William Schneider, DO, MA, FACEPWilliam Schneider, DO, MA, FACEPMedical Director, Pediatric Emergency ServicesMedical Director, Pediatric Emergency Services

Banner Thunderbird Medical CenterBanner Thunderbird Medical CenterEPIP Conference November 3EPIP Conference November 3rdrd and 4 and 4thth, 2011, 2011

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Case PresentationCase Presentation► 7 month old uncircumcised male 7 month old uncircumcised male gasping for airgasping for air► Low grade fever, cough and rhinorrhea for 2 daysLow grade fever, cough and rhinorrhea for 2 days► Now wheezing, grunting, with mod-severe retractionsNow wheezing, grunting, with mod-severe retractions► Unable to feed since this afternoonUnable to feed since this afternoon► Hx of wheezing in past – parents are treated for asthmaHx of wheezing in past – parents are treated for asthma► UTD with immunizations, ex-premie at 34 weeks gestationUTD with immunizations, ex-premie at 34 weeks gestation► VS: BP 92/60, HR 132, RR 55, Temp 39.1VS: BP 92/60, HR 132, RR 55, Temp 39.1 ̊̊C (R), POx 87% RAC (R), POx 87% RA► Moderately irritable and difficult to consoleModerately irritable and difficult to console► Nasal flaring with intercostal and substernal retractionsNasal flaring with intercostal and substernal retractions► Diffuse expiratory wheezingDiffuse expiratory wheezing

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Work UpWork Up► Asthma vs. Bronchiolitis pathway?Asthma vs. Bronchiolitis pathway?► Respiratory Score?Respiratory Score?► Suction vs. SVN?Suction vs. SVN?

Albuterol vs. Epinephrine SVN?Albuterol vs. Epinephrine SVN?

► Oxygen?Oxygen?► Steroids?Steroids?► CBC, BCx, UA, C&S, LP, CXR, viral studies?CBC, BCx, UA, C&S, LP, CXR, viral studies?► Nasal CPAP vs. Heliox vs. both combined?Nasal CPAP vs. Heliox vs. both combined?► Risk factors?Risk factors?

Severe BronchiolitisSevere Bronchiolitis ApneaApnea

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What is Your Work Up?

ObjectivesObjectivesBronchiolitisBronchiolitis

► Review the current literature and the AAP recommendations Review the current literature and the AAP recommendations for the diagnosis and management of Bronchiolitisfor the diagnosis and management of Bronchiolitis

► Become familiar with the Bronchiolitis respiratory scoring Become familiar with the Bronchiolitis respiratory scoring tool used in the assessment of the severity of Bronchiolitistool used in the assessment of the severity of Bronchiolitis

► Explore the risk factors for Severe Bronchiolitis and ApneaExplore the risk factors for Severe Bronchiolitis and Apnea

► Discuss the new Bronchiolitis Protocol using the Respiratory Discuss the new Bronchiolitis Protocol using the Respiratory Scoring Tool to be implemented within Banner HealthScoring Tool to be implemented within Banner Health

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IntroductionIntroduction Bronchiolitis Bronchiolitis

► Bronchiolitis is the most common lower respiratory tract Bronchiolitis is the most common lower respiratory tract infection in patients < 2 years of ageinfection in patients < 2 years of age Peak age: 2-8 monthsPeak age: 2-8 months Male predominance (1.5:1)Male predominance (1.5:1)

► 200,000 visits to EDs annually200,000 visits to EDs annually

► 19% admission rate19% admission rate

► Cost $700 million annuallyCost $700 million annually

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Definition AAPDefinition AAPBronchiolitisBronchiolitis

► “…“…rhinitis, tachypnea, rhinitis, tachypnea,

wheezing, cough, crackles, use wheezing, cough, crackles, use

of accessory muscles, and/or of accessory muscles, and/or

nasal flaring in a child younger nasal flaring in a child younger

than 24 months.”than 24 months.”

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PathophysiologyPathophysiologyBronchiolitisBronchiolitis

► Virus invades the nasopharynx and spreads by cell to cell Virus invades the nasopharynx and spreads by cell to cell transfer to the lower tract within a few daystransfer to the lower tract within a few days Viral infection of the lower respiratory tractViral infection of the lower respiratory tract

► Increased mucous secretion, cell death and sloughing of the Increased mucous secretion, cell death and sloughing of the bronchial ciliated epithelial cellsbronchial ciliated epithelial cells Clumps of necrotic epithelium and mucus decrease diameter of the Clumps of necrotic epithelium and mucus decrease diameter of the

bronchiolar lumen causing turbulent air flow particularly on expirationbronchiolar lumen causing turbulent air flow particularly on expiration

► Peribronchiolar lymphocytic infiltrate and submucosal edemaPeribronchiolar lymphocytic infiltrate and submucosal edema► Narrowing, air trapping, and obstruction of small airways:Narrowing, air trapping, and obstruction of small airways:

Hyperinflation and atelectasisHyperinflation and atelectasis Ventilation/perfusion mismatchVentilation/perfusion mismatch ↓ ↓ lung compliance and ↑ work of breathinglung compliance and ↑ work of breathing

► Smooth muscle constriction has limited roleSmooth muscle constriction has limited role

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RecoveryRecoveryBronchiolitisBronchiolitis

► Degree of obstruction may vary as some of the airways clear Degree of obstruction may vary as some of the airways clear resulting in rapidly changing clinical severity resulting in rapidly changing clinical severity

► Epithelial cells recover after 3 – 4 daysEpithelial cells recover after 3 – 4 days

► Cilia regenerate after 2 weeksCilia regenerate after 2 weeks

► Median duration of illness ~ 12 daysMedian duration of illness ~ 12 days

► Symptoms may persist for 3 (18%) to 4 (9%) weeksSymptoms may persist for 3 (18%) to 4 (9%) weeks

