Bronchiolitis
Summary
TLDRThis podcast episode from SketchyMedical dives into bronchiolitis, a common winter illness in children under two, often caused by respiratory syncytial virus (RSV). It presents with upper respiratory symptoms followed by lower respiratory distress. The episode humorously explores the condition's pathophysiology, diagnosis, and management, emphasizing supportive care over unnecessary treatments. It also discusses risk factors for severe disease, hospitalization criteria, and potential complications, providing a comprehensive review for medical professionals and students.
Takeaways
- 🌟 Bronchiolitis is a common winter illness in children, particularly affecting those under two years old and being the leading cause of hospitalization in infants and young children in the USA.
- 😷 The illness is characterized by initial upper respiratory symptoms like rhinorrhea and nasal congestion, followed by a lower respiratory inflammatory process.
- 🦠 The most common cause of bronchiolitis is the respiratory syncytial virus (RSV), which is responsible for about 80% of cases, with other viruses like rhinovirus, parainfluenza, and coronavirus also being possible causes.
- 🌡️ Clinical features of bronchiolitis are consistent regardless of the causative virus, but RSV and co-infections tend to result in more severe disease.
- 🍂 The physiological changes in bronchiolitis include airway edema, increased mucus production, and epithelial cell damage, all leading to lower airway obstruction.
- 👶 High-risk groups for severe bronchiolitis include infants under six months, especially those under three months, with additional risk factors being prematurity, chronic lung disease, congenital heart disease, daycare attendance, school-aged siblings, secondhand smoke exposure, and lack of breastfeeding.
- 🚫 Bronchiolitis is a clinical diagnosis, and routine lab work or imaging is not indicated for most cases. The American Academy of Pediatrics (AAP) advises against imaging due to the lack of correlation with clinical severity.
- 🛑 Treatment for bronchiolitis is primarily supportive, with no routine use of medications such as bronchodilators, racemic epinephrine, inhaled or oral glucocorticoids, leukotriene inhibitors, or antibiotics.
- 🏥 Hospitalization may be necessary for severe cases, indicated by dehydration, respiratory distress, apnea, lethargy, poor oxygenation, and a toxic appearance.
- 👨⚕️ Management of bronchiolitis in hospitalized patients includes supportive care with potential treatments like nebulized hypertonic saline, oxygen support, and in severe cases, intubation and mechanical ventilation.
Q & A
What is bronchiolitis?
-Bronchiolitis is a common winter illness in children, particularly affecting those under two years of age. It is characterized by an initial upper respiratory infection that progresses to a lower respiratory inflammatory process, often caused by a viral infection.
Why is bronchiolitis particularly frustrating for pediatricians and parents?
-Bronchiolitis can be frustrating due to its commonality and the fact that it primarily affects infants and young children, leading to significant distress for both the child and caregivers. Additionally, it often occurs during the winter months, which can compound the challenges of managing the illness.
What is the most common cause of bronchiolitis?
-The most common cause of bronchiolitis is the respiratory syncytial virus (RSV), which is responsible for about 80% of cases.
What are some other viruses that can cause bronchiolitis?
-Other possible viral causes of bronchiolitis include rhinovirus, parainfluenza, metapneumovirus, influenza, adenovirus, and coronavirus (not specifically COVID-19).
Why is bronchiolitis the number one reason for hospitalization among infants and young children in the USA?
-Bronchiolitis is the leading cause of hospitalization in this age group because it can cause severe respiratory symptoms that require medical intervention, especially in infants and young children who have not yet fully developed their respiratory systems.
What physiological changes occur in the airways during bronchiolitis?
-During bronchiolitis, the viral infection leads to lower respiratory airway edema, increased mucus production, and eventually sloughing and necrosis of epithelial cells within the airway, which results in obstruction of the lower airway.
What is the typical disease course of bronchiolitis?
