Bronchiolitis Medical Presentation

Bronchiolitis PowerPoint Presentation

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Published on : Oct 29, 2017 | Views : 2554 | Downloads : 13

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lolliwels

ill be using this quite a bit

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Bronchiolitis September 2017
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Case RW 5 month old male infant Presents on Day 3 of illness with 2 day history of: Rhinorrhoea Cough 12 hour history of increased WOB, reduced feeds and reduced wet nappies Nil fevers, apnoea or cyanosis Nil infective contacts
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Background Perinatal history NVD at 38/40, IOL for GDM on insulin BW 4.1kg Past medical history Bronchiolitis – Recently admitted at TSH in Aug 2017- Adenovirus/Rhinovirus positive Family history Older sister – Eczema Maternal uncle- Asthma Immunisations UTD Social Hx Lives with parents and older sister Risk Factors for Severe Dx Age < 10 weeks old Prematurity/SGA Congenital heart disease Chronic lung disease Chronic neurological conditions Immunodeficiency Indigenous ethnicity
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O/E in ED: Temp 36, RR 54, HR 172, SpO2 94% RA Alert WOB – tachypnoeic, tracheal tug, mild IC and marked SC recession (nil grunting/nasal flaring) Resp – widespread loud wheeze, scattered creps Abdo – SNT DSHNM https://www.youtube.com/watch?v=ZS-PJ9jlpFw Examination in ED
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Differentials? Bronchial Foreign body Hx of ingestion may be present Asymmetrical air entry and wheeze Bronchopulmonary dysplasia Hx of lung injury Hx of prematurity Vascular rings congenital anomalies that occur during the development of the aortic arch and great vessels Asthma Viral-induced Suspect if family history of atopy Improvement with ventolin Pneumonia Wheeze may be present – chlamydia and mycoplasma Prolonged fever Worsening WOB Focal signs Bronchiolitis Pertussis Unlikely to cause a wheeze GORD Common Subacute Sx lasting months “Spitting up” may be present Congenital heart disease Heart failure
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Bronchiolitis – How is it defined? Clinical studies (UptoDate): First episode of wheezing in child <12-24 months Viral respiratory infection No other cause for symptoms (e.g. atopy/asthma pneumonia) SCH Guideline: “Common chest infection that often affects children <12 months” “Caused by virus which affects the small breathing tubes (bronchioles) by making them narrowed by mucous and inflammation”
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Natural History (SCHN) Unwell for 7-10 days total. Duration depends on presence of risk factors, severity, and causative agent. Self limiting illness. Day 1-2: Rhinorrhea Mild cough Fever <38.3 Day 2-3 (Peak) Increased WOB/Respiratory effort, Tachypnoea Bilateral scattered audible wheeze (+/- crackles) Poor feeding Irritability + APNOEA (esp babies <2 months ) Post-viral cough may last 2-4 weeks
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Eitiology (NP swab) RSV causes 75% of Bronchiolitis Others: Adenovirus Rhinovirus Coronavirus Human metapneumovirus Influenza Parainfluenza
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Red Flags 10% of children (3% of infants <12 months) with RSV infection are hospitalised Average stay is 3-4 days Respiratory status improves in 2-5 days Risk Factors for Severe Dx Age < less than 3 months old Prematurity/Low birth weight Congenital heart disease (esp L R shunt) Chronic lung disease Chronic neurological conditions Immunodeficiency Indigenous ethnicity
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Assess Severity MILD BRONCHIOLITIS Normal behaviour Normal feeding Minimal/Nil respiratory distress SpO2>92% on RA and no O2 requirements
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Assess Severity MODERATE BRONCHIOLITIS Some irritability Reduced feeding due to WOB Moderate WOB – IC/SC recession (+/- tracheal tug and nasal flaring) SpO2 90-92% RA, corrected with O2 Brief apnoeic events
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Assess Severity SEVERE BRONCHIOLITIS Persistent irritability, Lethargy or Fatigue Refusing or unable to feed Severe respiratory distress – grunting, marked IC/SC recession, tracheal tug, nasal flaring SpO2 <90% RA, not corrected with O2 Frequent/prolonged apnoeic events
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RCH Guideline
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Management MILD BRONCHIOLITIS No investigations (may consider NPA/viral swab) Observe in ED over 4 hours Discharge and manage at home if parents capable and well informed Encourage small frequent feeds Provide advice on the expected course of illness and when to return (worsening symptoms and inability to feed adequately) Review with GP in 2 days
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Management MODERATE BRONCHIOLITIS Admit under paeds for observation Give 1L/kg/min oxygen via NP (max 2L/kg/min) if persistently low SpO2<90% RA (brief desats are ok) Consider HFNP if NP alone is ineffective Maintain O2>90% on O2 (hourly to two hourly obs) Gradually wean O2 when improving on ward Encourage small frequent PO/NG feeds NGT if feeding <50% over 12 hours
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Management SEVERE BRONCHIOLITIS Transfer to NICU/PICU if: Progressing to severe respiratory distress Prolonged apnoeas Uncorrectable hypoxaemia/desaturations ABG – resp failure High risk infant (Age < less than 3 months/Prematurity/Low birth weight/ CHD/ CLD/Chronic neurological conditions/Immunodeficiency/Indigenous ethnicity) Consider HFNP or CPAP Maintain O2>90% on O2 (hourly to two hourly obs) NGT if feeding <50% over 12 hours
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RW – Management in ED Oxygen HFNP 15L (1.5L/kg/min) FiO2 21% Nasal suction NGT inserted for insufflation of stomach. Commenced on 3 hrly NG feeds Admitted under paeds
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Day 4 on ward T/F to ward on HFNP 10L (1L/kg/min) FiO2 21% Tachypnoea (RR 45-55), Tachycardic HR 160-180, and worsening WOB – head bobbing, nasal flaring, tracheal tug, grunting, irritable, SC and IC recession Titrated FiO2 21% to 30% Suctioned copious nasal secretions NG feeds commenced given increased WOB Day 5 on ward Oxygen weaned  SpO2 95-98% on HFNP 5L (0.5L/kg/min), FiO30 to 21%  SpO2 98-100% on RA NGT removed. Able to tolerate oral feeds. Discharged home. Parents informed on indicators for review. RW - Progress on ward
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Investigations CXR- only if diagnostic uncertainty or atypical course Virological testing- NPA – if cohorting patients, diagnostic uncertainty Septic screen - if toxic and may have another infection EUC and BSL if IV fluid given BSL if sick
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RW - Investigations CXR - NAD NPA Enterovirus Rhinovirus Adenovirus
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Discharge Criteria Minimal respiratory distress Feeding well Sp02>92% (except high-risk needs to be higher) Parents happy, informed
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Prevention Father smokes cigarettes. There is a 5 week old baby admitted on the ward with SGA, FTT and poor feeding. Adequate, frequent hand washing by all staff and parents (more via hands than via cough) Isolate - Avoid nursing infants likely to have RSV with infants at high risk from RSV, unless they are proven to have it Avoid passive smoke Breast feed if possible Immunoprophylaxis - Palivizumab – humanized monoclonal antibody against RSV- consider individually in high risk infants
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Take home messages Bronchiolitis is a clinical diagnosis No investigations should be routinely performed Management is to support feeding and oxygenation as required No medication should be routinely administered