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EtiologyEtiologyBronchiolitisBronchiolitis

► RSV (50 – 80%):RSV (50 – 80%): November to MarchNovember to March Nearly all children (95%) infected within first 2 years of lifeNearly all children (95%) infected within first 2 years of life 4 to 6 day incubation period precedes URI symptoms4 to 6 day incubation period precedes URI symptoms Spread through direct contact with secretionsSpread through direct contact with secretions

► Human Metapneumovirus (3 – 19%)Human Metapneumovirus (3 – 19%)

► Parainfluenza Virus Type 3Parainfluenza Virus Type 3

► InfluenzaInfluenza

► AdenovirusAdenovirus

► Rhinovirus (common in asthma)Rhinovirus (common in asthma)

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Differential DiagnosisDifferential DiagnosisBronchiolitisBronchiolitis

LIFE-THREATENING CAUSES

Infection: pneumonia, Chlamydia, Pertussis (apnea)Foreign body: aspirated or esophagealCardiac anomaly: congestive heart failure, vascular ringAllergic reactionBronchopulmonary disorder exacerbation (CLD)

NON-LIFE THREATENING CAUSES

Congenital anomaly: tracheoesophageal fistula, bronchogenic cyst, laryngotracheomalacia

Gastroesophageal reflux diseaseMediastinal massCystic fibrosis

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Risk Factors For Severe Illness In Risk Factors For Severe Illness In Hospitalized PatientsHospitalized Patients

► PICNIC network (Pediatric Investigators Collaborative PICNIC network (Pediatric Investigators Collaborative Network on Infections in Canada 1995):Network on Infections in Canada 1995): 689 hospitalized children < 2 years:689 hospitalized children < 2 years:

6 out of 689 patients died (0.9%)6 out of 689 patients died (0.9%) 4 out of 6 had underlying disease (congenital heart disease, 4 out of 6 had underlying disease (congenital heart disease,

chronic lung disease, immunocompromised)chronic lung disease, immunocompromised) 2 were either premature or < 6 weeks old2 were either premature or < 6 weeks old

None of 372 pts died if older than 6 weeks and without None of 372 pts died if older than 6 weeks and without other risk factors for severe disease (95% CI 0-0.8%)other risk factors for severe disease (95% CI 0-0.8%)

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Risk Factors for Severe BronchiolitisRisk Factors for Severe BronchiolitisHistoryHistory

► Age < 6 - 12 weeksAge < 6 - 12 weeks

► Prematurity < 34 - 37 weeks gestationPrematurity < 34 - 37 weeks gestation

► Underlying chronic respiratory illness such as CF, CLD or BPDUnderlying chronic respiratory illness such as CF, CLD or BPD

► Significant congenital heart diseaseSignificant congenital heart disease

► Immune deficiency including human immunodeficiency Immune deficiency including human immunodeficiency virus, organ or bone marrow transplants, or congenital virus, organ or bone marrow transplants, or congenital immune deficienciesimmune deficiencies

► Prior intubationPrior intubation

► First 48 hours of illnessFirst 48 hours of illness

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Risk Factors for Severe BronchiolitisRisk Factors for Severe BronchiolitisPhysical ExaminationPhysical Examination

► General appearance: ill appearingGeneral appearance: ill appearing

► Oxygen saturation level < 92 - 94% on room airOxygen saturation level < 92 - 94% on room air 5 fold increase in likelihood of hospitalization5 fold increase in likelihood of hospitalization

► Respiratory rate > 60-70 breaths per minuteRespiratory rate > 60-70 breaths per minute

► Increased work of breathing - moderate to severe Increased work of breathing - moderate to severe retractions and/or accessory muscle useretractions and/or accessory muscle use

► DehydrationDehydration

► MaleMale

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Risk Factors for ApneaRisk Factors for Apnea

► Full-term birth and < 1 month of ageFull-term birth and < 1 month of age

► Preterm birth (< 37 weeks gestation) and age < 2 months Preterm birth (< 37 weeks gestation) and age < 2 months post conceptionpost conception

► History of Apnea of prematurityHistory of Apnea of prematurity

► Emergency Department presentation with apneaEmergency Department presentation with apnea

► Apnea witnessed by a caregiverApnea witnessed by a caregiver

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Bronchiolitis Scoring ToolBronchiolitis Scoring Tool► Assist in clinical decision-making within a protocolAssist in clinical decision-making within a protocol

Objective and subjective reproducible clinical parametersObjective and subjective reproducible clinical parameters

► Be applicable to its particular pathophysiology (LRTI) Be applicable to its particular pathophysiology (LRTI) Validity: score relates to disease severityValidity: score relates to disease severity Good inter-rater reliability >80%Good inter-rater reliability >80% Responsiveness: detect changes over timeResponsiveness: detect changes over time

► Apply to patients < 2 years of ageApply to patients < 2 years of age► Easily adopted by the provider, RT, RN, started in the ED and Easily adopted by the provider, RT, RN, started in the ED and

continued on the floor and/or PICUcontinued on the floor and/or PICU► Goals:Goals:

↓ ↓ LOS, ↓ cost & ↓admission rateLOS, ↓ cost & ↓admission rate ↑↑Consistency, ↑efficiency, and ↑qualityConsistency, ↑efficiency, and ↑quality

► Reflect AAP recommendationsReflect AAP recommendations

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AAP Clinical Practice Guideline AAP Clinical Practice Guideline (Pediatrics 2006;118:1774)(Pediatrics 2006;118:1774)

► ““Physical examination findings of importance include Physical examination findings of importance include respiratory raterespiratory rate, increased work of breathing as evidenced by , increased work of breathing as evidenced by accessory muscle useaccessory muscle use or retractions, and or retractions, and ausculatory findingsausculatory findings such as wheezes or crackles”such as wheezes or crackles”