-The disease course of bronchiolitis typically begins with upper respiratory symptoms like rhinorrhea and nasal congestion, followed by the onset of lower respiratory symptoms such as cough, trouble breathing, and wheezing or crackles two to three days later. These symptoms generally peak in severity around days three to five.
Which age group is most affected by bronchiolitis?
-Bronchiolitis usually affects children who are two years of age and younger, with those under six months of age, especially those under three months, at risk for more severe illness.
What are some risk factors for more severe bronchiolitis?
-Risk factors for more severe bronchiolitis include age under 12 weeks, a history of prematurity, chronic lung disease, significant congenital heart disease, daycare attendance, school-aged siblings, secondhand smoke exposure at home, and lack of breastfeeding in early infancy.
How is bronchiolitis diagnosed?
-Bronchiolitis is a clinical diagnosis based on a consistent history and physical exam findings. Lab work and imaging studies are not routinely indicated, but can be considered in special circumstances like severe illness or an unusual illness course.
What is the mainstay of treatment for bronchiolitis?
-The mainstay of treatment for bronchiolitis is supportive care. There is no indication for the use of medications such as bronchodilators, racemic epinephrine, inhaled or oral glucocorticoids, leukotriene inhibitors, or antibiotics, as they have not been shown to have benefit and can cause adverse effects.
What are some potential complications of bronchiolitis?
-Potential complications of bronchiolitis include aspiration pneumonia, respiratory failure, and the development of reactive airway disease, recurrent wheezing, or asthma, particularly in patients with severe disease or underlying conditions.
What preventive measures can be taken to reduce the severity of bronchiolitis and its spread?
-Preventive measures include smoking cessation, good hand hygiene, breastfeeding, and RSV immunoprophylaxis with palivizumab for a small subset of high-risk patients under one year of age with specific conditions.
Outlines
🌲 Introduction to Bronchiolitis and Its Impact
The podcast from SketchyMedical begins with an introduction to bronchiolitis, a common winter illness in children that is both prevalent and frustrating for pediatricians and parents. The episode aims to review material to reinforce learning through videos, quizzes, and the Symbol Explorer. It invites listeners to watch the accompanying video for a visual aid. Bronchiolitis is depicted as an inflamed condition of the bronchial trees with red fruits symbolizing the infection, primarily caused by the respiratory syncytial virus (RSV) in about 80% of cases. Other potential viruses include rhinovirus, parainfluenza, metapneumovirus, influenza, adenovirus, and the regular coronavirus. The condition is characterized by initial upper respiratory symptoms that progress to a lower respiratory inflammatory process, leading to obstruction of the lower airways.
👶 Clinical Features and Diagnosis of Bronchiolitis
This section delves into the clinical features of bronchiolitis, which are consistent regardless of the causative virus. It highlights the disease's typical progression from upper respiratory symptoms like rhinorrhea and nasal congestion to lower respiratory symptoms such as cough, trouble breathing, and wheezing. Bronchiolitis is the leading cause of hospitalization among infants and young children in the USA. The physical examination includes checking for fever, respiratory distress, signs of dehydration, and lung sounds that may indicate bronchiolitis. Risk factors for more severe disease include age under 12 weeks, prematurity, chronic lung disease, congenital heart disease, daycare attendance, school-aged siblings, secondhand smoke exposure, and lack of breastfeeding. The diagnosis is clinical, and lab work or imaging is not usually required unless there are complications or severe symptoms.
🏥 Management and Treatment of Bronchiolitis
The management of bronchiolitis is primarily supportive, with most cases being self-limited infections. The American Academy of Pediatrics (AAP) guidelines recommend against the routine use of bronchodilators, racemic epinephrine, inhaled or oral glucocorticoids, leukotriene inhibitors, antibiotics, and chest physiotherapy, as they have not been shown to benefit patients and may increase costs and adverse effects. Hospitalization is considered based on the severity of the illness, with indications including dehydration, respiratory distress, apnea, lethargy, a toxic appearance, and low oxygen saturation. Inpatient treatment may involve nasal suction, nebulized hypertonic saline, oxygen supplementation, and in severe cases, intubation and mechanical ventilation.
