Bronchiolitis

Published on 23/06/2015 by admin

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Last modified 23/06/2015

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6.6 Bronchiolitis

Introduction

Epidemiology

Bronchiolitis is a common presentation to emergency departments, with a seasonal pattern. It typically affects children under the age of 12 months, but may occur in children up to 2 years of age. The peak age is between 2 and 8 months of age, with males more commonly affected. Approximately 1% of children will require admission for bronchiolitis, which is the leading cause of admission for children with lower respiratory tract disease in the Western world.1 Epidemics of bronchiolitis occur during each winter, with the peaking of respiratory viruses. While respiratory syncytial virus (RSV) is the commonest organism responsible for bronchiolitis, others include parainfluenza virus, adenovirus, rhinovirus and influenza. Bronchiolitis may also complicate exanthems such as measles and varicella in young children. It is estimated that by the age of 2, 70% of children have been exposed to RSV. Despite the frequency, mortality is low at less than 1% of hospitalised babies. High-risk patients include those with underlying chronic lung disease, congenital heart disease, neuromuscular disorders or corrected age less than 2 months of age.1

Clinical assessment

Examination

Examination of the child will reveal a combination of signs of upper respiratory tract infection (URTI), along with signs indicative of lower respiratory tract infection (LRTI), which may fluctuate between examinations. The fever is usually low grade. A moist cough is common and wheeze may be audible at the bedside.

Tachypnoea and tachycardia are usually in proportion to the illness severity. Infants who are estimated to be feeding less than 50% of normal feeds usually have oxygen saturations less than 94%. Cyanosis is seen in children with severe disease.

Chest examination may reveal hyperinflation and recessions of the chest wall due to increased work of breathing. Paradoxically, as an infant fatigues, the recessions will decrease. In this situation the diminishing air entry signifies progressive disease. Auscultation reveals wheezes that are generally symmetrical. There may be inspiratory crepitations. The auscultation findings are dynamic as coughing will move secretions to more proximal airways, with resultant temporary clearing of the wheeze. A short time later, as the fluid returns to the more peripheral airways, the wheeze returns. Hence, babies referred by a local doctor with ‘marked wheeze’ may initially appear to be wheeze free when seen in the emergency department (ED) a short time later. Re-examination later will confirm the presence of wheeze.5

Oxygen saturations fall with disease severity and SaO2 levels below 94% indicate a need for admission.4 McIntosh graded severity of bronchiolitis by simply documenting children as needing no oxygen, requiring oxygen and needing ventilation.6 Certainly, increasing oxygen requirements will be associated with increasing severity of disease.