseptic agents and water. Currently, there are insufficient data to make a recommendation about suctioning, but it appears that routine use of “deep” suctioning151,153 may not be beneficial. The preponderance of the evidence suggests that 3% saline is safe and effective at improving symptoms of mild to moderate bronchiolitis after 24 hours of use and reducing hospital LOS in settings in which the duration of stay typically exceeds 3 days. Epinephrine and dexamethasone in children with bronchiolitis. Related article searches were conducted in PubMed. Can Bronchiolitis Ultrasound Score Predict Hospital Admission? A systematic review, The Fecal Microbiota Profile and Bronchiolitis in Infants. In June 2013, the AAP convened a new subcommittee to review and revise the 2006 bronchiolitis guideline. This guideline covers diagnosing and managing bronchiolitis in children. The subcommittee included primary care physicians, including general pediatricians, a family physician, and pediatric subspecialists, including hospitalists, pulmonologists, emergency physicians, a neonatologist, and pediatric infectious disease physicians. This statement pertains to generally healthy children ≤24 months of age with bronchiolitis. Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. OR exp Adrenal Cortex Hormones/ OR exp Leukotriene Antagonists/ OR montelukast.mp. Bronchiolitis typically presents in children under two years old and is characterized by a constellation of respiratory symptoms that consists of fever, rhinorrhea, cough, wheeze, tachypnea and increased work of breathing such as nasal flaring or grunting that develops over one to three days. Key action statements (KASs) based on that evidence are provided. A prospective randomized controlled blinded study of three bronchodilators in infants with respiratory syncytial virus bronchiolitis on mechanical ventilation. Treatment. Clinicians should not administer antibacterial medications to infants and children with a diagnosis of bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one (Evidence Quality: B; Recommendation Strength: Strong Recommendation). Is nasogastric fluid therapy a safe alternative to the intravenous route in infants with bronchiolitis? AHRQ Publication No. Give fluids by nasogastric or orogastric tube in children with bronchiolitis if they cannot take enough fluid by mouth. OR (exp Suction/)), AND ((MH “Chest Physiotherapy (Saba CCC)”) OR (MH “Chest Physical Therapy+”) OR (MH “Chest Physiotherapy (Iowa NIC)”)), Bronchiolitis AND (chest physiotherapy OR suction*), AND (exp Fluid Therapy/ AND (exp infusions, intravenous OR exp administration, oral)), Limit to (“all infant (birth to 23 months)” or “newborn infant (birth to 1 month)” or “infant (1 to 23 months)”), ((MM “Fluid Therapy+”) OR (MM “Hydration Control (Saba CCC)”) OR (MM “Hydration (Iowa NOC)”)), (exp Bacterial Infections/ OR exp Bacterial Pneumonia/ OR exp Otitis Media/ OR exp Meningitis/ OR exp *Anti-bacterial Agents/ OR exp Sepsis/ OR exp Urinary Tract Infections/ OR exp Bacteremia/ OR exp Tracheitis OR serious bacterial infection.mp. β2-Adrenoceptor agonist-induced RGS2 expression is a genomic mechanism of bronchoprotection that is enhanced by glucocorticoids. Thirdhand tobacco smoke: emerging evidence and arguments for a multidisciplinary research agenda. Does this infant have pneumonia? For infants with signs of shock (severe tachycardia, poor peripheral perfusion, anuria) consider an … The systematic review of corticosteroids in children with bronchiolitis cited previously did not find any differences in short-term adverse events as compared with placebo.86 However, corticosteroid therapy may prolong viral shedding in patients with bronchiolitis.17. A meta-analysis. Clinicians should counsel caregivers about exposing the infant or child to environmental tobacco smoke and smoking cessation when assessing a child for bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong). Factors predicting prolonged hospital stay for infants with bronchiolitis. An abnormal white blood cell count is not useful for predicting a concurrent SBI in infants and young children hospitalized with RSV lower respiratory tract infection.159 Several retrospective studies support this conclusion.160–166 Four prospective studies of SBI in patients with bronchiolitis and/or RSV infections also demonstrated low rates of SBI.167–171, Approximately 25% of hospitalized infants with bronchiolitis have radiographic evidence of atelectasis, and it may be difficult to distinguish between atelectasis and bacterial infiltrate or consolidation.169 Bacterial pneumonia in infants with bronchiolitis without consolidation is unusual.170 Antibiotic therapy may be justified in some children with bronchiolitis who require intubation and mechanical ventilation for respiratory failure.172,173. Infants with bronchiolitis frequently receive antibacterial therapy because of fever,152 young age,153 and concern for secondary bacterial infection.154 Early randomized controlled trials155,156 showed no benefit from routine