🍼 Supportive Care and Prevention Strategies
Supportive care for bronchiolitis includes monitoring hydration, respiratory status, and oxygenation. Nasal suction and small frequent feeds are recommended for outpatient care, while hospitalized patients may require enteric or intravenous fluids, frequent suctioning, and oxygen support. Contact precautions are necessary to prevent the spread of the viral infection. Preventive measures such as smoking cessation, good hand hygiene, and breastfeeding can help reduce the severity of symptoms and the spread of infection. RSV immunoprophylaxis with palivizumab is recommended for a small subset of high-risk patients under one year of age with specific conditions like prematurity, bronchopulmonary dysplasia, or significant cardiac disease.
🚑 Potential Complications and Long-Term Outcomes
Complications of bronchiolitis include aspiration pneumonia and respiratory failure, with infants under six months and those with comorbidities at higher risk. Long-term, bronchiolitis can lead to the development of reactive airway disease, recurrent wheezing, or asthma, particularly in patients who had severe bronchiolitis, were younger than six months, or had a family history of atopy. It is important for caregivers to be aware of these potential outcomes and to consult with a pediatrician if the child exhibits wheezing with future illnesses.
👋 Conclusion and Additional Resources
The episode concludes by summarizing the key points about bronchiolitis: it is a self-limited viral illness affecting children under two years old, most commonly caused by RSV. It is characterized by fever, upper respiratory symptoms, and worsening lower respiratory symptoms around days three through five. The physical exam shows signs of increased work of breathing and abnormal lung sounds. Treatment is supportive, and there are specific recommendations against certain medications and therapies. Risk factors for severe disease and indications for hospitalization are outlined. The episode also mentions potential complications and the importance of prevention and risk reduction strategies. Listeners are directed to SketchyMedical's YouTube channel and website for more topics and resources.
Mindmap
Keywords
💡Bronchiolitis
💡Respiratory Syncytial Virus (RSV)
💡Viral Infection
💡Pathophysiology
💡Hospitalization
💡Supportive Care
💡Dehydration
💡Respiratory Distress
💡Oxygenation
💡RSV Prophylaxis
💡Reactive Airway Disease
Highlights
Bronchiolitis is one of the most common winter illnesses in children and a leading cause of frustration for pediatricians and parents.
It is characterized by initial upper respiratory symptoms that progress to a lower respiratory inflammatory process.
Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis, seen in 80% of patients.
Clinical features of bronchiolitis are the same regardless of the causative virus.
Bronchiolitis is the top reason for hospitalization among infants and young children in the USA.
The physiological changes in bronchiolitis include airway edema, increased mucus production, and epithelial cell necrosis.
A classic pattern of bronchiolitis includes an upper respiratory prodrome followed by lower respiratory symptoms peaking around days three to five.
Bronchiolitis primarily affects children under two years of age, with those under six months at higher risk for severe illness.
Risk factors for severe bronchiolitis include age under 12 weeks, prematurity, chronic lung disease, congenital heart disease, daycare attendance, school-aged siblings, secondhand smoke exposure, and lack of breastfeeding.
Physical exam findings in bronchiolitis include fever, cough, trouble breathing, and signs of respiratory distress.
Bronchiolitis is a clinical diagnosis; lab work and imaging are not routinely indicated except in severe or complicated cases.
Treatment for bronchiolitis is primarily supportive care, with no routine use of medications like bronchodilators or antibiotics.
Hospitalization for bronchiolitis is indicated by severe dehydration, respiratory distress, apnea, lethargy, and low oxygen saturation.
Prevention strategies include smoking cessation, hand hygiene, breastfeeding, and RSV immunoprophylaxis for high-risk infants.
Complications of bronchiolitis can include aspiration pneumonia, respiratory failure, and the development of reactive airway disease or asthma.
AAP guidelines emphasize evidence-based treatment to avoid unnecessary interventions and therapies.
