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William Schneider, DO, MA, FACEP Medical Director, Pediatric Emergency Services Banner Thunderbird Medical Center EPIP Conference November 3rd and 4th, 2011 1 Case Presentation ► 7 month old uncircumcised male gasping for air ► Low grade fever, cough and rhinorrhea for 2 days ► Now wheezing, grunting, with mod-severe retractions ► Unable to feed since this afternoon ► Hx of wheezing in past – parents are treated for asthma ► UTD with immunizations, ex-premie at 34 weeks gestation ► VS: BP 92/60, HR 132, RR 55, Temp 39.1̊C (R), POx 87% RA ► Moderately irritable and difficult to console ► Nasal flaring with intercostal and substernal retractions ► Diffuse expiratory wheezing 2 Work Up ► Asthma vs. Bronchiolitis pathway? ► Respiratory Score? ► Suction vs. SVN? Albuterol vs. Epinephrine SVN? ► Oxygen? What is Your Work Up? ► Steroids? ► CBC, BCx, UA, C&S, LP, CXR, viral studies? ► Nasal CPAP vs. Heliox vs. both combined? ► Risk factors? Severe Bronchiolitis Apnea 3 Objectives Bronchiolitis ► Review the current literature and the AAP recommendations for the diagnosis and management of Bronchiolitis ► Become familiar with the Bronchiolitis respiratory scoring tool used in the assessment of the severity of Bronchiolitis ► Explore the risk factors for Severe Bronchiolitis and Apnea ► Discuss the new Bronchiolitis Protocol using the Respiratory Scoring Tool to be implemented within Banner Health 4 Introduction Bronchiolitis ► Bronchiolitis is the most common lower respiratory tract infection in patients < 2 years of age Peak age: 2-8 months Male predominance (1.5:1) ► 200,000 visits to EDs annually ► 19% admission rate ► Cost $700 million annually 5 Definition AAP Bronchiolitis ► “…rhinitis, tachypnea, wheezing, cough, crackles, use of accessory muscles, and/or nasal flaring in a child younger than 24 months.” 6 Pathophysiology Bronchiolitis ► Virus invades the nasopharynx and spreads by cell to cell transfer to the lower tract within a few days Viral infection of the lower respiratory tract ► Increased mucous secretion, cell death and sloughing of the bronchial ciliated epithelial cells Clumps of necrotic epithelium and mucus decrease diameter of the bronchiolar lumen causing turbulent air flow particularly on expiration ► Peribronchiolar lymphocytic infiltrate and submucosal edema ► Narrowing, air trapping, and obstruction of small airways: Hyperinflation and atelectasis Ventilation/perfusion mismatch ↓ lung compliance and ↑ work of breathing ► Smooth muscle constriction has limited role 7 Recovery Bronchiolitis ► Degree of obstruction may vary as some of the airways clear resulting in rapidly changing clinical severity ► Epithelial cells recover after 3 – 4 days ► Cilia regenerate after 2 weeks ► Median duration of illness ~ 12 days ► Symptoms may persist for 3 (18%) to 4 (9%) weeks 8 Etiology Bronchiolitis ► RSV (50 – 80%): November to March Nearly all children (95%) infected within first 2 years of life 4 to 6 day incubation period precedes URI symptoms Spread through direct contact with secretions ► Human Metapneumovirus (3 – 19%) ► Parainfluenza Virus Type 3 ► Influenza ► Adenovirus ► Rhinovirus (common in asthma) 9 Differential Diagnosis Bronchiolitis LIFE-THREATENING CAUSES Infection: pneumonia, Chlamydia, Pertussis (apnea) Foreign body: aspirated or esophageal Cardiac anomaly: congestive heart failure, vascular ring Allergic reaction Bronchopulmonary disorder exacerbation (CLD) NON-LIFE THREATENING CAUSES Congenital anomaly: tracheoesophageal fistula, bronchogenic cyst, laryngotracheomalacia Gastroesophageal reflux disease Mediastinal mass Cystic fibrosis 10 Risk Factors For Severe Illness In Hospitalized Patients ► PICNIC network (Pediatric Investigators Collaborative Network on Infections in Canada 1995): 689 hospitalized children < 2 years: 6 out of 689 patients died (0.9%) 4 out of 6 had underlying disease (congenital heart disease, chronic lung disease, immunocompromised) 2 were either premature or < 6 weeks old None of 372 pts died if older than 6 weeks and without other risk factors for severe disease (95% CI 0-0.8%) 11 Risk Factors for Severe Bronchiolitis History ► Age < 6 - 12 weeks ► Prematurity < 34 - 37 weeks gestation ► Underlying chronic respiratory illness such as CF, CLD or BPD ► Significant congenital heart disease ► Immune deficiency including human immunodeficiency virus, organ or bone marrow transplants, or congenital immune deficiencies ► Prior intubation ► First 48 hours of illness 12 Risk Factors for Severe Bronchiolitis Physical Examination ► General appearance: ill appearing ► Oxygen saturation level < 92 - 94% on room air 5 fold increase in likelihood of hospitalization ► Respiratory rate > 60-70 breaths per minute ► Increased work of breathing - moderate to severe retractions and/or accessory muscle use ► Dehydration ► Male 13 Risk Factors for Apnea ► Full-term birth and < 1 month of age ► Preterm birth (< 37 weeks gestation) and age < 2 months post conception ► History of Apnea of prematurity ► Emergency Department presentation with apnea ► Apnea witnessed by a caregiver 14 Bronchiolitis Scoring Tool ► Assist in clinical decision-making within a protocol Objective and subjective reproducible clinical parameters ► Be applicable to its particular pathophysiology (LRTI) Validity: score relates to disease severity Good inter-rater reliability >80% Responsiveness: detect changes over time ► Apply to patients < 2 years of age ► Easily adopted by the provider, RT, RN, started in the ED and continued on the floor and/or PICU ► Goals: ↓ LOS, ↓ cost & ↓admission rate ↑Consistency, ↑efficiency, and ↑quality ► Reflect AAP recommendations 15 AAP Clinical Practice Guideline (Pediatrics 2006;118:1774) ► “Physical examination findings of importance include respiratory rate, increased work of breathing as evidenced by accessory muscle use or retractions, and ausculatory findings such as wheezes or crackles” ► “Pulse oximetry has been rapidly adopted into clinical assessment of children with Bronchiolitis on the basis of data suggesting that it can reliably detect hypoxemia that is not suspected on physical examination” ► “The lack of uniformity of scoring systems make comparison between studies difficult” 16 Bronchiolitis Respiratory Score (Liu, 2004) 0 Respiratory Rate 1 2 3 0-6 mo < 50 6mo – 1yr < 40 1 yr+ < 30 ≥ 90 % Calm No distress 0-6 mo < 60 6mo – 1yr < 50 1 yr+ < 45 > 88 % Mildly irritable; easy to console 0-6 mo < 70 6mo – 1yr < 60 1 yr+ < 60 > 86 % Moderately irritable; difficult to console 0-6 mo > 70 6mo – 1yr > 60 1 yr+ > 60 ≤ 85 % Extremely irritable; cannot be comforted Retractions and nasal flaring (NF, SS, IC, SC) None 1 of 4 2 of 4 3 or more Auscultation Clear Scattered wheezes Diffuse expiratory wheezing Biphasic wheezing or very poor air movement SaO2 General Appearance 17 Diagnostic Studies - CXR Bronchiolitis ► Schuh S, Lalani A, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007; 150(4):429-433. Prospective Cohort study of 265 infants 2-23 months old Only 2 CXR inconsistent with bronchiolitis Lobar consolidation More likely to treat with antibiotics Pre-radiography: 7 infants (2.6%) identified for antibiotics Post-radiography: 39 infants (14.7%) identified for antibiotics ► Not routinely recommended ► Reserved for clinical deterioration or unclear presentation 18 Normal With Possible Hyperinflation 19 RUL Atelectasis 20 Mild RML Perihilar Markings With Peribronchial Cuffing 21 Worse Bilateral Perihilar Infiltrates With Flattened Diaphragms 22 Diagnostic Studies – Labs/Viral Swab Bronchiolitis ► Rapid viral testing: Direct Fluorescent Antibody (DFA) is the Gold standard (99% sensitive) More sensitive than Enzyme Immunoassay (EIA) and Cx (thermo labile virus) Most viruses have similar presentation Results have minimal effect on management May