Slide 1	Introduction to topic. Opportunity to review objectives of lecture.
Slide 2	An introduction to a common presentation of a child with bronchiolitis. Read case aloud.
Slide 3	The lecture format is as though a practitioner is having a discussion with concerned parents about the lesser known/understood diagnosis of bronchiolitis. “Parental questions will be in purple and can be proposed to the group.”
Slide 4	A lower respiratory tract infection (LRTI): THE most common LRTI in children <2 years old Typically occurs less than 2 years old with peak incidence at 2–6 months Can cause disease up to 5 years old One of the leading causes of hospitalization in infants and young children Accounts for 60% of all lower respiratory tract infections in the first year of life
Slide 5	Bronchiolitis is usually due to viruses. Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis, but not all cases of bronchiolitis are due to RSV.
Slide 6	Higher risk populations for bronchiolitis and complications from bronchiolitis.
Slide 7	Environmental risk factors for exposure to and complications from bronchiolitis.
Slide 8	Bronchiolitis is seasonal: Typically, prevalent in what are considered the Winter months to early Spring. Tropical climates see a predominance of bronchiolitis during the rainy season.
Slide 9	Bronchiolitis is a clinical diagnosis made on history and physical exam. There is no laboratory test or imaging exam that can make the diagnosis of bronchiolitis. Identifying the causative virus is generally not warranted because it rarely alters the treatment or outcomes. Signs and symptoms: Systemic findings: decreased oral intake and low-grade fever are common Respiratory symptoms: cough, wheezing, crackles, tachypnea, retractions, apnea Apnea can be the only clinical sign in infants <6 weeks old
Slide 10	No routine testing is indicated to make the diagnosis of bronchiolitis. A complete blood count would not change management. A blood gas analysis can help evaluate for impending respiratory failure, but a clinical exam can often yield the same conclusion. A chest x-ray (CXR) can help evaluate for pneumonia, effusion, or heart disease if the clinical picture is less clear. Chest x-rays are not routinely indicated. However, if a chest x-ray is obtained, the listed findings would suggest bronchiolitis over other diagnoses.
Slide 11	Pneumonia is a common diagnosis that can be difficult to decipher from bronchiolitis. Features that can point to the alternative diagnosis of pneumonia are fevers >39 °C and unilateral signs on chest exam, a worsening clinical course (if simply providing the supportive management indicated for bronchiolitis).
Slide 12	This study investigated the utility of obtaining radiographs in the setting of acute bronchiolitis. Objective: To determine the proportion of radiographs inconsistent with bronchiolitis in children with typical presentation of bronchiolitis and to compare rates of intended antibiotic therapy before radiography versus those given antibiotics after radiography. Conclusions: Infants with typical bronchiolitis do not need imaging because it is almost always consistent with bronchiolitis. Risk of airspace disease appears particularly low in children with saturation higher than 92% and mild to moderate distress. Schuh S, Lalani A, Allen U, et al. Evaluation of the Utility of Radiography in Acute Bronchiolitis. The Journal of Pediatrics. 2007;150(4):429–433.
Slide 13	The American Academy of Pediatrics (AAP) does not routinely recommend obtaining CXRs in uncomplicated cases of bronchiolitis. A CXR should only be obtained when there is high pre-test probability of a complication of bronchiolitis, or an alternate diagnosis, or a patient is ill and requiring critical care. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014;134(5):e1474–e1502. Pediatrics. Reference correction: 2015;136(4).
Slide 14	The typical clinical course for bronchiolitis is often predictable: upper respiratory infection (URI) symptoms, then lower respiratory infection (LRI) symptoms, then resolution. We can often predict when the course will get a little worse before it gets better. Deviation from this typical course should raise suspicion for alternative diagnoses or complications.
Slide 15	Indications for hospitalization are usually due to inability for the caregivers to provide necessary care at home, often due to poor feeding and dehydration and/or respiratory distress or failure.
Slide 16	Supportive measures for bronchiolitis are ensuring proper hydration and appropriate pulmonary toilet. Maintain adequate fluid intake with PO, NG, or IV fluids Nasal bulb suctioning as needed to clear nasal obstruction Routine deep suctioning is not recommended Antipyretics are used as a comfort measure The child should be allowed to rest Mechanical ventilation (pressure support or intubation) should be performed if any indication of respiratory failure. Oxygen goal should be >90–92% Mechanical ventilation indicated for hypercarbia or apnea Consider early fluid support due to insensible losses from heavy breathing and decreased intake.
Slide 17	Few therapeutic options exist for the management of bronchiolitis: Chest physiotherapy – does not reduce oxygen need or shorten hospitalization; may increase distress and irritability. Bronchodilators – a subset of children with Hx of pulmonary disease, or reactive airway disease, or atopy with significant wheezing may respond; a trial of albuterol or epinephrine may be appropriate; discontinue if not clearly helpful. Corticosteroids – not recommended if previously healthy child with 1st episode of bronchiolitis and no response to bronchodilators; may help with chronic lung disease or history of recurrent wheezing. Antivirals (oseltamivir, ribavirin) – modest effectiveness and costly; may be useful if confirmed RSV and severe disease, but must be given early in course of illness. Antibiotics – only if there is evidence of concomitant bacterial infection (positive urine culture, acute otitis media, consolidation on CXR). Surfactant – may decrease duration of mechanical ventilation or ICU stay, but not routinely recommended.
Slide 18	Complications of bronchiolitis are few, but most commonly include: Apnea particularly in children <6 weeks old Respiratory failure Concomitant or superimposed bacterial failure
Slide 19	The majority of children will be able to be discharged to home in the care of their parents/guardians. Caretakers need to be educated on the expectant clinical course and signs that the child may be deviating from that course. Caretakers need to be educated on how to properly suction the child and when to suction the child (ie, if having difficulty breathing or difficulty feeding). The healthcare provider needs to empower the caretaker to care for the child at home and recognize a worsening clinical course.
Slide 20	An explanation of the meaning of the American Academy of Pediatrics (AAP) recommendations based on aggregate evidence quality.
Slide 21	AAP Recommendations for diagnosis: The AAP revised recommendations about treatment of bronchiolitis in 2014. Bronchiolitis should be a clinical diagnosis, not relying on laboratory or imaging studies. Severe disease includes age less than 12 weeks, history of prematurity, underlying cardiopulmonary disease, immunodeficiency. Ralston SL, Lieberthal AS, Meissner HC, et al; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502.
Slide 22	AAP recommendations for management Beta-agonist are only recommended in certain populations – specifically for populations with chronic lung disease. Previously healthy children should not routinely receive beta-agonists. Hypertonic saline may be more useful in admitted patients in the inpatient setting than patients in the emergency setting.
Slide 23	AAP recommendations for management: Corticosteroids are indicated in reactive airway disease or sometimes in other chronic lung disease states, but they are not indicated in acute bronchiolitis in the previously healthy child. A clinician should ensure that a child is staying hydrated due to the high risk of dehydration. Avoid routine use of antibiotics for this condition that is usually due to a viral source unless there is a strong suspicion for superinfection or concomitant infection.