Pediatrics

Children with bronchiolitis are often over-investigated in EDs in the U.S.¹¹ For a child who presents typically, no investigations are necessary. The American Association of Pediatricians (AAP) Clinical Practice Guideline for the Management and Diagnosis of Bronchiolitis states: “clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination. Clinicians should not routinely order laboratory and radiologic studies for diagnosis.”¹² The chest Xray (CXR) findings of bronchiolitis are often nonspecific patchy infiltrates and hyperinflation that can often be misinterpreted as consolidation and lead to inappropriate antibiotic use.¹³ Routine CXR for bronchiolitis is not recommended, as this often leads to unnecessary use of antibiotics.⁵ One study found that pediatric emergency physicians over-read CXRs at a rate of five to one compared to radiologists.¹⁴ Testing for respiratory viruses should be reserved for neonates, immuno-compromised patients, those with a prolonged fever, and those with atypical presentation.¹⁵

It is incumbent upon the ED physician to identify high-risk bronchiolitis patients who should be considered for admission to hospital. Factors considered high-risk in patients with bronchiolitis include heart rate greater than 180, respiratory rate greater than 70, awake persistent saturations less than 90 percent, age less than two months, prematurity less than 32 weeks, chronic lung disease, cyanosis or history of apnea, hemodynamically significant congenital heart disease, immunodeficiency, and neuromuscular disease.¹⁶ In the decision of whether or not to admit a child with bronchiolitis, it is important to understand that 30 percent of hospitalized infants receive no therapies needing hospitalization.¹³ Hospitalization for otherwise healthy children with mild bronchiolitis has been described as “expensive baby-sitting.”¹⁷ Remember that bronchiolitis symptoms usually peak around days three to five. If the patient presents on day two, you can expect the patient may get worse before they get better. This should be factored into your disposition decision.

Bronchiolitis is a self-limited disease, which can be managed at home with supportive care in the majority of cases. Parental education is vital. Explain the duration of illness and dynamic nature of symptoms. Explain why drugs are ineffective. Suggest frequent feeding (every two hours) to maintain adequate hydration. Explain the red flags of poor feeding and behavioral change as reasons to return.

Medications for Children

Pharmacotherapy is generally ineffective in children with bronchiolitis. There is no compelling evidence that bronchodilators, steroids, or epinephrine improves outcomes. While nasal suctioning is frequently employed with the goal of improving feeding in the child with nasal obstruction, its efficacy is unknown. One large bronchiolitis study suggests that in-hospital nasal suctioning significantly increases hospital length of stay.¹⁸ Given that pharmacotherapy and nasal suctioning are not backed by strong evidence, management should concentrate on three things: maintaining adequate volume status/feeding, oxygenation, and airway support.