be considered in infants <3 months of age Limit further lab testing Limit unnecessary antibiotics Not routinely recommended ► Routine CBC, BMP and blood cultures are not recommended ► Febrile neonate (> 38.0̊ C) with RSV and/or clinical bronchiolitis Requires septic workup and admission 23 RSV in Febrile Infants Study Information Bronchiolitis ► Study: The Risk of Serious Bacterial Infections in Young Febrile Infants with RSV Infections ► Pediatric Emergency Medicine Collaborative Research Committee of the AAP ► Authors: D Levine, S Platt, P Dayan, C Macias, J Zorc, W Krief, J Schor, D Bank, K Shaw, M Stein, C Jacobstein, N Fefferman and N Kuppermann and The Multicenter RSVSBI Study Group ► Pediatrics 2004; 113;1728 24 Background: RSV in Febrile Infants Bronchiolitis ► Young febrile infants are at substantial risk of SBI ► Clinical assessment may be difficult ► Unclear whether viral infection alters the risk of bacterial disease in this age 25 Methods: RSV in Febrile Infants Bronchiolitis ► Prospective, multi-center, cross sectional study: Eight Pediatric Emergency Departments October-March, 1998-2001 1,248 patients enrolled ► Inclusion: Age < 60 days Rectal temp > 38.0oC ► Exclusion: Received antibiotics w/in 48 hrs 26 Evaluation: RSV in Febrile Infants Bronchiolitis ► Clinical: History and physical examination Yale Observation Scale and Pulmonary Score ► Diagnostic Testing: Rapid RSV antigen Fever evaluation: urine, blood, CSF Stool culture - if symptomatic Chest radiograph ► Treatment / Disposition at discretion of physician ► Telephone follow-up 27 Categorization: RSV in Febrile Infants Bronchiolitis ► RSV Status: “Indeterminate” considered Negative ► Clinical Bronchiolitis: Wheezing or retractions with URI No lobar infiltrate on chest radiograph URI: history/presence of cough or Rhinorrhea 28 RSV in Febrile Infants Positive vs Negative NP Swab Results Variable RSV (+) RSV (-) RR N = 269 N = 979 (95% CI) Any SBI 17/244 116/925 7.0% 12.5% (10.5,14.8%) (0.3,0.9) UTI 14/261 98/966 0.5 5.4% 10.1% (0.3,0.9) (4.1,10.9%) (3.0, 8.8%) (8.3,12.2%) 0.5 p .013 .015 0.5 22/968 Bacteremia 3/267 1.1% (0.2, 3.2%) 2.3% (1.4, 3.4%) (0.1,1.6) .33 Meningitis 0/251 .21 8/938 (0, 1.2%) 0.9% (0.4, 1.7%) 0 3 RSV (+) with Bacteremia were neonates 29 RSV in Febrile Infants Clinical Bronchiolitis (CB) Results CB (+) CB (-) RR N = 156 N =1035 (95% CI) Any SBI 10/141 122/976 0.57 UTI 10/153 Variable 7.1% 6.5% (3.5,12.7%) 12.5% (10.5,14.7%) (0.3,1.1) 102/1018 (3.2,11.7%) 10% Bacteremia 0/154 Meningitis 0/146 (8.2,12.0%) (0.3,1.2) 24/1026 (0, 1.9%) 2.3% (1.5, 3.5%) 8/989 (0, 2.0%) 0.8% 0.65 (.3, 1.6%) p .069 .19 0 .06 0 .61 30 Conclusion: RSV in Febrile Infants Bronchiolitis ► Young febrile infants with RSV or clinical Bronchiolitis are at lower risk of SBI than febrile infants without these findings Routine RSV testing not necessary ► Risk of UTI, however, remains significant 31 Treatment Bronchiolitis ► Suctioning – First line therapy Nasal suction: BBG nasal aspirator Age-appropriate bulb suction Use prior to: – Feeds – SVN trials or therapy Deep posterior nasal-pharyngeal suctioning: Reserved for mod-severe respiratory distress from significant airway obstruction Data does not support routine use – May induce bronchospasm from irritation and /or agitation Normal saline nose drops may be used prior to suctioning 32 Treatment Bronchiolitis ► Oxygen - First line therapy Supplemental oxygen administered if POx consistently < 90%: After nasal suctioning, airway positioning and POx probe repositioning Titrate 02 to keep POx > 90% while awake or > 88% while sleeping Consider using continuous pulse oximetry Significant respiratory distress – First 12 to 24 hours High risk infants < 2 months of age Hx of prematurity RS > 10 Until patient is clinically improving 33 Treatment Bronchiolitis ► Albuterol nebulized therapy: Controversial Inconsistent results in studies Gadomski, et al. Bronchodilators for