Bronchiolitis

Questionnaire/history: Prodromal coryzal symptoms for 1-3 days?

1. Persistent cough +

2. Tachypnoea and/or chest recession +

3. Wheeze and/or crackles (fine (not coarse) bilateral crepitations) on chest auscultation

Associated symptoms include:- Fever (30%, usually low grade, fever > 39°C unusual (other diagnosis eg pneumonia to be considered)

- Poor feeding (most common days 3-5)

- Apnoea may be the presenting feature in very young children (especially < 6 weeks old)

Examination:

Temperature?

Heart rate?

Respiratory rate?

Capillary refill time?

SpO2?

Respiratory distress? - Nasal flaring? - Recession?

- Exhaustion?

Dehydration?

- Oral intake?

- Wet nappies?

Low risk (green)?

Behaviour: alert, normal?

Skin: CRT < 2 secs, moist mucous membranes, normal colour skin, lips and tongue?

Resp: < 12 months < 50 breaths/min, mild resp distress - mild chest recession, no nasal flaring, no grunting, no apnoeas?

Sats: 95% or over?

Feeding: normal - tolerating 75% of fluid or more, occasional cough-induced vomit?

Intermediate risk (amber)?

Behaviour: irritable, ↓ activity, ↓ response to social cues, no smile?

Skin: CRT 2-3 secs, pale/mottled, pallor reported by parent/carer, cool peripheries?

Resp: all ages > 60 breaths/min, ↑ work of breathing, moderate chest recession, nasal flaring may be present, no grunting, no apnoeas?

Sats: 92-94% or over?

Feeding: tolerating 50-75% of fluid intake over 3-4 feeds, reduced urine output?

Any risk factors for severe disease?

High risk (red)?

Behaviour: unable to rouse, wakes only with prolonged stimulation, no response to social cues, weak or continuous cry, appears ill to the health professional?

Skin: CRT >3 secs, pale/mottled/ashen blue, cyanosis?

Resp: all ages > 70 breaths/min, resp distress, severe chest recession, nasal flaring and grunting present, apnoeas?

Sats: < 92%?

Feeding: < 50-75% over 2-3 feeds/12 hours, appears dehydrated, significantly reduced urine output?

Differential diagnosis:- Pneumonia (if T > 39 and/or persistently focal crackles)- Viral-induced wheeze or early-onset asthma in older infants (over 1) and young children (if persistent wheeze without crackles, recurrent episodic wheeze or history of atopy)

Management:

Immediate admission (usually via 999):

Apnoea (observed or reported)

Child looks seriously unwell

Severe respiratory distress (eg marked recession, grunting, RR >70bpm)

Central cyanosis

Persistent SpO2 < 90% in children aged 6 weeks or over, and < 92% in children aged under 6 weeks or children of any age with underlying conditions

Note the following are signs of impending respiratory failure:

Signs of exhaustion, recurrent apnoea, failure to maintain O2 sats despite oxygen.

Lower thresholds for referral in children with underlying conditions (eg prematurity, existing heart, lung or neuromuscular disorders, immune deficiency etc) or if factors affecting the ability of carers to safely monitor and look after at home.

Consider referring children with bronchiolitis if:

Respiratory rate > 60 bpmDifficulty breastfeeding or inadequate oral intake (50-75% of usual volume)

Clinical dehydration

Persistent SpO2 < 92%

Green: Provide guidance and give patient advice sheet, confirm carer comfortable with action

Amber:

Seek advice from paeds and/or give clear management plan agreed with parents; ensure safety netting, give advice sheet and info on where to go if child deteriorates

Red:

Consider 999, call paeds, consider O2 and any treatment required to stabilise child

Also consider that bronchiolitis often deteriorates until day 3, which may influence advice given and referral threshold - it is particularly important in children with risk factors for severe disease.

Advised:

- To read online info Healthier Together/RCPCH/NHS: Bronchiolitis

- To maintain fluid intake

- To monitoring for signs of increasing illness, eg:

--- Worsening work of breathing

--- Fluid intake is 50-75% of normal or no wet nappy for 12 hours

--- Apnoea or cyanosis

--- Exhaustion (eg not responding normally, wakes only after prolonged stimulation)

- Paracetamol/ibuprofen with food (if no nausea/vomiting) if fever and distress

- Symptoms usually peak at day 3 to 5

- Cough resolves in 90% by 3 weeks

- No smoking