PV Card: Algorithm for acute bronchiolitis management

Bronchiolitis is a common lower respiratory tract infection in children less than 2 years old, and especially in those 3-6 months old. In a collaboration with the American Academy of Pediatrics’ (AAP) Section on Emergency Medicine Committee on Quality Transformation, we present a PV card summarizing the Section’s “Clinical Algorithm for Bronchiolitis in the Emergency Department Setting” (reproduced with permission).¹ Dr. Shabnam Jain sums it up best in her expert peer review below: “In bronchiolitis, less is more.”

How to use the Bronchiolitis Algorithm

Scope

• Does not apply if severe or atypical presentation

Inclusion Criteria

• Children, 1‐12 months of age, presenting with symptoms and signs suggestive of a clinical diagnosis of bronchiolitis, such as upper respiratory tract infection such as rhinitis and coughing, progressing to lower respiratory symptoms including wheezing, crackles, and/or tachypnea that may result in difficulty breathing and/or difficulty feeding

Exclusion Criteria

• Full‐term infants that are <28 days old
• Premature infants that are <48 weeks post‐conception
• Patients with hemodynamically significant cardiac or significant pulmonary disease (such as bronchopulmonary dysplasia or asthma) or other major chronic conditions (such as immunodeficiency and neuromuscular disease)

[Download the PV card]

Bronchiolitis is a self-limited, viral lower respiratory tract infection that affects infants and young children. It is the most common cause of hospital admission in infants in the United States. In 2014, the American Academy of Pediatrics published a clinical practice guideline entitled The Diagnosis, Management, and Prevention of Bronchiolitis.¹ Based on this CPG, in 2015 the AAP Section on Emergency Medicine’s Committee on Quality Transformation developed a clinical algorithm for bronchiolitis in the ED setting, addressing some newer therapies that can be considered in severe or undifferentiated presentations in the ED. It also offers criteria for which patients can be discharged from the ED. Below are some ED-relevant recommendations for the generally healthy infant with bronchiolitis:

1. Diagnosis and severity assessment is made on the basis of history and physical exam and assessment of risk factors. Routine chest X-rays and RSV testing are not recommended.
2. Management: Albuterol may improve the respiratory score (subjective), but has no effect on clinical course, disease resolution, admission, or length of stay. It does however, increase adverse effects (tremors, tachycardia) which outweighs any small potential benefits. Albuterol is not recommended for routine use in bronchiolitis. Furthermore, there is no benefit from routine use of epinephrine in inpatients or outpatient settings. Epinephrine may be used as a rescue agent in severe disease. Finally, steroids have no role in the management of bronchiolitis. High flow nasal cannula is a newer adjunct therapy that may be considered in severe patients.
3. Oxygen and pulse oximetry: There is poor correlation between respiratory distress and oxygen saturation values. Transient hypoxemia is common in bronchiolitis; pulse oximetry has been associated with perceived need for admission and is a primary determinant of inpatient LOS. Oxygen may be provided if needed to keep O2 if sats >90%.
4. Antibacterials are not indicated unless there is a concomitant bacterial infection.

This algorithm is for use in the ED at the bedside; it is not meant to be a comprehensive guideline on bronchiolitis.

(AAP) Section on Emergency Medicine Committee on Quality Transformation: Bronchiolitis Content Expert Team

• Shabnam Jain, MD | Champion (Children’s Healthcare of Atlanta)
• Anne Stack, MD | Co‐Champion (Boston Children’s Hospital)
• Marc Baskin, MD (Boston Children’s Hospital)
• Laura Chapman, MD (Hasbro Children’s Hospital)
• Peter Dayan, MD (Morgan Stanley Children’s Hospital)
• Mark Meredith, MD (Le Bonheur Children’s Hospital)
• Graham Thompson, MD (Alberta Children’s Hospital)
• Joseph Zorc, MD (Children’s Hospital of Philadelphia)

Note : This algorithm does not represent AAP policy and was not reviewed or approved by the AAP Board of Directors.

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