bronchiolitis. Cochrane Collaboration Database Syst rev. 2006;(3):CD001266: Small short term clinical improvements at best (14%) Do not affect rate of hospitalization or length of hospital stay Slightly more effective in those patients with history of wheezing or Atopy Routine use not recommended: – Consider SVN trial to determine effectiveness in individual patients 34 Treatment Bronchiolitis ► Epinephrine nebulized therapy: Hartling L, et al. Epinephrine for Bronchiolitis. Cochrane Collaboration Database Syst Rev. 2004;(1): CD003123: Slightly better clinical effect when compared with placebo or Albuterol Short-term improvements in clinical scores, POx, and respiratory rates The improvements possibly related to the alpha effect of vasoconstriction Should be reserved for mod-severe disease No reduction in the admission rates or length of hospital stay ► Anticholinergic agents (Ipratropium): Everad M, et al. Anticholinergic drugs for wheeze in children under the age of two years. Cochrane Collaboration Database Syst Rev. 2009: Review of 6 trials involving 321 infants No significant clinical improvement Not justified if used alone or in combination with B-adrenergic agents 35 AAP Treatment Recommendation Bronchiolitis ► “Bronchodilators should not be used routinely in the management of Bronchiolitis” ► “A carefully monitored trial of alpha-adrenergic or beta- adrenergic medication is an option. Inhaled Bronchodilators should be continued only if there is a documented positive clinical response to the trial using an objective means of evaluation.” 36 Treatment - Corticosteroids: Bronchiolitis ► Patel H. et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Collaboration Database syst rev. 2004;(3):CD004878. 13 studies with 1,198 patients No significant difference between steroid & placebo treatment groups: Clinical scores Oxygen sats Admission rates Length of stay Return visits 37 Corticosteroids Treatment Bronchiolitis ► Corneli HM, et al. A Multicenter Randomized, Controlled Trial of Dexamethasone for Bronchiolitis. N Engl J Med. 2007;357:331-339 (Bronchiolitis study group of the Pediatric Emergency Care Applied Research Network): 600 patients with first episode of bronchiolitis 2 – 12 months of age with mod-severe disease 2004 – 2006 / 20 medical center Eds Dexamethasone 1 mg/kg vs. placebo: Measure outcome at 4 hours: No significant difference in clinical respiratory scores No difference in admit rates (39.7% vs. 41%) No difference in readmission rates or hospital LOS Conclusion: Did not improve outcomes – ED – Hospital 38 Corticosteroids Treatment AAP Recommendation ► “Corticosteroid medications should not be used routinely in the management of Bronchiolitis.” 39 Treatment Bronchiolitis ► Inhaled steroids: 2 small studies Showed no benefit in the course of the acute disease ► Nebulized Hypertonic 3% Saline: Improves mucociliary clearance in cystic fibrosis Kuzik, et al. Nebulized hypertonic saline in the treatment of viral bronchiolitis in infants. J Pediatr 2007; 151:266-270. Multi-center trial of 96 patients admitted 3% saline vs. normal saline SVN 26% reduction in hospital length of stay (2.6 vs. 3.5 days) Chaudhry K, Sinert R. Is nebulized hypertonic saline solution an effective treatment for bronchiolitis in infants? Annals of Emerg. Med. 2010; 55 (1): 120-12122: No significant clinical outcome in ED or admission rate 40 Treatment Bronchiolitis ► Nasal Continuous Positive Airway Pressure (CPAP): Noninvasive humidified high flow nasal cannula (1L/kg/min) Decreases inspiratory muscle work load Relieves atelectasis Prevents airway collapse Improves ventilation Bridge to intubation Severe respiratory distress Apnea spells Heliox alone or in addition to nasal CPAP: Helium + 21% oxygen mixed gas 1/3 as dense as air Reduces gaseous flow resistance Improves gaseous exchange and alveolar ventilation Increases C02 elimination Response seen within first hour 41 Ineffective