► ““Pulse oximetry Pulse oximetry has been rapidly adopted into clinical has been rapidly adopted into clinical assessment of children with Bronchiolitis on the basis of data assessment of children with Bronchiolitis on the basis of data suggesting that it can reliably detect hypoxemia that is not suggesting that it can reliably detect hypoxemia that is not suspected on physical examination”suspected on physical examination”

► ““The lack of uniformity of scoring systems make comparison The lack of uniformity of scoring systems make comparison between studies difficult”between studies difficult”

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Bronchiolitis Respiratory Score Bronchiolitis Respiratory Score (Liu, 2004)(Liu, 2004)

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Diagnostic Studies - CXRDiagnostic Studies - CXRBronchiolitisBronchiolitis

► Schuh S, Lalani A, et al. Evaluation of the utility of Schuh S, Lalani A, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007; radiography in acute bronchiolitis. J Pediatr. 2007; 150(4):429-433.150(4):429-433. Prospective Cohort study of 265 infants 2-23 months oldProspective Cohort study of 265 infants 2-23 months old Only 2 CXR inconsistent with bronchiolitisOnly 2 CXR inconsistent with bronchiolitis

Lobar consolidationLobar consolidation More likely to treat with antibioticsMore likely to treat with antibiotics

Pre-radiography: 7 infants (2.6%) identified for antibioticsPre-radiography: 7 infants (2.6%) identified for antibiotics Post-radiography: 39 infants (14.7%) identified for antibioticsPost-radiography: 39 infants (14.7%) identified for antibiotics

► Not routinely recommendedNot routinely recommended

► Reserved for clinical deterioration or unclear presentationReserved for clinical deterioration or unclear presentation

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Normal With Possible HyperinflationNormal With Possible Hyperinflation

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RUL AtelectasisRUL Atelectasis

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Mild RML Perihilar Markings Mild RML Perihilar Markings With Peribronchial CuffingWith Peribronchial Cuffing

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Worse Bilateral Perihilar Infiltrates With Worse Bilateral Perihilar Infiltrates With Flattened DiaphragmsFlattened Diaphragms

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Diagnostic Studies – Labs/Viral SwabDiagnostic Studies – Labs/Viral SwabBronchiolitisBronchiolitis

► Rapid viral testing:Rapid viral testing: Direct Fluorescent Antibody (DFA) is the Gold standard (99% sensitive)Direct Fluorescent Antibody (DFA) is the Gold standard (99% sensitive)

More sensitive than Enzyme Immunoassay (EIA) and Cx (thermo labile virus)More sensitive than Enzyme Immunoassay (EIA) and Cx (thermo labile virus) Most viruses have similar presentationMost viruses have similar presentation Results have minimal effect on managementResults have minimal effect on management May be considered in infants <3 months of ageMay be considered in infants <3 months of age

Limit further lab testingLimit further lab testing Limit unnecessary antibioticsLimit unnecessary antibiotics

Not routinely recommendedNot routinely recommended

► Routine CBC, BMP and blood cultures are not recommendedRoutine CBC, BMP and blood cultures are not recommended

► Febrile neonate (Febrile neonate (>> 38.0 38.0 ̊̊ C) with RSV and/or clinical bronchiolitis C) with RSV and/or clinical bronchiolitis Requires septic workup and admissionRequires septic workup and admission

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RSV in Febrile Infants Study InformationRSV in Febrile Infants Study InformationBronchiolitisBronchiolitis

► Study: The Risk of Serious Bacterial Infections in Young Study: The Risk of Serious Bacterial Infections in Young Febrile Infants with RSV InfectionsFebrile Infants with RSV Infections

► Pediatric Emergency Medicine Collaborative Research Pediatric Emergency Medicine Collaborative Research Committee of the AAP Committee of the AAP

► Authors:Authors: D Levine, S Platt, P Dayan, C Macias, J Zorc, D Levine, S Platt, P Dayan, C Macias, J Zorc, W Krief, J Schor, D Bank, K Shaw, M Stein, C Jacobstein, N W Krief, J Schor, D Bank, K Shaw, M Stein, C Jacobstein, N Fefferman and N Kuppermann and The Multicenter RSV-Fefferman and N Kuppermann and The Multicenter RSV-SBI Study Group SBI Study Group

► PediatricsPediatrics 2004; 113;1728 2004; 113;1728

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Background: RSV in Febrile InfantsBackground: RSV in Febrile InfantsBronchiolitisBronchiolitis

► Young febrile infants are at substantial risk of SBIYoung febrile infants are at substantial risk of SBI

► Clinical assessment may be difficultClinical assessment may be difficult

► Unclear whether viral infection alters the risk of bacterial Unclear whether viral infection alters the risk of bacterial disease in this agedisease in this age

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Methods: RSV in Febrile InfantsMethods: RSV in Febrile InfantsBronchiolitisBronchiolitis

► Prospective, multi-center, cross sectional study: Prospective, multi-center, cross sectional study: Eight Pediatric Emergency DepartmentsEight Pediatric Emergency Departments October-March, 1998-2001October-March, 1998-2001 1,248 patients enrolled1,248 patients enrolled

► Inclusion:Inclusion: Age Age << 60 days 60 days Rectal temp Rectal temp >> 38.0 38.0ooC C

► Exclusion:Exclusion: Received antibiotics w/in 48 hrsReceived antibiotics w/in 48 hrs

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Evaluation: RSV in Febrile InfantsEvaluation: RSV in Febrile InfantsBronchiolitisBronchiolitis

► Clinical:Clinical: History and physical examinationHistory and physical examination Yale Observation Scale and Pulmonary ScoreYale Observation Scale and Pulmonary Score

► Diagnostic Testing:Diagnostic Testing: Rapid RSV antigenRapid RSV antigen Fever evaluation: urine, blood, CSFFever evaluation: urine, blood, CSF Stool culture - if symptomaticStool culture - if symptomatic Chest radiograph Chest radiograph