Transcripts
hey this is sketchy we're all Learning
Company and this podcast is a review of
the material meant to be used in tandem
with our videos quizzes and symbol
Explorer to help the lessons stick
or use this to passively review a topic
while you're on the go
check out the link in the episode bio to
watch the video that goes with this
podcast
alright let's get started
[Music]
in this sketch we'll focus on one of the
most common winter illnesses in kids
broncholitis
[Laughter]
it's also one of the most frustrating
illnesses for pediatricians and parents
alike so stay tuned to find out why
for this sketch we'll Venture into a
wintry Forest of never before seen
snow-covered bronchial trees except
something strange about this Forest
it appears to be occupied by some
ghostly campers but these specters don't
seem that spooky in fact
they appear downright friendly so pop
into your up and atom machines and let's
Dive In
bronchiolitis depicted by the inflamed
red fruits on the tips of the bronchial
trees is a viral process characterized
by initial upper respiratory symptoms
such as rhinorrhea and nasal congestion
that progresses to a prominent lower
respiratory inflammatory process
the most common cause of bronchiolitis
seen in 80 of patients is respiratory
syncytial virus or RSV
Gasper the Friendly Ghost the mascot of
this ghost Camp is chilling next to an
RSV Tombstone to help remind you of this
other possible viral causes of
bronchiolitis include rhinovirus para
influenza cumulent metanumovirus
influenza adenovirus and Coronavirus the
regular one we're not talking covid here
the clinical features of bronchiolitis
are the same regardless of the causative
virus but RSV and co-infection with
multiple viruses tends to cause more
severe disease
bronchiolitis is the number one reason
for hospitalization among infants and
young children in the USA which is why
the number one on this Tombstone is the
only number that hasn't faded away
so what happens physiologically to the
Airways in bronchiolitis the viral
infection leads to lower respiratory
Airway edema represented by these
icicles dripping fluid off the bronchial
tree branches increased mucous
production depicted by this sticky
accumulation of sap and eventually
sloughing and necrosis of epithelial
cells within the airway denoted by the
sloughing bark breaking off of the tree
just looking at this picture of goopy
drippy shedding bronchioles makes me
want to get bronchiolitis
um
never
all of these changes lead to obstruction
of the lower airway kind of like how
this chubby squirrel is now obstructing
this hole in the tree someone ate a few
too many nuts today
there's a classic pattern to the disease
course of bronchiolitis and knowing this
pattern will help as you assess a
patient's clinical status there's an
initial prodrome of pretty standard
upper respiratory symptoms for example
rhinorrhea and nasal congestion which is
Then followed by the onset of lower
respiratory symptoms which includes
cough trouble breathing and wheezing and
or crackles two to three days later
these lower respiratory symptoms
generally peak in severity around days
three to five we'll talk a lot more
about the details in just a second when
we review the history and physical exam
you might hear pediatricians refer to
the winter as bronchiolitis season
because at least in the northern
hemisphere it affects patients primarily
in the fall and winter that's why the
Gasper ghost Camp is held in the dead of
winter I prefer a nice warm summer camp
but that's just me so who tends to get
bronchiolitis bronchiolitis usually
affects children two years of age and
younger represented by the two candles
on Gasper's birthday cake or I guess
it's his
death Day cake
the ghosts even eat cake
or eat at all
Egon I have questions for you
kids under six months of age and
especially those under three months of
age are at risk for more severe illness
you can see this depicted by this rough
looking corporeal cake which only has
half a candle I guess ghosts don't like
real cakes noted so how do kids with
bronchiolitis typically present they
will come in with a cough represented by
this puff of air coming from Gasper as
well as a fever which is seen in about
50 percent of cases and is depicted by
gaspar's flaming head
getting a good history is also important
as patients will often have had an upper
respiratory prodrome usually consisting
of a runny or stuffy nose and pictured
here by the ghost mom blowing her nasty
or shall we say ghastly nose boogers
gives a new meaning to the term
Boogeyman doesn't it
uh where was I these nasal symptoms
typically last for a couple days
