Bronchiolitis - Clinicals, Diagnosis, and Management

Pulmonology

Clinicals - History

Fact Explanation
Fever Due to initial upper respiratory tract infection followed by lower respiratory tract infection, caused by the Respiratory Syncytial virus (RSV), Parainfluenza, Mycoplasma and other viruses . Fever
Due to initial upper respiratory tract infection followed by lower respiratory tract infection, caused by the Respiratory Syncytial virus (RSV), Parainfluenza, Mycoplasma and other viruses .
Rhinorrhoea Initial upper respiratory tract infection causing increased secretions. Rhinorrhoea
Initial upper respiratory tract infection causing increased secretions.
Cough Stimulation of cough receptors in the respiratory tract epithelium, by secretions caused by inflammation of the bronchioles . Cough
Stimulation of cough receptors in the respiratory tract epithelium, by secretions caused by inflammation of the bronchioles .
Poor feeding Due to dyspnoea . Poor feeding
Due to dyspnoea .
Apnoea Reduced stimulation of the respiratory center by lack of carbon dioxide, caused by compensatory hyperventilation to overcome the hypoxia . Apnoea
Reduced stimulation of the respiratory center by lack of carbon dioxide, caused by compensatory hyperventilation to overcome the hypoxia .

Clinicals - Examination

Fact Explanation
Tachypnoea Increased effort of breathing. Tachypnoea
Increased effort of breathing.
Expiratory wheeze Oscillation of narrowed bronchioles of which the radius is narrowed by edema, mucus, cellular debris and bronchospasm caused by inflammation and further narrowed during expiration . Expiratory wheeze
Oscillation of narrowed bronchioles of which the radius is narrowed by edema, mucus, cellular debris and bronchospasm caused by inflammation and further narrowed during expiration .
Nasal flaring Increased effort of breathing. Nasal flaring
Increased effort of breathing.
Subcostal, intercostal and supraclavicular recessions Increased effort of breathing . Subcostal, intercostal and supraclavicular recessions
Increased effort of breathing .
Hyper-inflated chest with prominent sternum and liver displaced downwards Trapping of air during expiration as the resistance to flow is more due to further reduction of the radius of the bronchiole, resulting in hyper inflation . Hyper-inflated chest with prominent sternum and liver displaced downwards
Trapping of air during expiration as the resistance to flow is more due to further reduction of the radius of the bronchiole, resulting in hyper inflation .
Fine inspiratory crackels Noice produced by the abrupt opening of the peripheral airways during inspiration, which were collapsed during expiration . Fine inspiratory crackels
Noice produced by the abrupt opening of the peripheral airways during inspiration, which were collapsed during expiration .
Prolonged expiration Activates Hearing-Breuer reflex and allow secretions to flow from small airways to larger airways up to the trachea . Prolonged expiration
Activates Hearing-Breuer reflex and allow secretions to flow from small airways to larger airways up to the trachea .
Cyanosis Hypoxia due to ventlation-perfusion mismatch . Cyanosis
Hypoxia due to ventlation-perfusion mismatch .

Investigations - Diagnosis

Fact Explanation
Chest radiograph Reveals hyper-inflated lungs with patchy atelectasis .
Note: Acute bronchiolitis is essentially a clinical diagnosis. Investigations to diagnose should not be carried out in typical acute bronchiolitis, except when there is diagnostic uncertainty .
Chest radiograph
Reveals hyper-inflated lungs with patchy atelectasis .
Note: Acute bronchiolitis is essentially a clinical diagnosis. Investigations to diagnose should not be carried out in typical acute bronchiolitis, except when there is diagnostic uncertainty .
Viral testing by rapid immunofluorescence, polymerase chain reaction or culture Can be used when the diagnosis is uncertain or for epidemiological studies .
Note: Rapid testing for Respiratory Syncytial virus is recommended for hospitalized infants to guide cohort arrangements .
Viral testing by rapid immunofluorescence, polymerase chain reaction or culture
Can be used when the diagnosis is uncertain or for epidemiological studies .
Note: Rapid testing for Respiratory Syncytial virus is recommended for hospitalized infants to guide cohort arrangements .

Investigations - Management

Fact Explanation
Pulse oxymetry A useful guide to asses the severity of the diseases and decide on management . Pulse oxymetry
A useful guide to asses the severity of the diseases and decide on management .
Arterial/capillary blood gases Help in the assessment of infants with severe respiratory distress and those who are entering respiratory failure.
Arterial carbon dioxide values may be useful in deciding on the need of high dependency or intensive care .
Arterial/capillary blood gases
Help in the assessment of infants with severe respiratory distress and those who are entering respiratory failure.
Arterial carbon dioxide values may be useful in deciding on the need of high dependency or intensive care .