► Treatment / Disposition at discretion of physicianTreatment / Disposition at discretion of physician

► Telephone follow-upTelephone follow-up

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Categorization: RSV in Febrile InfantsCategorization: RSV in Febrile InfantsBronchiolitisBronchiolitis

► RSV Status:RSV Status: ““Indeterminate” considered NegativeIndeterminate” considered Negative

► Clinical Bronchiolitis:Clinical Bronchiolitis: Wheezing or retractions with URIWheezing or retractions with URI No lobar infiltrate on chest radiographNo lobar infiltrate on chest radiograph URI: history/presence of cough or Rhinorrhea URI: history/presence of cough or Rhinorrhea

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RSV in Febrile InfantsRSV in Febrile InfantsPositive vs Negative NP Swab Positive vs Negative NP Swab ResultsResults

Variable

RSV (+) N = 269

RSV (-) N = 979

RR (95% CI)

p

Any SBI 17/244 7.0% (4.1,10.9%)

116/925 12.5% (10.5,14.8%)

0.5 (0.3,0.9) .013

UTI 14/261 5.4% (3.0, 8.8%)

98/966 10.1% (8.3,12.2%)

0.5 (0.3,0.9) .015

Bacteremia 3/267 1.1% (0.2, 3.2%)

22/968 2.3% (1.4, 3.4%)

0.5 (0.1,1.6) .33

Meningitis 0/251 (0, 1.2%)

8/938 0.9% (0.4, 1.7%)

0 .21

3 RSV (+) with Bacteremia were neonates29

RSV in Febrile InfantsRSV in Febrile InfantsClinical Bronchiolitis (CB) Clinical Bronchiolitis (CB) ResultsResults

Variable CB (+) N = 156

CB (-) N =1035

RR (95% CI) p

Any SBI 10/141 7.1% (3.5,12.7%)

122/976 12.5% (10.5,14.7%)

0.57 (0.3,1.1) .069

UTI 10/153 6.5% (3.2,11.7%)

102/1018 10% (8.2,12.0%)

0.65 (0.3,1.2) .19

Bacteremia 0/154 (0, 1.9%)

24/1026 2.3% (1.5, 3.5%)

0 .06

Meningitis 0/146 (0, 2.0%)

8/989 0.8% (.3, 1.6%)

0 .61

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Conclusion: RSV in Febrile InfantsConclusion: RSV in Febrile InfantsBronchiolitisBronchiolitis

► Young febrile infants with RSV or clinical Bronchiolitis are at Young febrile infants with RSV or clinical Bronchiolitis are at lower risk of SBI than febrile infants without these findingslower risk of SBI than febrile infants without these findings Routine RSV testing not necessaryRoutine RSV testing not necessary

► Risk of UTI, however, remains significantRisk of UTI, however, remains significant

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TreatmentTreatmentBronchiolitisBronchiolitis

► Suctioning – First line therapySuctioning – First line therapy Nasal suction:Nasal suction:

BBG nasal aspiratorBBG nasal aspirator Age-appropriate bulb suctionAge-appropriate bulb suction Use prior to:Use prior to:

– Feeds– SVN trials or therapy

Deep posterior nasal-pharyngeal suctioning:Deep posterior nasal-pharyngeal suctioning: Reserved for mod-severe respiratory distress from significant airway Reserved for mod-severe respiratory distress from significant airway

obstructionobstruction Data does not support routine useData does not support routine use

– May induce bronchospasm from irritation and /or agitation

Normal saline nose drops may be used prior to suctioningNormal saline nose drops may be used prior to suctioning

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TreatmentTreatmentBronchiolitisBronchiolitis

► Oxygen - First line therapyOxygen - First line therapy Supplemental oxygen administered if POx consistently < 90%:Supplemental oxygen administered if POx consistently < 90%:

After nasal suctioning, airway positioning and POx probe repositioningAfter nasal suctioning, airway positioning and POx probe repositioning

Titrate 0Titrate 022 to keep POx to keep POx >> 90% while awake or 90% while awake or >> 88% while sleeping 88% while sleeping

Consider using continuous pulse oximetryConsider using continuous pulse oximetry Significant respiratory distress Significant respiratory distress

– First 12 to 24 hours

High risk infants < 2 months of ageHigh risk infants < 2 months of age Hx of prematurityHx of prematurity RS RS >> 10 10 Until patient is clinically improvingUntil patient is clinically improving

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TreatmentTreatmentBronchiolitisBronchiolitis

► Albuterol nebulized therapy:Albuterol nebulized therapy: ControversialControversial Inconsistent results in studiesInconsistent results in studies Gadomski, et al. Bronchodilators for bronchiolitis. Cochrane Gadomski, et al. Bronchodilators for bronchiolitis. Cochrane

Collaboration Database Syst rev. 2006;(3):CD001266:Collaboration Database Syst rev. 2006;(3):CD001266: Small short term clinical improvements at best (14%)Small short term clinical improvements at best (14%) Do not affect rate of hospitalization or length of hospital stayDo not affect rate of hospitalization or length of hospital stay Slightly more effective in those patients with history of wheezing or AtopySlightly more effective in those patients with history of wheezing or Atopy Routine use not recommended:Routine use not recommended:

– Consider SVN trial to determine effectiveness in individual patients

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TreatmentTreatmentBronchiolitisBronchiolitis

► Epinephrine nebulized therapy:Epinephrine nebulized therapy: Hartling L, et al. Epinephrine for Bronchiolitis. Cochrane Collaboration Hartling L, et al. Epinephrine for Bronchiolitis. Cochrane Collaboration

