Makindo Medical Notes.com

A monoclonal antibody to RSV is available given as monthly im injection to high-risk preterm infants but is expensive

Aetiology

• Is usually due to RSV causing inflammation in small airways

Epidemiology

• Affects infants aged 1-9 months old up to 2 years
• Seasonal commoner in winter months
• A subset will go on to develop Asthma

Higher risk

• Congenital heart disease, Neuromuscular disorders
• Immunodeficiency, Chronic lung disease.

Clinical

• Findings are coryzal symptoms 1-3 days and persistent cough
• Pale, sweaty, tired. Snuffly, Crackles, wheeze on auscultation
• Grunting, nostrils flaring, using stomach muscles to breathe
• Tachypnea or Subcostal and intercostal recession

Differential

• Air leak, pneumonia, ARDS (sepsis)
• Foreign body, pulmonary oedema (myocardial failure, CHD)

Investigations

• CXR shows hyperinflated lungs but NICE states "Do not routinely perform a chest X-ray in children with bronchiolitis, because changes on X-ray may mimic pneumonia and should not be used to determine the need for antibiotics. ". Consider performing a chest X-ray if intensive care is being proposed for a child.
• Do not routinely carry out blood gas testing in children with bronchiolitis. Consider carrying out capillary blood gas testing in children with severe worsening respiratory distress (when supplemental oxygen concentration is greater than 50%) or suspected impending respiratory failure

Prevention

• Palivizumab is a monoclonal antibody produced by recombinant DNA technology. It is used in the prevention of respiratory syncytial virus (RSV) infections.
• It is recommended for infants that are high-risk because of prematurity or other medical problems such as congenital heart disease

Management

• Breathing may be easier for your baby if they sleep with the head of the cot slightly raised.
• Treat Fever (above 37.4 C) or is irritable, you can give them paracetamol as per manufacturer's guidelines. If your child is 3 months or over they can also have ibuprofen.
• Saline nasal drops: these are available over the counter from a pharmacy. Placing the drops in your baby's nose before they feed may help to relieve a blocked nose however always follow the manufacturer's instructions
• Humidify the air: moistening the air may help ease your baby's cough, humidifiers are available to buy. Alternatively, run the hot tap in the bath for several minutes to steam up the room, then sit your baby in the room with you for a few minutes. Their clothes may need changing after this as they may be damp. Be careful not to scald your baby with hot water or steam.
• Nasal aspirator: these can be bought from pharmacies and are used to slowly suck the mucus from your baby's nose. Again, please follow the manufacturer's instructions

Referral to Hospital

• Refer Immediately (999) to hospital if apnoea (observed or reported) and
  • child looks seriously unwell to a healthcare professional
  • severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
  • Central cyanosis
  • Persistent oxygen saturation of less than 92% when breathing air.
• Consider referring
  • A respiratory rate of over 60 breaths/minute
  • Difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume, taking account of risk factors and using clinical judgement)
  • clinical dehydration.
• Only a small subset will need hospital admission. Many are maintained at home with good hydration and antipyretics.
• NICE States do not use antibiotics, hypertonic saline, adrenaline (nebulised), salbutamol [US Albuterol] , montelukast, ipratropium bromide, systemic or inhaled corticosteroids, a combination of systemic corticosteroids and nebulised adrenaline.
• Give oxygen supplementation to children with bronchiolitis if their oxygen saturation is persistently less than 92%.
• Give fluids by nasogastric or orogastric tube in children with bronchiolitis if they cannot take enough fluid by mouth
• Consider continuous positive airway pressure (CPAP) in children with bronchiolitis who have impending respiratory failure
• Consider upper airway suctioning in children who have respiratory distress or feeding difficulties because of upper airway secretions
• Infants at high risk are those with cardiac/lung problems, age < 6 weeks and preterms

Indications for ventilation

• Progressive tachypnoea + work of breathing, lethargy
• Worsening respiratory acidaemia, persistent/ prolonged apnoeas
• Increasing oxygen requirement

References

• NICE guidance on Bronchiolitis 2016