BRONCHIOLITIS CLINICAL PRACTICE GUIDELINE This clinical guideline has been developed to ensure appropriate diagnosis, evaluation, and treatment for otherwise healthy patients who are less than 2 years of age, presenting with a first episode of mild to moderate bronchiolitis. Please direct any questions to Dr. Lorraine McElwain, BBCH In-Patient Director, or Dr. Jennifer Jewell, BBCH Pediatric Hospitalist, at 207-662-2541. Bronchiolitis is a self-limited viral infection of the bronchioles, marked by edema but not smooth muscle contraction. Because the airway resistance is high in younger children, bronchiolitis is most common in patients less than 2 years of age. Viral etiologies include RSV, influenza, parainfluenza, bocavirus, metapneumovirus, and adenovirus. The treatment goal is to maintain hydration and oxygenation and to monitor for apnea and respiratory distress. A significant percentage of patients with bronchiolitis are diagnosed with asthma during childhood. The cause-effect relationship between asthma and bronchiolitis is unclear. The following are evidence-based recommendations. SIGNS AND SYMPTOMS OF BRONCHIOLITIS Evaluation: in the clinical setting of mild/moderate bronchiolitis, URI symptoms: fever, cough, coryza evidence for the following diagnostic tests are as indicated: Wheezing BLOOD GAS: not indicated Respiratory Distress CHEST RADIOGRAPH: not indicated RSV WASH: indicated for cohorting purposes only Criteria for PICU Admission/Transfer Criteria for IPU Admission Severe respiratory distress Significant respiratory distress/hypoxia Difficulty feeding or dehydration PCO2 > 50 torr on an ABG or a CBG Unclear diagnosis Social concerns (no phone access, transportation, etc.) TREATMENT The following treatment modalities are not indicated: ORAL ANTIHISTAMINES, ORAL DECONGESTANTS, ANTIBIOTICS, COOL MIST, CHEST PHYSIOTHERAPY OXYGEN is indicated to maintain saturations > 90%. Apply oxygen only if saturations are persistently below 90%. Continuous monitoring is recommended if suppl emental oxygen is required. If supplemental oxygen is not needed, Q4 hour oxygen saturation monitoring may be used. Consider maintaining higher oxygen saturations for patients with: fever, acidosis, hemoglobinopathy, ch ronic lung disease, significant cardiac disease, or prematurity. ALBUTEROL is not typically beneficial. If a patien t has a strong family history of asthma or a component of bronchospasm, albuterol may be helpful. A trial of albuterol should be discontinued if no response is noted after an initial dose. Patients who respond to albuterol may have undiagnosed asthma. RACEMIC EPINEPHERINE may be beneficial and deserv es a trial in moderately ill patients. A trial of racemic epinepherine should be discontinued if no respon se is noted after the initial dose or if the response wanes within 60 minutes of a dose. STEROIDS are not found to be benefi cial in bronchiolitis. However, in a patient with a strong family history of asthma or a past history of wheezing/asthma, ster oids may be beneficial particularly if a patient is deteriorating. Patients who respond to steroids may have undia gnosed asthma. NASAL SALINE DROPS and FREQUENT SUCTIONING , especially prior to feeding, is useful. RESPIRATORY MONITOR and OXYGEN SATURATION MONITOR (if the patient requires supplemental oxygen) is appropriate for admitted patients. RIBAVIRIN, an anti-viral administered in a negative flow room via aerosolized particles, may be indicated for high- risk patients with severe RSV bronchiolitis or for patien ts at risk for severe RSV bronchiolitis and requires pediatric critical care consultation. Ribavirin may be c onsidered for patients with the following characteristics: Complicated congenital heart disease Less than 6 weeks of age Immunocompromised Bronchopulmonary dysplasia (BPD) Multiple congenital anomalies Metabolic disease Chronic lung disease (CLD) Less than 37 weeks gestation Neurologic disease NGT FEEDS are indicated if a patient is clinically dehy drated and unwilling to feed despite suctioning prior to feeding attempts, has a persistent RR > 80/minute, vo miting, decreased oxygen saturation to < 90% despite supplemental oxygen during feedings, or