Database Syst Rev. 2004;(1): CD003123:Database Syst Rev. 2004;(1): CD003123: Slightly better clinical effect when compared with placebo or AlbuterolSlightly better clinical effect when compared with placebo or Albuterol Short-term improvements in clinical scores, POx, and respiratory ratesShort-term improvements in clinical scores, POx, and respiratory rates The improvements possibly related to the alpha effect of vasoconstrictionThe improvements possibly related to the alpha effect of vasoconstriction Should be reserved for mod-severe diseaseShould be reserved for mod-severe disease No reduction in the admission rates or length of hospital stayNo reduction in the admission rates or length of hospital stay

► Anticholinergic agents (Ipratropium):Anticholinergic agents (Ipratropium): Everad M, et al. Anticholinergic drugs for wheeze in children under Everad M, et al. Anticholinergic drugs for wheeze in children under

the age of two years. Cochrane Collaboration Database Syst Rev. the age of two years. Cochrane Collaboration Database Syst Rev. 2009:2009:

Review of 6 trials involving 321 infantsReview of 6 trials involving 321 infants No significant clinical improvementNo significant clinical improvement Not justified if used alone or in combination with B-adrenergic agentsNot justified if used alone or in combination with B-adrenergic agents

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AAP Treatment RecommendationAAP Treatment RecommendationBronchiolitisBronchiolitis

► ““Bronchodilators should not be used routinely in the Bronchodilators should not be used routinely in the management of Bronchiolitis”management of Bronchiolitis”

► ““A carefully monitored trial of alpha-adrenergic or beta-A carefully monitored trial of alpha-adrenergic or beta-adrenergic medication is an option. Inhaled Bronchodilators adrenergic medication is an option. Inhaled Bronchodilators should be continued only if there is a documented positive should be continued only if there is a documented positive clinical response to the trial using an objective means of clinical response to the trial using an objective means of evaluation.”evaluation.”

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Treatment - Corticosteroids:Treatment - Corticosteroids:BronchiolitisBronchiolitis

► Patel H. et al. Glucocorticoids for acute viral bronchiolitis in Patel H. et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. infants and young children. Cochrane Collaboration Cochrane Collaboration Database syst rev. Database syst rev. 2004;(3):CD004878.2004;(3):CD004878. 13 studies with 1,198 patients13 studies with 1,198 patients No significant difference between steroid & placebo treatment No significant difference between steroid & placebo treatment

groups:groups: Clinical scoresClinical scores Oxygen satsOxygen sats Admission ratesAdmission rates Length of stay Length of stay Return visitsReturn visits

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Corticosteroids Treatment Corticosteroids Treatment BronchiolitisBronchiolitis

► Corneli HM, et al. A Multicenter Randomized, Controlled Corneli HM, et al. A Multicenter Randomized, Controlled Trial of Dexamethasone for Bronchiolitis. Trial of Dexamethasone for Bronchiolitis. N Engl J Med. N Engl J Med. 2007;357:331-339 2007;357:331-339 (Bronchiolitis study group of the Pediatric Emergency (Bronchiolitis study group of the Pediatric Emergency Care Applied Research Network):Care Applied Research Network): 600 patients with first episode of bronchiolitis600 patients with first episode of bronchiolitis 2 – 12 months of age with mod-severe disease2 – 12 months of age with mod-severe disease 2004 – 2006 / 20 medical center Eds2004 – 2006 / 20 medical center Eds Dexamethasone 1 mg/kg vs. placebo: Measure outcome at 4 hours:Dexamethasone 1 mg/kg vs. placebo: Measure outcome at 4 hours:

No significant difference in clinical respiratory scoresNo significant difference in clinical respiratory scores No difference in admit rates (39.7% vs. 41%)No difference in admit rates (39.7% vs. 41%) No difference in readmission rates or hospital LOSNo difference in readmission rates or hospital LOS Conclusion: Did not improve outcomesConclusion: Did not improve outcomes

– ED– Hospital

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► ““Corticosteroid medications should not be used routinely Corticosteroid medications should not be used routinely

in the management of Bronchiolitis.”in the management of Bronchiolitis.”

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Corticosteroids Treatment Corticosteroids Treatment AAP Recommendation AAP Recommendation

TreatmentTreatmentBronchiolitisBronchiolitis

► Inhaled steroids:Inhaled steroids: 2 small studies2 small studies Showed no benefit in the course of the acute diseaseShowed no benefit in the course of the acute disease

► Nebulized Hypertonic 3% Saline:Nebulized Hypertonic 3% Saline: Improves mucociliary clearance in cystic fibrosis Improves mucociliary clearance in cystic fibrosis Kuzik, et al. Nebulized hypertonic saline in the treatment of viral Kuzik, et al. Nebulized hypertonic saline in the treatment of viral

bronchiolitis in infants. bronchiolitis in infants. J Pediatr J Pediatr 2007; 151:266-270.2007; 151:266-270. Multi-center trial of 96 patients admittedMulti-center trial of 96 patients admitted 3% saline vs. normal saline SVN3% saline vs. normal saline SVN 26% reduction in hospital length of stay (2.6 vs. 3.5 days)26% reduction in hospital length of stay (2.6 vs. 3.5 days)

Chaudhry K, Sinert R. Is nebulized hypertonic saline solution an Chaudhry K, Sinert R. Is nebulized hypertonic saline solution an effective treatment for bronchiolitis in infants? effective treatment for bronchiolitis in infants? Annals of Emerg. MedAnnals of Emerg. Med. . 2010; 55 (1): 120-12122: 2010; 55 (1): 120-12122:

No significant clinical outcome in ED or admission rateNo significant clinical outcome in ED or admission rate40

TreatmentTreatmentBronchiolitisBronchiolitis

► Nasal Continuous Positive Airway Pressure (CPAP):Nasal Continuous Positive Airway Pressure (CPAP): Noninvasive humidified high flow nasal cannula (1L/kg/min)Noninvasive humidified high flow nasal cannula (1L/kg/min) Decreases inspiratory muscle work loadDecreases inspiratory muscle work load Relieves atelectasisRelieves atelectasis Prevents airway collapsePrevents airway collapse Improves ventilationImproves ventilation Bridge to intubationBridge to intubation

