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Bronchiolitis Clinical Practice: An Evidence-Based Approach

Bronchiolitis Clinical Practice: An Evidence-Based Approach. William Schneider, DO, MA, FACEP Medical Director, Pediatric Emergency Services Banner Thunderbird Medical Center EPIP Conference November 3 rd and 4 th , 2011. Case Presentation. 7 month old uncircumcised male gasping for air

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Bronchiolitis Clinical Practice: An Evidence-Based Approach

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  1. Bronchiolitis Clinical Practice: An Evidence-Based Approach William Schneider, DO, MA, FACEP Medical Director, Pediatric Emergency Services Banner Thunderbird Medical Center EPIP Conference November 3rd and 4th, 2011

  2. 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

  3. Work Up • 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 combined? • Risk factors? • Severe Bronchiolitis • Apnea What is Your Work Up?

  4. ObjectivesBronchiolitis • 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

  5. 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

  6. Definition AAPBronchiolitis • “…rhinitis, tachypnea, wheezing, cough, crackles, use of accessory muscles, and/or nasal flaring in a child younger than 24 months.”

  7. PathophysiologyBronchiolitis • 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

  8. RecoveryBronchiolitis • 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

  9. EtiologyBronchiolitis • 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)

  10. Differential DiagnosisBronchiolitis

  11. 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%)

  12. Risk Factors for Severe BronchiolitisHistory • 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

  13. Risk Factors for Severe BronchiolitisPhysical 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

  14. 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

  15. 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

  16. 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”

  17. Bronchiolitis Respiratory Score (Liu, 2004)

  18. Diagnostic Studies - CXRBronchiolitis • 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

  19. Normal With Possible Hyperinflation

  20. RUL Atelectasis

  21. Mild RML Perihilar Markings With Peribronchial Cuffing

  22. Worse Bilateral Perihilar Infiltrates With Flattened Diaphragms

  23. Diagnostic Studies – Labs/Viral SwabBronchiolitis • 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

  24. RSV in Febrile Infants Study InformationBronchiolitis • 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 RSV-SBI Study Group • Pediatrics 2004; 113;1728

  25. Background: RSV in Febrile InfantsBronchiolitis • 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

  26. Methods: RSV in Febrile InfantsBronchiolitis • 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

  27. Evaluation: RSV in Febrile InfantsBronchiolitis • 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

  28. Categorization: RSV in Febrile InfantsBronchiolitis • 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

  29. RSV in Febrile InfantsPositive vs Negative NP Swab Results 3 RSV (+) with Bacteremia were neonates

  30. RSV in Febrile InfantsClinical Bronchiolitis (CB) Results

  31. Conclusion: RSV in Febrile InfantsBronchiolitis • 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

  32. TreatmentBronchiolitis • 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

  33. TreatmentBronchiolitis • 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

  34. TreatmentBronchiolitis • 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

  35. TreatmentBronchiolitis • 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

  36. AAP Treatment RecommendationBronchiolitis • “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.”

  37. 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

  38. 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

  39. Corticosteroids Treatment AAP Recommendation • “Corticosteroid medications should not be used routinely in the management of Bronchiolitis.”

  40. TreatmentBronchiolitis • 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

  41. TreatmentBronchiolitis • 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

  42. 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

  43. Criteria for HospitalizationBronchiolitis • 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

  44. Criteria for PICU AdmissionBronchiolitis • Intubation • Nasal CPAP (HHNC/Heliox) • Apnea • RS > 10 • Sepsis • Frequent bronchodilator SVN less than 2 hours apart • Physician discretion

  45. Criteria for DischargeBronchiolitis • 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

  46. Risk Factors for ED Return VisitBronchiolitis • 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]: ORp-value • < 2 months of age: 2.1 0.03 • Sex: male: 1.7 0.02 • History of hospitalizations: 1.7 0.02 • Prematurity (< 35 weeks): 1.6 0.16

  47. ConclusionBronchiolitis • 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

  48. Bronchiolitis Protocol Process Flow ED and Inpatient

  49. ASSESS & SCORE using Respiratory Scoring Tool (“Assess – Suction – Assess” process) Bronchiolitis Protocol Process Flow (ED and Inpatient) No Supportive Care Orders Observation or Admit if admission criteria met Patient meets Discharge Criteria? Yes No RS > 5 (AFTER Suction) Discharge with Supportive Care and Family Education Yes History of wheezing, atopy, or FH of asthma? No Yes DISCHARGE Trial of Albuterol Nebulizer (2.5 mg/3cc) or MDI 4 puffs Trial of Racemic Epinephrine SVN <5kg: 5.63mg (0.25ml) >5kg: 11.25mg (0.5ml) • 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 Yes Score improved >3 points? Score improved >3 points? No Yes No Yes • Albuterol Responder: • 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 Classified as Epi Responder Classified as Non-Bronchodilator Responder Classified as Albuterol Responder ADMIT No Patient meets Discharge Criteria?

  50. 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

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