Manage Bronchiolitis
Neonates less than one month of age are at highest risk for apnea — they should be admitted - Tim Horeczko MD
image by: JAMA
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Bronchiolitis – “Seriously, what should I do?”
Bottom Line {from my unscientific and non-randomized opinion}...
Bronchiolitis will continue to be studied and these studies will continue to yield conflicting results. It offers you the opportunity to actually use your clinical skills to determine the best management strategy. Tailor the management to the particular patient. These children should be assessed multiple times to determine their respiratory status while alert, sleepy, eating, playing, etc. A trial of bronchodilator is appropriate… but you must assess them right before and after its use to determine efficacy in that patient (not useful to go back 2 hours later to see if it worked). For those who aren’t responding… try…
Resources
Acute Bronchiolitis: Assessment and Management in the Emergency Department
While studies have demonstrated a lack of efficacy for bronchodilators and corticosteroids, more recent studies suggest a potential role for combination therapies and high-flow nasal cannula therapy.
Episode 59: Bronchiolitis
Remember that bronchiolitis symptoms peak around days 3-5. If the patient presents on Day 2, you can expect the patient may get worse before they get better. This should be factored into your disposition decision. Also, 50% of patients who develop severe disease do so after their first ED visit, so clear discharge instructions are very important.
PEM Playbook – Bronchiolitis
Should we use bronchodilators in bronchiolitis? It seems lately that this is a loaded question – with strong feelings on either side amongst colleagues. The short answer is that the American Academy of Pediatrics, the UK’s National Institute for Health and Care Excellence, as well as the Canadian Pediatric Society currently recommend against them. However, in continental Europe and Australia, the language is softened to “not routinely recommended”.
Summer Surprise...RSV Bronchiolitis
Routine administration of albuterol has not been shown to have benefit, the most recent AAP guidelines have a recommendation against trial of albuterol (common practices continue to be variable). It should be noted that children with severe disease were excluded from the studies used to make this recommendation.
Bronchiolitis – “Seriously, what should I do?”
DEEP NASAL Suctioning!! (no randomized control trials to assess this… but seems to make the most sense!). There are numerous studies that continually conflict with each other. Part of the problem is the heterogeneity of the disease makes it difficult to study consistently.
Core EM
Routine use of nebulized bronchodilators does not alter clinical course (Gadomski 2014, PMID: 24937099).
WikEM
Randomized controlled trials of bronchodilator or corticosteroid therapy have shown mixed results. Bronchodilators could aggravate the symptoms.
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