Severe respiratory distressSevere respiratory distress Apnea spellsApnea spells

Heliox alone or in addition to nasal CPAP:Heliox alone or in addition to nasal CPAP: Helium + 21% oxygen Helium + 21% oxygen mixed gas 1/3 as dense as air mixed gas 1/3 as dense as air Reduces gaseous flow resistanceReduces gaseous flow resistance Improves gaseous exchange and alveolar ventilationImproves gaseous exchange and alveolar ventilation Increases C0Increases C022 elimination elimination Response seen within first hourResponse seen within first hour

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Ineffective TreatmentsIneffective Treatments

► Ribavirin: No role Ribavirin: No role (Randolph 1996 Arch Ped Adoles Med)(Randolph 1996 Arch Ped Adoles Med)

► Antibiotics:Antibiotics: < 2% have concurrent bacterial infection < 2% have concurrent bacterial infection

(Purcell 2002 Arch Ped Adoles Med)(Purcell 2002 Arch Ped Adoles Med)

No difference in hospitalization with or without antibioticsNo difference in hospitalization with or without antibiotics(Friis 1984 Arch Dis Child)(Friis 1984 Arch Dis Child)

► Antihistamines, Decongestants, SingulairAntihistamines, Decongestants, Singulair► Inhaled Interferon Inhaled Interferon -2a-2a► Nebulized FurosemideNebulized Furosemide► Chest PhysiotherapyChest Physiotherapy

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Criteria for HospitalizationCriteria for HospitalizationBronchiolitisBronchiolitis

► Persistent respiratory distress after treatment (RS > 5)Persistent respiratory distress after treatment (RS > 5)► POx consistently < 92% POx consistently < 92% ► Dehydration with inadequate po intakeDehydration with inadequate po intake► Significant risk factors for Apnea: Significant risk factors for Apnea:

< 1-2 month old with hx of prematurity < 35 weeks gestation< 1-2 month old with hx of prematurity < 35 weeks gestation► Unreliable caretakerUnreliable caretaker► Witnessed Apnea by caretaker or ED personnelWitnessed Apnea by caretaker or ED personnel► Febrile neonateFebrile neonate► Respiratory rate > 60 breaths per minute after treatmentRespiratory rate > 60 breaths per minute after treatment► Continual need for deep NP suctioningContinual need for deep NP suctioning► Physician discretionPhysician discretion

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Criteria for PICU AdmissionCriteria for PICU AdmissionBronchiolitisBronchiolitis

► IntubationIntubation► Nasal CPAP (HHNC/Heliox)Nasal CPAP (HHNC/Heliox)► ApneaApnea► RS > 10RS > 10► SepsisSepsis► Frequent bronchodilator SVN less than 2 hours apartFrequent bronchodilator SVN less than 2 hours apart► Physician discretionPhysician discretion

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Criteria for DischargeCriteria for DischargeBronchiolitisBronchiolitis

► Oxygen sats consistently Oxygen sats consistently >> 92% 92%► No respiratory distress (RS < 5) No respiratory distress (RS < 5) ► No apnea or significant risk factorsNo apnea or significant risk factors► Respiratory rate < 60 breaths per minuteRespiratory rate < 60 breaths per minute► Adequate oral intakeAdequate oral intake► Family education completeFamily education complete► Adequate bulb suctioningAdequate bulb suctioning► Physician discretionPhysician discretion► Caretaker comfortable and reliableCaretaker comfortable and reliable

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Risk Factors for ED Return VisitRisk Factors for ED Return VisitBronchiolitisBronchiolitis

► 17 - 20% ED return rate: 17 - 20% ED return rate: 65% within 2 days65% within 2 days

► Norwood A, Mansbach JM, Clark S, et al. Prospective multi-Norwood A, Mansbach JM, Clark S, et al. Prospective multi-center study of bronchiolitis: predictors of an unscheduled center study of bronchiolitis: predictors of an unscheduled visit after discharge from the emergency department. visit after discharge from the emergency department. Acad. Acad. Emerg Med.Emerg Med. 2010 Apr;17(4):376-82. [722 patients younger 2010 Apr;17(4):376-82. [722 patients younger than 2 years of age]:than 2 years of age]:

OROR p-valuep-value < 2 months of age:< 2 months of age: 2.12.1 0.030.03 Sex: male:Sex: male: 1.71.7 0.020.02 History of hospitalizations:History of hospitalizations: 1.71.7 0.020.02 Prematurity (< 35 weeks):Prematurity (< 35 weeks): 1.61.6 0.160.16

46

ConclusionConclusionBronchiolitisBronchiolitis

► Bronchiolitis is mainly a clinical diagnosisBronchiolitis is mainly a clinical diagnosis

► Diagnostic laboratory and radiographic tests play a limited roleDiagnostic laboratory and radiographic tests play a limited role

► Bronchodilators and steroids lack significant clinical effectivenessBronchodilators and steroids lack significant clinical effectiveness

► Supplemental oxygen indicated if POx < 90% consistentlySupplemental oxygen indicated if POx < 90% consistently

► Assess patients for risk factors when making final disposition Assess patients for risk factors when making final disposition decisionsdecisions

► Respiratory tool and protocol aid in treatment and disposition Respiratory tool and protocol aid in treatment and disposition decisionsdecisions

► Most patients recover with suction, OMost patients recover with suction, O22 & fluids only & fluids only

47

Bronchiolitis Bronchiolitis Protocol Protocol

Process FlowProcess Flow

48

ED and InpatientED and Inpatient

49

History of wheezing, atopy, or FH of asthma?

Patient meets

Discharge Criteria?