antibacterial therapy for children with bronchiolitis. The IMpact-RSV Study Group. Palivizumab, a humanized respiratory syncytial virus monoclonal antibody, reduces hospitalization from respiratory syncytial virus infection in high-risk infants. Given that epinephrine has a transient effect and home administration is not routine practice, discharging an infant after observing a response in a monitored setting raises concerns for subsequent progression of illness. Prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis. Antibiotic treatment of pneumonia and bronchiolitis. Monthly palivizumab prophylaxis should be restricted to infants born before 29 weeks, 0 days’ gestation, except for infants who qualify on the basis of congenital heart disease or chronic lung disease of prematurity. Improved outcome of respiratory syncytial virus infection in a high-risk hospitalized population of Canadian children. It is usually associated with a viral pathogen and can be associated with wheezing and/or rales. How Bronchiolitis Is Treated. Chest physiotherapy in acute bronchiolitis. Effect of palivizumab prophylaxis on subsequent recurrent wheezing in preterm infants. It is key that your child drinks lots of fluids to avoid dehydration. Follicular bronchiolitis is a distinctive subset of cellular bronchiolitis characterized by the dramatic proliferation of lymphoid follicles with germinal centers along the airways and an infiltration of the epithelium by lymphocytes (lymphoid hyperplasia of bronchus-associated lymphoid tissue [BALT]) (Fig. Hygienic hand antiseptics: should they not have activity and label claims against viruses? Diagnosis and management of bronchiolitis. Rather, it is intended to assist clinicians in decision-making. As such, they cannot substitute the individual judgment brought to each clinical situation by the patient’s family physician. Palivizumab in congenital heart disease: should international guidelines be revised? Patient Satisfaction and Antibiotic Prescribing for Respiratory Infections by Telemedicine, Pediatric Respiratory Illness Measurement System (PRIMES) Scores and Outcomes, Patterns of Electrolyte Testing at Childrens Hospitals for Common Inpatient Diagnoses, High-flow nasal cannula therapy for children with bronchiolitis: a systematic review and meta-analysis, Protocol: randomised trial to compare nasoduodenal tube and nasogastric tube feeding in infants with bronchiolitis on high-flow nasal cannula; Bronchiolitis and High-flow nasal cannula with Enteral Tube feeding Randomised (BHETR) trial, Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Severity of respiratory syncytial virus bronchiolitis is affected by cigarette smoke exposure and atopy. Bronchiolitis is almost always caused by a virus. Excretion patterns of human metapneumovirus and respiratory syncytial virus among young children. Glucocorticoids for acute viral bronchiolitis in infants and young children. Antibiotic treatment of epidemic bronchiolitis—a double-blind trial. The search strategy is shown in the Appendix. J. Schiappa, DO 4 . American Academy of Pediatrics Steering Committee on Quality Improvement and Management. The effect of high flow nasal cannula therapy on the work of breathing in infants with bronchiolitis [published online ahead of print May 21, 2014]. Clinical Guideline Acute Bronchitis 3 | P a g e CHC Acute Bronchitis Clinical Guideline Workgroup 2018 CHC Workgroup: 1. Smoking in parents of children with asthma and bronchiolitis in a pediatric emergency department. Children with respiratory distress treated with high-flow nasal cannula. Asthma Intravenous Fluids High Flow Nasal Prong (HFNP) therapy - Nursing Guideline Oxygen delivery - Nursing Guideline OR technical specifications.mp.) Although transient improvements in clinical score have been observed, most infants treated with bronchodilators will not benefit from their use. 68 There is conflicting information across clinical guidelines about the role of nebulized hypertonic saline in acute management of bronchiolitis. Transient hypoxemia is common in healthy infants.104 Travel of healthy children even to moderate altitudes of 1300 m results in transient sleep desaturation to an average of 84% with no known adverse consequences.105 Although children with chronic hypoxemia do incur developmental and behavioral problems, children who suffer intermittent hypoxemia from diseases such as asthma do not have impaired intellectual abilities or behavioral disturbance.106–108, Oxyhemoglobin dissociation curve showing percent saturation of hemoglobin at various partial pressures of oxygen (reproduced with permission from the educational Web site www.anaesthesiauk.com).102, Supplemental oxygen provided for infants not requiring additional respiratory support is best initiated with nasal prongs, although exact measurement of fraction of inspired oxygen is unreliable with this method.109, Pulse oximetry is a convenient method to assess the percentage of hemoglobin bound by oxygen in children. 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