#SimBlog: 'Tis the Season to be Bronchy
Red call ☎️ “Pre alert – 15 minutes. 21-day-old baby with bronchiolitis”
Distraught father: “He’s not been feeding. It was just a cold. The GP said it was bronchiolitis. Why are his lips blue?” Observations: (A) HR 160 bpm; (B) RR 60 bpm; (C) BP 80/60 mmHg; (D) Sats 86% in air; (E) Temp 37.9°C
Why Did We Sim?
Emergency departments across the country and bracing themselves for the “bronchy” season. Soon enough a cacophony of coughs and colds will fill the corridors. Babies of all shapes and sizes will flood in with accompanying worried parents.
Many with mild bronchiolitis can be safely discharged home. Some may need admission due to severe respiratory distress or poor fluid intake. And rarely, things may not always be as they appear.
For this simulation, our planned learning outcomes were…
Knowledge: management and differential diagnosis for bronchiolitis.
Skill: setting up a Vapotherm circuit for a 1-month-old baby within 15 minutes.
Attitude: to remain vigilant when managing babies with suspected bronchiolitis.
What actually happened?
Following handover from the paramedic, problems identified included severe respiratory distress and resistant hypoxia.
Initial 15 minutes involved nebulised Salbutamol, high flow oxygen, intravenous access, one 20ml/kg bolus of fluids and one dose of IV Ceftriaxone.
The following 5 minutes involved escalating to Vapotherm, 8L/min 50% oxygen and contacting senior help.
Positives worth mentioning – Good communication. Safe care. Careful approach. Good escalation. Not identified during simulation – absent femoral pulses. Discrepancy between pre- and post-ductal saturations. Underlying congenital heart disease (coarctation of the aorta).
What did we learn?
Knowledge: nebulised Salbutamol does not help infants with bronchiolitis. Always check the femoral pulses.
Skill: the Vapotherm circuit comes in two versions, one “low flow” for babies (up to 8L/min), one “high flow” for older children (up to 40L/min).
Attitude: remember the mimics of Bronchiolitis. Avoid the pitfall of diagnostic momentum (being told it is bronchiolitis)… there may be something else (e.g. cardiac).
And finally, share your thoughts aloud between your team to piece together the jigsaw.
Let’s Review…
What is bronchiolitis?
Bronchiolitis is a common childhood illness. This viral lower respiratory tract infection is most commonly caused by RSV (respiratory syncytial virus) though other viruses are also found. The result is inflammation of the small airways (the bronchioles) which restricts the amount of air able to enter the lungs. This makes more difficult for the child to breathe. This is made worse by secretions and mucous.
Typically it affects young babies who are three to six months old. However it can affect any child under the age of 2 years old. It usually occurs during the winter months (from October to March) when the viruses that cause bronchiolitis are more widespread. Recurrence is also possible within the same winter period.
How do we diagnose it?
The diagnosis is clinical. Viral testing is not routine. Chest x-rays and blood tests are very rarely needed.
Symptoms include:
A slightly high temperature (fever)
A dry and persistent raspy cough
Rapid or noisy breathing (wheezing, crackles, crepitations)
Difficulty feeding
This may initially appear as a viral upper respiratory tract infection for one to two days.
Symptoms can then worsen by day three to five:
Difficulty breathing, exhaustion and apnoeas
Reduced conscious level, poor fluid intake with poor feeding
Poor perfusion, mottling and pale skin
As a result, categorising severity and risk is important
How do we risk assess?
Firstly, consider the severity…
Secondly, consider risk factors for rapid deterioration…
Risk factors for rapid deterioration:
A baby less than 10 weeks old
Ex-prematurity – chronic lung disease
Congenital heart disease
Chronic illness (e.g. neurological, immune compromised)
Congenital or genetic syndrome
Thirdly, is this really bronchiolitis? Could it be something else?
What are the mimics/differential diagnoses?
Consider if presentation is atypical. Don’t ignore niggling doubts…
Pneumonia: suspect if there is a focal area of decreased air entry or coarse crackles.
Sepsis: suspect with a temperature greater than 39°C.
Metabolic: suspect with hypoglycaemia, prolonged vomiting and failure to thrive.
Surgical: suspect intestinal obstruction if vomiting persists, is projectile and bilious.
Neurological: suspect if baby struggles with feeds, has recurrent choking and is floppy.
Cardiac: suspect if poor response to oxygen, abnormal heart sounds, absent femoral pulses, discrepancy between pre-and post ductal sats.
Further Reading:
- Garcia-Mauriño C, Moore-Clingenpeel M, Wallihan R, et al. Discharge Criteria for Bronchiolitis: An Unmet Need. The Pediatric infectious disease journal. 2018;37(6):514-519
- Cunningham S, Rodriguez A, Boyd KA, McIntosh E, Lewis SC. Bronchiolitis of Infancy Discharge Study (BIDS): a multicentre, parallel group, double-blind, randomised controlled, equivalence trial with economic evaluation. Health Technol Assess 2015;19(71)
- Ricci Valentina, Delgado Nunes Vanessa, Murphy M Stephen, Cunningham Steve. Bronchiolitis in children: summary of NICE guidance BMJ 2015;350:h2305
- Barben J, Kuehni CE, Trachsel D, et al. Management of acute bronchiolitis: can evidence based guidelines alter clinical practice? Thorax 2008;63:1103-1109.
Additionally…
- The Rolobot Rambles: Do nothing without appearing there is nothing to do
- #EM3: Winter in the paeds ED and If you focus on the problem…
- EM Cases: Bronchiolitis 🎧
- RCEM Learning: NICE Bronchiolitis 🎧