Yes

Yes

Trial of Racemic Epinephrine SVN

<5kg: 5.63mg (0.25ml)

>5kg: 11.25mg (0.5ml)

Trial of Albuterol Nebulizer (2.5

mg/3cc) or MDI 4 puffs

No Yes

RS > 5 (AFTER Suction) No

No Score improve

d >3 points?

Classified as Epi Responder Classified as

Non-Bronchodilator

Responder

No

Yes

Patient meets

Discharge Criteria?

Classified as Albuterol

Responder

Yes

Supportive Care Orders

■ Albuterol Responder: • Supportive Care • Alb MDI or Neb Q4 hours

■ Epi Responder: • Before D/C: Monitor for Minimum of 60

minutes post treatment for rebound (RS>5)• Supportive Care

■ Non Bronchodilator Responder: • Supportive Care • Family Education

Bronchiolitis Protocol Bronchiolitis Protocol Process Flow Process Flow

(ED and Inpatient)(ED and Inpatient)

No

Yes

■ Albuterol Responder: • Supportive Care Orders• Alb MDI or Neb Q4 hours prn for RS >5

– ED: Q1 hour prn• Alb MDI or Neb Q2 hours prn for RS >7

– ED: Q30 minutes prn• Notify MD if on Q2 hours

■ Epi Responder: • Supportive Care Orders• Racemic Epi Q4 hours prn for RS >5

– ED: Q1 hour prn• Racemic Epi Q2 hours prn for RS >7

– ED: Q30 minutes prn• Notify MD if on Q2 hours

■ Non Bronchodilator Responder: • Supportive Care Orders• Notify MD for RS >7

Score improve

d >3 points?

Observation or Admit if admission

criteria met

NoASSESS & SCORE using Respiratory

Scoring Tool (“Assess –

Suction – Assess” process)

Discharge with Supportive Care and

Family Education

Bronchiolitis ProtocolBronchiolitis Protocol

► Inclusion criteria:Inclusion criteria: Diagnosis of bronchiolitisDiagnosis of bronchiolitis Less than 2 years of ageLess than 2 years of age

► Exclusion criteria:Exclusion criteria: Hx of cystic fibrosis (CF)Hx of cystic fibrosis (CF) Hx of Bronchopulmonary dysplasia (BPD) Hx of Bronchopulmonary dysplasia (BPD) Significant or cyanotic congenital heart diseaseSignificant or cyanotic congenital heart disease ImmunocompromisedImmunocompromised On home oxygenOn home oxygen Has significant comorbid conditions complicating careHas significant comorbid conditions complicating care

50

Bronchiolitis ProtocolBronchiolitis Protocol

► Does the patient meet eligibility criteria?Does the patient meet eligibility criteria?

► Use Banner Health System (BHS) Bronchiolitis Order Set/RT Use Banner Health System (BHS) Bronchiolitis Order Set/RT Bronchiolitis ProtocolBronchiolitis Protocol

► Assess & Score using BHS Sheet (Always score before and Assess & Score using BHS Sheet (Always score before and after intervention):after intervention): Allow 10-15 minutes after each intervention before reassessment and Allow 10-15 minutes after each intervention before reassessment and

scoringscoring

► Document patient past medical history of Atopy, allergies, Document patient past medical history of Atopy, allergies, or wheezingor wheezing

► Document family medical history of asthma:Document family medical history of asthma: First degree relatives First degree relatives treatedtreated for asthma (parents, siblings) for asthma (parents, siblings)

51

ED and Inpatient Supportive Care OrdersED and Inpatient Supportive Care Orders► Oral or nasopharyngeal suctioning prn by RT/RN :Oral or nasopharyngeal suctioning prn by RT/RN :

Age appropriate suction bulb or BBG nasal aspiratorAge appropriate suction bulb or BBG nasal aspirator Reserve deep suction for airway obstruction causing significant respiratory compromiseReserve deep suction for airway obstruction causing significant respiratory compromise

► Scheduled spot check pulse oximetry Q4 hrs Scheduled spot check pulse oximetry Q4 hrs (Q1 hrs in ED) (Q1 hrs in ED) and prn:and prn: Consider continuous pulse oximetry in pts in ED or with significant respiratory distress (first Consider continuous pulse oximetry in pts in ED or with significant respiratory distress (first

12-24 hrs), high risk infants <1-2 months of age, hx of prematurity, RS 12-24 hrs), high risk infants <1-2 months of age, hx of prematurity, RS >>10)10)

► Begin Oxygen Protocol:Begin Oxygen Protocol: Supplemental OSupplemental O22 begins ONLY when pulse Ox consistently < 90% after suction/repositioning begins ONLY when pulse Ox consistently < 90% after suction/repositioning OO22 weaning starts when O weaning starts when O22 consistently consistently >> 90% while awake or 90% while awake or >> 88% asleep comfortably 88% asleep comfortably

► Bronchiolitis assessment: Scoring to be done PRE & POST intervention Bronchiolitis assessment: Scoring to be done PRE & POST intervention primarily by the RT (RN if RT not available): primarily by the RT (RN if RT not available): (Q 30-60 minutes and prn in ED)(Q 30-60 minutes and prn in ED) PRN if post score 0 - 4PRN if post score 0 - 4 Q4 hrs and prn if post score is Q4 hrs and prn if post score is >> 5 5 Q2 hrs and prn if post score is Q2 hrs and prn if post score is >> 7 7

► Begin family education upon hospital admission or complete at dischargeBegin family education upon hospital admission or complete at discharge► Notify physician if score Notify physician if score >> 10, clinical deterioration, or new O 10, clinical deterioration, or new O22 requirements requirements► Consider nasal CPAP (HHNC/Heliox) if severe respiratory distress or apnea Consider nasal CPAP (HHNC/Heliox) if severe respiratory distress or apnea

spellsspells► Notify physician when discharge criteria are metNotify physician when discharge criteria are met

52

Bronchiolitis Protocol Process FlowBronchiolitis Protocol Process Flow

53

History of wheezing, Atopy,

or first degree relative treated

for asthma?

