Microsoft word - bronchiolitis_guideline.doc

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 with hemodynamically 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 season with 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.

Source: http://www.mainehealth.com/workfiles/mmc_bush/Bronchiolitis_Guideline.pdf