Treatments ► Ribavirin: No role (Randolph 1996 Arch Ped Adoles Med) ► Antibiotics: < 2% have concurrent bacterial infection (Purcell 2002 Arch Ped Adoles Med) No difference in hospitalization with or without antibiotics (Friis 1984 Arch Dis Child) ► Antihistamines, Decongestants, Singulair ► Inhaled Interferon -2a ► Nebulized Furosemide ► Chest Physiotherapy 42 Criteria for Hospitalization Bronchiolitis ► Persistent respiratory distress after treatment (RS > 5) ► POx consistently < 92% ► Dehydration with inadequate po intake ► Significant risk factors for Apnea: < 1-2 month old with hx of prematurity < 35 weeks gestation ► Unreliable caretaker ► Witnessed Apnea by caretaker or ED personnel ► Febrile neonate ► Respiratory rate > 60 breaths per minute after treatment ► Continual need for deep NP suctioning ► Physician discretion 43 Criteria for PICU Admission Bronchiolitis ► Intubation ► Nasal CPAP (HHNC/Heliox) ► Apnea ► RS > 10 ► Sepsis ► Frequent bronchodilator SVN less than 2 hours apart ► Physician discretion 44 Criteria for Discharge Bronchiolitis ► Oxygen sats consistently > 92% ► No respiratory distress (RS < 5) ► No apnea or significant risk factors ► Respiratory rate < 60 breaths per minute ► Adequate oral intake ► Family education complete ► Adequate bulb suctioning ► Physician discretion ► Caretaker comfortable and reliable 45 Risk Factors for ED Return Visit Bronchiolitis ► 17 - 20% ED return rate: 65% within 2 days ► Norwood A, Mansbach JM, Clark S, et al. Prospective multi- center study of bronchiolitis: predictors of an unscheduled visit after discharge from the emergency department. Acad. Emerg Med. 2010 Apr;17(4):376-82. [722 patients younger than 2 years of age]: OR < 2 months of age: 2.1 Sex: male: 1.7 History of hospitalizations: 1.7 Prematurity (< 35 weeks): 1.6 p-value 0.03 0.02 0.02 0.16 46 Conclusion Bronchiolitis ► Bronchiolitis is mainly a clinical diagnosis ► Diagnostic laboratory and radiographic tests play a limited role ► Bronchodilators and steroids lack significant clinical effectiveness ► Supplemental oxygen indicated if POx < 90% consistently ► Assess patients for risk factors when making final disposition decisions ► Respiratory tool and protocol aid in treatment and disposition decisions ► Most patients recover with suction, O2 & fluids only 47 Bronchiolitis Protocol Process Flow ED and Inpatient 48 Supportive Care Orders Observation or Admit if admission criteria met RS > 5 (AFTER Suction) No (ED and Inpatient) Patient meets Discharge Criteria? Yes History of wheezing, atopy, or FH of asthma? 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 Yes Yes Classified as Epi Responder Score improved >3 points? No Classified as Non-Bronchodilator Responder No Score improved >3 points? Discharge with Supportive Care and Family Education ■ 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 ■ Albuterol Responder: Yes • • Classified as Albuterol Responder No Patient meets Discharge Criteria? Yes Yes D I S C H A RGE No Bronchiolitis Protocol Process Flow No ADMIT ASSESS & SCORE using Respiratory Scoring Tool (“Assess – Suction – Assess” process) 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 49 Bronchiolitis Protocol ► Inclusion criteria: Diagnosis of bronchiolitis Less than 2 years of age ► Exclusion criteria: Hx of cystic fibrosis (CF) Hx of Bronchopulmonary dysplasia (BPD) Significant or cyanotic congenital heart disease Immunocompromised On home oxygen Has significant comorbid conditions complicating care 50 Bronchiolitis Protocol ► Does the patient meet eligibility criteria? ► Use Banner Health System (BHS) Bronchiolitis Order Set/RT Bronchiolitis Protocol ► Assess & Score using BHS Sheet (Always score before and after intervention): Allow 10-15 minutes after each intervention before reassessment and scoring ► Document patient past medical history of Atopy, allergies, or wheezing ► Document family medical history of asthma: