Lightning Learning: Bronchiolitis
Bronchiolitis is the most common cause of hospitalisation for children under 1 year – increasing yearly!
The majority can be managed at home.
No investigations are routinely needed.
No medications are routinely required.
Doing nothing is ok! (if symptoms mild)
Good advice is everything.
1) Bronchiolitis is a Clinical Diagnosis
Typical history (under 12 months) – 2 to 3 days of cold, cough and mild fever
Typical examination – Coryzal, widespread crackles and wheeze
Typical situation – feeding little and often, happy, wetting nappies
If atypical, read… #SimBlog: If You Focus On The Problem
2) Mild Severity = ?discharge
O2 saturations consistently above 92% (see discussion below)
No cyanosis, no apnoeas, normal behaviour
Nil to mild recessions, nil to mild tachypnoea
Feeding adequately, more than 50% of normal*
Wetting nappies adequately*
*see #LightningLearning: Feeding Assessment (coming soon)
Ok, the votes are in? What did we think? In my discussions locally, 92% seemed to reflect the general consensus. On twitter 94% achieved the most votes. Does this reflect caution in the face of uncertain disease progression?— carlvanheyningen (@carlvanheyning1) October 15, 2018
Discussion; Disease trajectory is a critical question. A baby (Baby A) who is day 5 with mild symptoms and saturations of 90-92% who looks to be improving is a very different scenario to a baby (Baby B) with mild symptoms saturating 90-92% on day 2 or 3 of illness. pic.twitter.com/hbXze5ArNX— carlvanheyningen (@carlvanheyning1) October 15, 2018
As the picture suggests, we might confidently expect Baby A to safely return home whilst Baby B we can anticipate worsening that same day or the next.— carlvanheyningen (@carlvanheyning1) October 15, 2018
To summarise: Without clear evidence, consensus suggests a threshold between 92-94% (dependent on the full clinical picture).
3) No Risk Factors = ?discharge
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
4) Safety Net Carefully
This is THE most important bit, their baby could get worse. Give EVERY parent a leaflet and EXPLAIN it.
IF IN DOUBT OR THE PARENTS ARE UNHAPPY, GET A SENIOR OPINION!
- BMJ: Bronchiolitis in Children – summary of NICE guidance
- Advice website for parents? www.morethanacold.co.uk
- NCBI: Bronchiolitis of Infancy Discharge Study
- The Rolobot Rambles: Do Nothing Without Appearing There is Nothing to Do
- EM Cases: Bronchiolitis 🎧
- RCEM Learning: NICE Bronchiolitis 🎧