followed by the onset of cough and
trouble breathing looks like the ghost
dad is coming down with something too
infants less than two months of age may
present with apnea alone and no other
bronchiolitis symptoms shown here by
this apnic ghost baby
parents may also report that their child
is making fewer wet diapers than usual
this trickling sap from the bronchial
tree and this puddle of yellow snow
should help remind you of this
this can be a sign of dehydration
related to insensible losses from their
increased respiratory effort and or from
decreased po intake secondary to nasal
congestion or reduced energy represented
by this falling slice of cake
when I'm sick I certainly don't want to
eat much either but I have to be pretty
darn sick to pass up chocolate cake
[Music]
when taking your history be sure to ask
about risk factors that can increase the
chance of more severe disease
an age Under 12 weeks and a history of
prematurity can both put an infant at
risk for more severe disease you can see
this represented by these three Moon
eggs one Moon covers the span of one
month remember and this tiny owl that
has hatched prematurely
in the case of premature infants this
increased bronchiolitis risk is because
they have a greater chance of having
underlying laryngo or tracheal Malaysia
or a floppy Airway and may have missed
the maternal transfer of some protective
antibodies in utero
other risk factors for severe
bronchiolitis include chronic lung
disease or bronchopulmonary dysplasia
represented by these wilty lung shaped
leaves hemodynamically significant
congenital heart disease depicted by
this Jagged crossed out heart carving on
the tree daycare attendance symbolized
by this little gathering of ghost kids
around the campfire having school-aged
siblings oh look Little Ghost twins
secondhand smoke exposure at home see
the smoke coming from the fire and a
lack of breastfeeding in early infancy
hence this formula bottle
the next clue to a diagnosis of
bronchiolitis is your physical exam pay
careful attention to the lung exam as
that will usually really cinch the
diagnosis don't forget to check and
review vital signs for all of these kids
in addition to a fever persistent or
transient oxygen desaturations may also
be present you can see this represented
by this living boy who with the help of
his glowing red ghost detector ring has
stumbled onto the ghost Camp you may
also see tachycardia which is depicted
by his elevated heart watch
next up after Vital Signs be sure to
check the overall appearance and mental
status of these kids altered mental
status manifesting is lethargy increased
sleepiness or decreased interaction with
others may be a sign of more severe
illness and is represented here by our
ghost detecting kid who is scratching
his head in confusion
I'd be a little perplexed myself if I
stumbled on a group of ghosts sitting
around a campfire let alone one drinking
from a baby bottle unless
next you'll want to check for signs of
dehydration depicted here by this
falling water bottle signs of
dehydration can include dry mucous
membranes a sunken fontanelle in infants
and or delayed capillary refill and poor
skin turgor
next up is your lung exam before jumping
to auscultation check for signs of
respiratory distress these include nasal
flaring which is a reflection of
increased Airway resistance grunting
which is the body's clever way to create
auto peep or positive end expiratory
pressure to help keep the Airways open
accessory muscle use like belly
breathing retractions which may be
subcostal intercostal and or
supraclavicular and tachypnea you can
see these signs represented by our
living kid who is huffing and puffing so
much after his encounter with the
ghostly campers that he has stretch
marks on his jacket okay okay now you
can listen on lung all sculptation you
may hear rails or fine crackles which if
you remember sound a bit like opening
velcro kind of like the straps on our
ghost hunting kids shoes
you may also hear expiratory wheezing
which reflects lower airway obstruction
wheezes often sound similar to a whistle
which is why we've depicted them here
with an actual whistle around our ghost
Hunter's neck
be sure to check for air movement as
well since a child with severely
obstructed Airways may not demonstrate
much wheezing if they are moving little
air
and these kids it can sometimes be
difficult to distinguish transmitted
upper Airway noises from their
rhinorrhea and nasal congestion from
lower airway noises
a helpful tip is to put your stethoscope
in front of your patient's mouth and
nose then compare those sounds to what
you hear on your lung exam transmitted