Patient meets

Discharge

Criteria?

Yes

Yes

Trial of Racemic Epinephrine SVN

<5kg: 5.63mg (0.25ml)>5kg: 11.25mg (0.5ml)

Trial of Albuterol Nebulizer (2.5 mg / 3cc)

or MDI 4 puffs

No Yes

DISCHARGE CRITERIA:DISCHARGE CRITERIA:■ OO22 Sats consistently Sats consistently >>92%92%

■ No respiratory distress (RS <5)No respiratory distress (RS <5)■ Feeding adequatelyFeeding adequately■ Family comfortable & reliableFamily comfortable & reliable■ Family education completeFamily education complete■ Respiratory rate <60Respiratory rate <60■ No Apnea or significant riskNo Apnea or significant risk■ Bulb suction adequateBulb suction adequate■ Physician discretionPhysician discretion

RS > 5 (AFTER Suction)

No

NoScore

improved >3

points?

Score improve

d >3 points?

Include: 0-24 months; Dx Bronchiolitis

Exclude: hx BPD, CHD, home O2, or significant comorbid

conditionsSupportive Care Orders

No

ASSESS & SCORE using Respiratory Scoring

Tool (“Assess – Suction – Assess” process)

Observation or Admit if admission

criteria met

D/C with Supportive Care & Family

Education

Bronchiolitis Protocol Process Flow Bronchiolitis Protocol Process Flow continuedcontinued

54

Trial of Racemic Epinephrine SVN

<5kg: 5.63mg (0.25ml)

>5kg: 11.25mg (0.5ml)

Trial of Albuterol Nebulizer (2.5 mg/ 3cc)

or MDI 4 puffs

NoScore

improved >3

points?

Score improve

d >3 points?

Classified as Epi

Responder Classified as Non-

Bronchodilator Responder

No

Yes

Patient meets

Discharge Criteria?

Classified as Albuterol

Responder

Yes

ADMISSION CRITERIA:ADMISSION CRITERIA:■ OO22 Sats consistently <92% Sats consistently <92%

■ RS >5RS >5■ Feeding poorly or dehydratedFeeding poorly or dehydrated■ Family unreliableFamily unreliable■ Respiratory rate >60Respiratory rate >60■ Apnea witnessedApnea witnessed■ Significant risk factors for apneaSignificant risk factors for apnea■ Neonatal feverNeonatal fever■ Bulb suction inadequateBulb suction inadequate■ Physician discretionPhysician discretion

PICU CRITERIA:PICU CRITERIA:■ IntubationIntubation■ Nasal CPAP (HHNC/Heliox)Nasal CPAP (HHNC/Heliox)■ RS > 10RS > 10■ ApneaApnea■ Frequent bronchodilator <2 hrsFrequent bronchodilator <2 hrs■ SepsisSepsis■ Physician discretionPhysician discretion

55

Patient meets

Discharge

Criteria?

■ Albuterol Responder: • Supportive Care • Alb MDI or Neb Q4 hours prn

■Epi Responder: • Before D/C: Monitor for Minimum of 60

minutes post treatment for rebound (RS >5)

• Supportive Care

■Non Bronchodilator Responder: • Supportive Care • Family Education

Yes

■Albuterol Responder: • Supportive Care Orders• Alb MDI or Neb Q4 hours prn for RS >5

– ED: Q1 hour prn• Alb MDI or Neb Q2 hours prn for RS >7

– ED: Q30 minutes prn• Notify MD if on Q2 hours

■Epi Responder: • Supportive Care Orders• Racemic Epi Q4 hours prn for RS >5

– ED: Q1 hour prn• Racemic Epi Q2 hours prn for RS >7

– ED: Q30 minutes prn• Notify MD if on Q2 hours

■Non Bronchodilator Responder: • Supportive Care Orders• Notify MD for RS >7

No

Bronchiolitis Protocol Process Flow Bronchiolitis Protocol Process Flow continuedcontinued

Case ConclusionCase Conclusion► 7 month old male 7 month old male gasping for air:gasping for air:

low grade feverlow grade fever cough and rhinorrhea for 2 dayscough and rhinorrhea for 2 days now wheezing, grunting, with mod-now wheezing, grunting, with mod-

severe retractionssevere retractions unable to feed since this afternoonunable to feed since this afternoon hx of wheezing in pasthx of wheezing in past parents treated for asthmaparents treated for asthma UTD with immunizations, UTD with immunizations,

uncircumciseduncircumcised ex-premie at 34 weeks gestationex-premie at 34 weeks gestation VS: BP 92/60, HR 132,RR 55, TVS: BP 92/60, HR 132,RR 55, T 39.1 39.1 ̊̊C C

(R), POx 87% RA(R), POx 87% RA moderately irritable and difficult to moderately irritable and difficult to

consoleconsole nasal flaring with intercostal and nasal flaring with intercostal and

substernal retractionssubsternal retractions diffuse expiratory wheezingdiffuse expiratory wheezing

■ Asthma vs. Bronchiolitis pathway?Asthma vs. Bronchiolitis pathway?■ Respiratory Score?Respiratory Score?■ Suction vs. SVN?Suction vs. SVN?

– Albuterol vs. Epinephrine SVN?Albuterol vs. Epinephrine SVN?

■ Oxygen?Oxygen?■ Steroids?Steroids?■ CBC, BCx, UA, C&S, LP, CXR, viral CBC, BCx, UA, C&S, LP, CXR, viral

studies?studies?■ Nasal CPAP vs. Heliox vs. both?Nasal CPAP vs. Heliox vs. both?■ Risk factors?Risk factors?

– Severe BronchiolitisSevere Bronchiolitis– ApneaApnea

56

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