CPS Statement: Bronchiolitis in children one to 24 months of age

CPS Statement: Bronchiolitis in children one to 24 months of age

The following was adapted from the Canadian Pediatric Society’s statement on "Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age." Please see the full statement for the full recommendations from the Canadian Pediatric Society.

Background:

Bronchiolitis is a viral lower respiratory tract infection that leads to obstruction of the small airways. Respiratory syncytial virus (RSV) is responsible for most cases, however other viruses can cause a similar clinical picture. In Canada, RSV season usually begins between November and January and persists for four to five months. Bronchiolitis affects more than one third of children in the first two years of life and is the most common cause of admission to hospital in the first year. Despite being so common, there is great variation in standards for diagnosis and management of bronchiolitis, which you may see in clinical practice. These guidelines incorporate the most recent evidence to provide recommendations on optimal, evidence-based management of bronchiolitis in children one to 24 months of age. These guidelines do not apply to children with chronic lung disease, immunodeficiency or serious underlying chronic disease.

Diagnosis:

Bronchiolitis is a clinical diagnosis based on history and physical examination.  There is a wide range of symptoms and severity, including the following features:

  • Preceding viral upper respiratory tract infection (URTI), cough and/or rhinorrhea
  • Exposure to individuals with viral URTI
  • Tachypnea
  • Intercostal and/or subcostal retractions
  • Accessory muscle use
  • Nasal flaring
  • Colour change or apnea
  • Wheezing or crackles
  • Lower O2 saturations

While the majority of infants presenting like this in RSV season will have bronchiolitis it is important to consider a broad differential diagnosis, particularly if there are atypical features, or no preceding viral URTI signs and symptoms.

Diagnostic studies and imaging are not indicated for bronchiolitis. Tests can lead to unnecessary admissions, further testing and ineffective therapies.  Investigations should only be considered if the severity or course of the disease suggests an alternate diagnosis, or if concerned about respiratory failure.

Management:

Bronchiolitis is a self-limiting illness and most children can be managed with supportive care at home.

Some children may require admission to hospital for monitoring and supportive care including oxygen and hydration. Guidelines for admission to hospital may include:

  • Infants at high risk for severe disease (eg. premature infants, <3 months of age at presentation, significant cardiopulmonary disease, immunodeficiency)
  • Signs of severe respiratory distress (eg. indrawing, grunting, RR > 70/min)
  • Dehydration
  • Cyanosis or history of apnea
  • Family unable to cope

The following therapies have stong evidence and are recommended for patients hospitalized with bronchiolitis:

  • Oxygen therapy to maintain saturations >90%
  • Hydration through either frequent feeds, or nasogastric/intravenous routes if necessary

The following therapies have equivocal evidence and are left to the interpretation of the individual clinician as they may benefit some patients but not others:

  • Epinephrine nebulization, either alone or combined with dexamethasone
  • Nasal suctioning
  • 3% hypertonic saline nebulization

The following therapies are not recommended. They have been shown to either have no benefit or be potentially harmful:

  • Salbutamol
  • Corticosteroids in either oral or inhaled forms
  • Antibiotics (unless there is clear evidence of a secondary bacterial infection)
  • Antivirals
  • Chest physiotherapy
  • Cool mist therapy or aerosol therapy with isotonic saline

Patients admitted to hospital should have regular and repeated clinical assessment including respiratory rate, oxygen saturation, auscultation, and feeding/hydration status. The use of continuous cardiorespiratory monitoring is controversial and should be reserved for high risk patients.

Last updated by PedsCases: January 8, 2015.

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