upper Airway sounds will be the same in
both places whereas lower airway noises
should only be present when auscultating
the lungs
bronchiolitis is a clinical diagnosis
lab work is not routinely indicated
especially for your run-of-the-mill case
in the outpatient setting viral panels
can be considered for hospitalized
patients or For Those whom the viral
panel result might change clinical
management note that we're not talking
about the workup of fever in a neonate
here that's a horse of a different color
and outside the scope of the sketch
Imaging is also not routinely indicated
in bronchiolitis the American Academy of
Pediatrics AAP policy is to avoid
Imaging in routine bronchiolitis
patients since the hyperinflation
scattered atelectasis and infiltrates
commonly seen do not correlate well with
clinical disease severity and finding
them can lead to the administration of
unnecessary antibiotics but
if your patient's presentation is severe
enough for an ICU admission or if
there's concern for a possible
complication like
secondary bacterial pneumonia then for
sure you can go ahead and order that
chest x-ray
chest x-rays and patients with
bronchiolitis typically reveal
peri-bronchial coughing represented by
this hand warmer wrapped around this
tree branch hyperinflation depicted by
these over-inflated balloons and or
atelectasis represented by these
shriveled collapsed balloons
with a consistent history in supporting
physical exam findings you're just about
ready to diagnose your patient with
bronchiolitis
but it's always a good idea to run
through a differential quickly to ensure
you're not missing something common
differentials for bronchiolitis include
viral triggered asthma exacerbation
bacterial pneumonia pertussis and
foreign body aspiration
head on over to the differential
diagnosis menu to learn more
now that you feel unconfident about the
clinical presentation and diagnosis of
bronchiolitis let's jump into management
so you know how to best take care of
these kids
the good news is that for the most part
bronchiolitis is a self-limited
infection there's a surprising
variability in the clinical management
of bronchiolitis despite updated
evidence-based AAP clinical practice
guidelines
pursuing interventions and therapies
that aren't recommended has been
associated with an increased length of
Hospital stay and no change in
readmission rate so keep those AAP
guidelines handy as you head onto the
wards and into Peds clinics and remember
that evidence-based treatment is the way
to go
the very first step in your management
plan is to evaluate the severity of your
patient's illness
during your history and physical exam
pay careful attention to hydration
respiratory status and oxygenation to
determine whether hospitalization
represented by the Red Cross on this
Tombstone is indicated or if your
patient is safe to stay at home
indications for hospitalization include
dehydration respiratory distress apnea
lethargy a toxic appearance and an
oxygen saturation less than 90 to 95
percent on room air keep in mind that
you'll want to reassess these kids a few
times before making a decision as the
clinical exam can change over time
the most important takeaway from this
lesson today is that the Mainstay of
treatment for bronchiolitis whether
hospitalized or at home is supportive
care
kind of like the supports on this
treehouse for the majority of previously
healthy infants with bronchiolitis
there's no indication for the use of
medications as part of your management
plan
take note of this treehouse sign to
remind you no meds allowed there's no
reason to routinely give bronchodilators
racemic epinephrine inhaled or oral
glucocorticoids leukotriene Inhibitors
or antibiotics to patients with
bronchiolitis none of these treatments
have been shown to have benefit they are
all associated with increased costs and
could result in adverse effects
similarly chest physiotherapy also
called chest PT is not recommended for
patients with bronchiolitis as there's a
no proven benefit and it could result in
your patient becoming more agitated and
distressed for hospitalized patients
with more severe disease there are a few
other options you can think about but
for the most part these kids just need
time and support of care too
all patients with bronchiolitis should
be placed on contact precautions
including gowns gloves and a mask like
these ones you see hung up in the tree
house to help prevent the spread of
viral infection
nasal suction often provided in
combination with saline nasal drops is
commonly used to help relieve nasal
obstruction and can be pretty helpful
it's depicted here by this ghostly Dust
Buster in the tree house
