Bronchiolitis: RSV, covid, flu and rhino oh my!
It’s that time of year, the pediatric ED is filled with bronchiolitis. Let’s review what bronchiolitis is and how to manage this condition.
What is bronchiolitis?
Bronchiolitis: Umbrella term for viral URI causing cough/congestion and lung mucus and inflammation leading to trouble breathing and wheezing in children under age 2 years old. RSV is the most common cause, however all viruses can cause bronchiolitis. Bronchiolitis is typically seen in the winter months or “flu season”, though in Florida we seem to see it nearly year-round! Viruses that cause this are easily spread by coughing and sneezing and most children have had RSV infection by the age of 2.
How does bronchiolitis present?
Child <2 yo typically presenting with cough/nasal mucus/possible fever. Normally, around day 3 of illness, with worsening breathing issues. You may note the child has increased work of breathing (nasal flaring, tachypnea, grunting, subcostal or intercostal retractions, or belly breathing). On exam, you hear a musical wheeze/crackles that comes and goes with cough/screaming.
What are the complications of bronchiolitis?
Bronchiolitis can lead to significant breathing issues with increased WOB like nasal flaring, retractions, grunting and at times hypoxia. The nasal mucus and/or increased WOB can lead to trouble taking bottles and eating leading to dehydration. Fever and increased RR lead to increased insensible fluid losses as well. Coughing can lead to vomiting too. Any viral URI can lead to eventual ear infections and or pneumonia if symptoms last long enough. Severe cases need admission for hydration and/or to support breathing and oxygen levels.
What’s the treatment of bronchiolitis?
The mainstay of treatment is suctioning the nose with saline to help loosen mucus.
Additional treatment tips:
Encouraging hydration at home.
Tylenol and motrin (>6 months old) for fevers.
Close watching for decreased urine output (strive for 3 wet diapers in 24 hours at minimum, with wet mouth/tears).
Humidifier in the room and/or steam showers before bed to loosen mucus can help.
In kids> 1 year old, honey and tea soothes cough. Remember no honey in kids < 1 year.
Never give children under 5 yo OTC cough cold meds with dextromethorophan. Typically zarabees which is a homeopathic sugar/honey OTC medication is considered safe.
Albuterol typically DOES NOT work for bronchiolitis. Keep in mind that Children with bronchiolitis can have crackles/wheezes at home and you do NOT have to treat that with albuterol if their WOB is normal. IF they did have increased WOB in ER and you gave albuterol and it fixed them, you can send home on albuterol.
When deciding on whether or not to use albuterol as a treatment, keep in mind that albuterol doesn’t typically work since this is not asthma. However, if I am looking at a kid working hard to breath with wheezes and my nose suctioning doesn’t work and the only other option is admission, I will try it. It is more likely that albuterol will work in kids> 1 year old with h/o eczema or family h/o asthma.
Provide good return precautions!
Make sure parents understand return precautions: like not peeing well, not taking enough POs, and retractions and grunting that they can not make better at home with suctioning +/- albuterol if it worked for them.
What are the inpatient treatment options for kids that aren’t well enough to go home?
For in hospital treatment, the mainstay is still nose suction/deep suction. If hypoxic, NC oxygen is used. If still with increased WOB after suction most children will need additional oxygen support. Most of the time we use heated high-flow nasal canula (HHFNC). This provides oxygen starting at 21% Fi02 and increasing for sats over 90%. It also provides a continuous flow support like PEEP. Starting at 1L up to 60L. Normally this is started at 1-2L/Kg and decreased for improved WOB. The American Board of Pediatrics came out with a position statement in 2019, saying that CXR, abx, steroids and inhaled bronchodilators do not work. However, the closer the child is to age 2 yo or a child with family hx of asthma, personal history of eczema/food allergies are more likely to have benefit with bronchodilator. If you use it, document if you thought it worked for the inpatient teams to decide if they will keep using it. If you felt it made a significant improvement, the patient may have some underlying reactive airway disease and they may also benefit from steroids.
You do NOT have to do a CXR for routine bronchiolitis. CXR can be done for prolonged fevers, concern for cardiac issues, foreign bodies, or asymmetric breath sounds. Most children will have some component of dehydration since it's difficult to drink a bottle while congested in the nose, but also increased fluid losses from fever and increased RR. We typically place an IV and check at minimum CMP for dehydration and give 20cc/kg NS bolus. If any concern for superimposed bacterial infection, you may also get CBC, blood culture, procal, CRP and UA. We typically check RSV/covid/flu swab for admissions, since if you are sick enough to stay you would likely warrant Tamiflu treatments and possibly even covid treatments. If any concern for cardiac issues you may do a CXR and BNP/EKG.
Severe cases happen in children <3 mo or prior premies, kids with lung dz. In neonates, infection with RSV in particular can cause apneic episodes, so consider testing BRUE patients for RSV if under 6 weeks. If patient doesn’t respond to HHFNC or appears to be tiring out, you may need to intubate them. Once intubated the PICU team may need to place the child on high levels of oxygen and PEEP to overcome the mucus and inflammation. In rare cases they may need to paralyze them and place them on Inhaled Nitric Oxide. At times, ventilators on oscillator mode may need to be used and patients may need to be placed on ECMO.
How long does the illness last?
Patients typically recover in 5-14 days but the cough can linger for 3 weeks. Fever typically lasts less than 5 days, if longer you may need to consider post viral PNA, ear infection, new viral infection or Kawasaki in the correct age group. For neonates that get RSV, it can make them more at risk for ongoing respiratory distress with all viral illnesses and there is some assoc with early RSV infection and reactive airway disease.
RSV Vaccines & Prevention
RSV Vaccines
RSV vaccines—It’s a monoclonal ab! Nirsevimab targets the F fusion protein on RSV (inhibits fusion with human target cell) with a longer half-life than synagis (1). Only one shot covers the same time as the 5 monthly synagis vaccines. Approved in Oct 23 for infants < 8 months during RSV season who’s parent didn’t get RSV vaccine during last 32-36 weeks or pregnancy and at least 14 days before delivery. A Randomized trial showed that vaccinated infants had 70% and 78% lower medically attending RSV infections and incidence of hospitilizations.
RSV vaccine for adults: Arexy approved in May 2023 for age >60yo and found up to 94% efficacy against severe RSV related lower resp tract illness. In places where monoclonal ab vaccine for infants isn’t available, vaccinated moms with Abryso (inactivated/nonadjuvanted vax) can be given to mom at 32-37 weeks in Sept-Jan time frame to prevent infection in newborns and infants.
References
1. Silver AH, Nazif JM. Bronchiolitis. Pediatr Rev. 2019 Nov;40(11):568-576. doi: 10.1542/pir.2018-0260. PMID: 31676530.
2. AAP. Comm On Infect Dis and Bronchiolitis Guidelines Comm. Updated Guidance for synagis prophylaxis among infants and young children at increased risk of hisp for RSV infection. Pediatrics. 2014; 134(2):415-420. Doi:10.1542/peds.2014-1665 [PubMed 25070315]
3. https://www.mayoclinic.org/diseases-conditions/bronchiolitis/symptoms-causes/syc-20351565
About the Author
Dr. Jasmine Patterson is faculty at USF Emergency Medicine and is the Medical Director for the Pediatric Emergency Department.