marked work of breathing during feeds. PO FEEDS are recommended if patients are stable with RR < 80/minute. Thickening feeds with 1-2 teaspoons of cereal/ounce of formula or breast milk has been shown to decrease the risk of aspiration and is recommended. Continued breastfeeding should be encouraged. IV FLUIDS are rarely required in mildly to moderately ill patients with bronchiolitis. INFECTION CONTROL INFECTION CONTROL MEASURES for hospitalized patients include standard and contact precautions (gowns and gloves). Placing patients with proven RSV in a room together is acceptable. Visitors with URI symptoms should be discouraged from visiting hospitalized patients, especially during the winter months. Attention to hand hygiene should be emphasized for visitors, families, patients, and providers. RSV PROPHYLAXIS - PALIVIZUMAB Palivizumab (humanized mouse monoclonal antibodies) is administered every 30 days by IM injection during RSV season at a dose of 15 mg/kg. The goal of RSV prophylaxis is to decrease the rate of RSV-associated hospitalizations; it has no role in the treatment of RSV infection. For patients living in the Northeast, RSV prophylaxis should be administered from November through March (5 monthly doses). The following patients are candidates for RSV prophylaxis: Less than 24 months old at the beginning of RSV season with CLD (of prematurity) who required medical treatment for CLD within 6 months of the beginning of RSV season. Administer 5 doses. Less than 32-week gestation without CLD, depending on the age at the beginning of RSV season: If < 28 weeks gestation and < 12 months old at the beginning of RSV season, administer 5 doses. If 29-32 weeks gestation and < 6 months old at the beginning of RSV season, administer 5 doses. If 32-35 weeks gestation and < 3 months of age, RSV prophylaxis should be reserved for the following patients: Less than 3 months of age at the beginning of RSV season OR Infants born during RSV season Attend day care OR Reside in the same home with at least one sibling < 5 years of age For this group, RSV prophylaxis should end at 3 months of age. Maximum is 3 doses. Less than 12 months old at the beginning of RSV season with congenital airway abnormalities or neuromuscular diseases which impair airway clearance. Maximum 5 doses during the first year of life. Less than 24 months old at the beginning of RSV season withhemodynamically significant heart disease, especially patients who require medications to control congestive heart failure, have moderate-to-severe pulmonary hypertension, or have cyanotic heart disease. Administer 5 doses. Less than 24 months old at the beginning of RSV seasonwith severe immunodeficiency (SCID, advanced AIDS, etc.). Administer 5 doses. If patients receiving RSV prophylaxis contract RSV, continue monthly palivizumab as outlined above. Palivizumab does not interfere with vaccination response. REFERENCES 1. Khoshoo V. Benefits of thickened feeds in previously healthy infants with respiratory syncytial viral bronchiolitis. Pediatr Pulmonol 2001;31:301-2. 2. Kini NM, Robbins JM, Kirschbaum MS, Frisbee SJ, Kotagal UR. Inpatient care for uncomplicated bronchiolitis. Arch Pediatr Adolesc Med 2001;155:1323-7. 3. Perlstein PH, Kotagal UR, Bolling C, Steele R, Schoettker PJ, Atherton HD, Farrell MK. Evaluation of an evidence- based guideline for bronchiolitis. Pediatrics 1999;104:1334-41. 4. Perlstein PH, Kotagal UR, Schoettker PJ, Atherton HD, Farrell MK, Gerhardt WE. Sustaining the implementation of an evidence-based guideline for bonchiolitis. Arch Pediatr Adolesc Med 2000;154:1001-7. 5. Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics 2006;118:1774-93. 6. Committee on Infectious Diseases. Policy statement – modified recommendations for use of palivizumab for prevention of respiratory syncytial virus infections. Pediatrics 2009;124:1694-1701. Algorithms are not intended to replace providers’ clinical judgment or to establish a single protocol. Some clinical problems may not be adequately addressed in this guideline. As always, clinicians are urged to document management strategies. Last revised January 2010.
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