I wonder if the Ethereal HEPA filter is
good at getting ectoplasmic goo
just no there's not enough evidence for
a formal recommendation one way or
another on its use and make sure to
avoid deep suctioning as it can actually
be harmful
you can also try nebulized hypertonic
saline in the inpatient setting but it
should not be used in the emergency
department setting
monitoring oxygenation status is
important for patients with
bronchiolitis it's generally recommended
that for stable patients intermittent
oxygen saturation checks should be
performed rather than continuous
monitoring to avoid the unnecessary use
of supplemental oxygen you can see this
represented by this ghost's glowing red
human detector ring of course if your
patient has severe respiratory distress
or is admitted to the ICU then that's a
different story and you'll need more
thorough monitoring if your patient's
oxygen saturation dips below 90 then the
use of supplemental oxygen depicted by
this giant green O2 tank is indicated
and can be administered via typical
nasal cannula high flow nasal cannula or
even CPAP if they need a higher level of
support
intubation may be necessary in severe
cases with impending respiratory failure
which is usually manifested by severe
retractions poor or no air entry
lethargy fatigue and decreased
responsiveness
patients with bronchiolitis are at an
increased risk for dehydration so you'll
need to monitor their eyes and O's
closely
small frequent feeds are recommended in
stable patients if their respiratory
status allows
initiation of NG feeds represented by
this nose picker or IV fluids
represented by the fluid bag like icicle
hanging from the ivy vine and dripping
water may be necessary if respiratory
distress limits their po intake puts
them at risk of aspiration if they are
vomiting or their urine output has
dropped off
all patients with bronchiolitis whether
at home or hospitalized will also need
frequent monitoring with continual
reassessment for the need to escalate or
de-escalate care
for hospitalized kids most pediatric
hospitals have bronchiolitis treatment
Pathways based on AAP guidelines that
can be super helpful
in addition to the treatment options
we've talked about it's important to
address prevention and risk reduction
strategies too smoking cessation good
hand hygiene of the wash sink in the
treehouse and breastfeeding like this
opossum mama is doing should all be
encouraged since these can help reduce
the severity of symptoms and the spread
of infection
RSV immunoprophylaxis with palavizumab
also called synergist represented by
this super pale high-risk ghost sitting
next to an antibody shaped tree branch
is recommended for only a small subset
of high-risk patients under one year of
age including preemies born at less than
29 weeks gestation and infants with
bronchopulmonary dysplasia or
hemodynamically significant cardiac
disease
guidelines and eligibility criteria for
palavizzumab change yearly so be sure to
check each winter this is a highly
expensive medication but it does help
reduce the risk of hospitalization for
RSV infection in these kiddos
for many patients the bronchiolitis
clinical course is relatively
uncomplicated
but you still need to know about
potential short and long-term
complications to watch out for so let's
quickly review them
remember that infants with severe
disease and especially those with
underlying conditions are at a higher
risk for complications
as we mentioned earlier patients with
bronchiolitis are at risk for aspiration
pneumonia due to their tachypnea and
increased work of breathing check out
these two ghosts in the corner they're
super freaked out by the sight of a real
human in their woods so much so that
one's vomited all over the lung shirt of
his buddy infants who are struggling
with significantly increased worker
breathing generally need to be made NPO
and provided with enteral or IV
hydration to minimize the risk of
aspiration
patients with severe bronchiolitis May
progress to respiratory failure and
require intubation and mechanical
ventilation represented by this
laryngoscope flashlight
huh you'd think a ghost wouldn't have
trouble seeing in the dark
you know what they say about assuming
from a long-term standpoint the most
common complication of bronchiolitis is
the development of reactive airway
disease recurrent wheezing or asthma
note the inhaler in this ghost's mouth
the fear of seeing a human has
apparently spun his asthma out of
control
this asthma risk seems to be higher
among patients that had severe
bronchiolitis those younger than six
months and of course among patients with
a family history of atopy so be sure to