First degree relatives treated for asthma (parents, siblings) 51 ED and Inpatient Supportive Care Orders ► Oral or nasopharyngeal suctioning prn by RT/RN : Age appropriate suction bulb or BBG nasal aspirator Reserve deep suction for airway obstruction causing significant respiratory compromise ► Scheduled spot check pulse oximetry Q4 hrs (Q1 hrs in ED) and prn: 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 >10) ► Begin Oxygen Protocol: Supplemental O2 begins ONLY when pulse Ox consistently < 90% after suction/repositioning O2 weaning starts when O2 consistently > 90% while awake or > 88% asleep comfortably ► Bronchiolitis assessment: Scoring to be done PRE & POST intervention primarily by the RT (RN if RT not available): (Q 30-60 minutes and prn in ED) PRN if post score 0 - 4 Q4 hrs and prn if post score is > 5 Q2 hrs and prn if post score is > 7 ► Begin family education upon hospital admission or complete at discharge ► Notify physician if score > 10, clinical deterioration, or new O2 requirements ► Consider nasal CPAP (HHNC/Heliox) if severe respiratory distress or apnea spells ► Notify physician when discharge criteria are met 52 ASSESS & SCORE using Respiratory Scoring Tool (“Assess – Suction – Assess” process) Bronchiolitis Protocol Process Flow Include: 0-24 months; Dx Bronchiolitis Exclude: hx BPD, CHD, home O2, or significant comorbid conditions Supportive Care Orders Observation or Admit if admission criteria met RS > 5 (AFTER Suction) No Yes No History of wheezing, Atopy, or first degree relative treated for asthma? Trial of Racemic Epinephrine SVN <5kg: 5.63mg (0.25ml) >5kg: 11.25mg (0.5ml) Patient meets Discharge Criteria? Yes D/C with Supportive Care & Family Education Yes Trial of Albuterol Nebulizer (2.5 mg / 3cc) or MDI 4 puffs No Score improved >3 points? No Score improved >3 points? DISCHARGE CRITERIA: ■ O 2 Sats consistently >92% ■ No respiratory distress (RS <5) ■ Feeding adequately ■ Family comfortable & reliable ■ Family education complete ■ Respiratory rate <60 ■ No Apnea or significant risk ■ Bulb suction adequate ■ Physician discretion 53 Bronchiolitis Protocol Process Flow continued 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 Classified as Epi Responder Score improved >3 points? No Classified as Non-Bronchodilator Responder Patient meets Discharge Criteria? Score improved >3 points? Yes Classified as Albuterol Responder ADMISSION CRITERIA: ■ O 2 Sats consistently <92% ■ RS >5 ■ Feeding poorly or dehydrated ■ Family unreliable ■ Respiratory rate >60 ■ Apnea witnessed ■ Significant risk factors for apnea ■ Neonatal fever ■ Bulb suction inadequate ■ Physician discretion PICU CRITERIA: ■ Intubation ■ Nasal CPAP (HHNC/Heliox) ■ RS > 10 ■ Apnea ■ Frequent bronchodilator <2 hrs ■ Sepsis ■ Physician discretion 54 ■ 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 ■Albuterol Responder: No ADMIT Patient meets Discharge Criteria? Yes D I S C H A RG E Bronchiolitis Protocol Process Flow continued • 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 55 Case Conclusion ► 7 month old male gasping for air: low grade fever cough and rhinorrhea for 2 days now wheezing, grunting, with modsevere retractions unable to feed since this afternoon hx of wheezing in past parents treated for asthma UTD with immunizations, uncircumcised ex-premie at 34 weeks gestation VS: BP 92/60, HR 132,RR 55, T 39.1̊C (R), POx 87% RA moderately irritable and difficult to console nasal flaring with intercostal and substernal retractions diffuse expiratory wheezing ■ Asthma vs. Bronchiolitis pathway? ■ Respiratory Score? ■ Suction vs. SVN? – Albuterol vs. Epinephrine SVN? ■ Oxygen? ■ Steroids? ■ CBC, BCx, UA, C&S, LP, CXR, viral studies? ■ Nasal CPAP vs. Heliox vs. both? ■ Risk factors? – Severe Bronchiolitis – Apnea 56 References ► Bronchiolitis Guideline Team, Cincinnati Chi8ldren’s Hospital Medical Center. 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