let caregivers know that the child might
wheeze with future illnesses and remind
them to talk to their pediatrician if
this does occur
so there you have it you're now the
master of one of the most common
infectious diseases you'll see in
Pediatrics especially during cold and
flu season seeing really is believing
once you've seen your first case of
bronchiolitis you'll never forget the
sound of those classic lung findings so
before the not so friendly ghostly Trio
shows up let's take one last look at
what we've learned
bronchiolitis is a self-limited viral
illness affecting the lower airway in
kids generally under age two it is the
most common reason for hospitalization
in infants and young children in the USA
and is especially common in the winter
months bronchiolitis is most commonly
caused by respiratory syncytial virus or
RSV for short but can be caused by other
viruses such as rhinovirus influenza and
para influenza virus coronavirus and
more
bronchiolitis classically presents with
one to two days of fever and upper
respiratory symptoms such as nasal
congestion and rhinorrhea followed by
worsening of symptoms around days three
through five with development of lower
respiratory symptoms like cough and
trouble breathing the pathophysiology of
bronchiolitis involves viral-induced
Airway edema increased mucus production
and necrosis and sloughing of Airway
epithelial cells leading to lower airway
obstruction the physical exam in
patients with bronchiolitis generally
demonstrates signs of increased work of
breathing such as tachypnea retractions
accessory muscle use grunting and nasal
flaring as well as abnormal lung sounds
like wheezes and crackles luckily most
kids with bronchiolitis do okay it is
generally a self-limiting viral illness
granted a frustrating and scary one for
pediatricians and parents alike that is
treated with supportive care
some kids are at risk for more severe
disease risk factors include age Under
12 weeks a history of prematurity
chronic lung disease significant cardiac
disease as well as other social factors
such as daycare attendants school-aged
siblings limited breastfeeding during
infancy and second-hand smoke exposure
RSV prophylaxis is recommended to help
prevent bronchiolitis in a small subset
of high risk infants those under one
year of age with a history of
prematurity less than 29 weeks
bronchopulmonary dysplasia or
hemodynamically significant congenital
heart disease
bronchiolitis is a clinical diagnosis
labs and imaging studies are not
indicated in your run-of-the-mill
bronchiolitis case but can be considered
in special circumstances like severe
illness or an unusual illness course
treatment of bronchiolitis involves
knowing what not to do as much as it is
knowing what to do AAP recommendations
include avoiding bronchodilators
antibiotics glucocorticoids racemic
epinephrine chest PT and deep suctioning
these do not improve treatment outcomes
and can in fact cause more complications
the Mainstay of treatment for
bronchiolitis in an outpatient setting
includes nasal saline drops and suction
small frequent feeds and monitoring
respiratory status and hydration as well
as other standard supportive care
measures
infants with severe bronchiolitis need
to be hospitalized for escalation of
care indications for hospitalization
include dehydration significant
increased work of breathing especially
if you are concerned about respiratory
fatigue or apnea poor oxygenation and
lethargy
patients who are hospitalized for
bronchiolitis may need hydration via
enteric or intravenous fluids frequent
suctioning as well as oxygen support
respiratory support generally starts
with nasal cannula and advances to high
flow nasal cannula CPAP or even
intubation if needed in severe cases of
respiratory failure nebulized hypertonic
saline is also sometimes tried luckily
the vast majority of kids with
bronchiolitis even those who need
hospitalization do well in the short
term complications of bronchiolitis
include aspiration pneumonia and
respiratory failure those children with
severe disease especially if under six
months of age and those with other
comorbidities are at higher risk for
developing recurrent wheezing or asthma
in the future
and that's it folks our time today is
just about up hopefully our ghost
hunting friend has enough instant
primordial soup mix to go around or at
the very least is pretty talented at
helping ghosts take care of their
unfinished business
oh geez uh Here Comes one now gotta go
see you next time
check out our other topics on YouTube or
go to sketchu.com for our full Suite of
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