Management - Supportive

Fact Explanation
Oxygen therapy To treat hypoxia. Supplemental oxygen should be given to infants with oxygen saturation <90%. Oxygen may be discontinued of the saturation is at or above 90% and the infant is feeding well and has minimal respiratory distress . Oxygen therapy
To treat hypoxia. Supplemental oxygen should be given to infants with oxygen saturation <90%. Oxygen may be discontinued of the saturation is at or above 90% and the infant is feeding well and has minimal respiratory distress .
Maintain fluid balance To maintain good input which can be difficult due to poor feeding associated with dyspnoea. Consider naso-gastric feeding in infants who cannot maintain oral intake .
Important: Caution should be taken in fluid balance as there is a risk of Syndrome of Inappropriate ADH Secretion associated with bronchiolitis. Restriction of water may be neccessary .
Maintain fluid balance
To maintain good input which can be difficult due to poor feeding associated with dyspnoea. Consider naso-gastric feeding in infants who cannot maintain oral intake .
Important: Caution should be taken in fluid balance as there is a risk of Syndrome of Inappropriate ADH Secretion associated with bronchiolitis. Restriction of water may be neccessary .
Nasal suction Useful in infants showing respiratory distress due to nasal blockage . Nasal suction
Useful in infants showing respiratory distress due to nasal blockage .
Ventilatory support Consider in infants with severe respiratory distress or apnoea . Ventilatory support
Consider in infants with severe respiratory distress or apnoea .
Chest physiotherapy This is not recommended .
However it may be used in infants receiving intensive care .
Chest physiotherapy
This is not recommended .
However it may be used in infants receiving intensive care .
Take steps to prevent nosocomial spread of bronchiolitis Hand decontamination with alcohol based rubs: Essential step to prevent the nosocomial spread of Respiratory Syncytial virus (RSV) .
Health education: Educating the family members and care givers on hand sanitation can reduce the nosocomial spread of RSV .
Take steps to prevent nosocomial spread of bronchiolitis
Hand decontamination with alcohol based rubs: Essential step to prevent the nosocomial spread of Respiratory Syncytial virus (RSV) .
Health education: Educating the family members and care givers on hand sanitation can reduce the nosocomial spread of RSV .
Health education to mother and other family members Education on breast feeding and preventing the child from exposure to passive smoking is important in reducing the child's risk of having lower respiratory tract infections in the future . Health education to mother and other family members
Education on breast feeding and preventing the child from exposure to passive smoking is important in reducing the child's risk of having lower respiratory tract infections in the future .

Management - Specific

Fact Explanation
Therapy with bronchodilators Not recommended for treatment of acute bronchiolitis in infants .
However a trial of alpha or beta adrenergic mediaction can be tried and it should only be continued if there is a documented positive response .
Therapy with bronchodilators
Not recommended for treatment of acute bronchiolitis in infants .
However a trial of alpha or beta adrenergic mediaction can be tried and it should only be continued if there is a documented positive response .
Therapy with antivirals (Ribavarin) Not recommended to be used routinely in bronchiolitis . Therapy with antivirals (Ribavarin)
Not recommended to be used routinely in bronchiolitis .
Therapy with corticosteroids Not recommended to be used routinely in bronchiolitis . Therapy with corticosteroids
Not recommended to be used routinely in bronchiolitis .
Therapy with antibiotics Not recommended to be used routinely .
Should only be used in infants with co-existing bacterial infection, in the same manner as in the absence of bronchiolitis .
Therapy with antibiotics
Not recommended to be used routinely .
Should only be used in infants with co-existing bacterial infection, in the same manner as in the absence of bronchiolitis .
Therapy with nebulized epinephrine Not recommended to be used routinely in bronchiolitis . Therapy with nebulized epinephrine
Not recommended to be used routinely in bronchiolitis .
Prophylaxis with Palivizumab May be used in selected infants with bronchopulmonary dysplasia, history of prematurity (less than 35 weeks gestation) or congenital heart diesease . Prophylaxis with Palivizumab
May be used in selected infants with bronchopulmonary dysplasia, history of prematurity (less than 35 weeks gestation) or congenital heart diesease .

Concise, fact-based medical articles to refresh your knowledge

Access a wealth of content and skim through a smartly presented catalog of diseases and conditions.

  1. Bronchiolitis in children: A national clinical guideline. Scottish intercollegiate guidelines network, 2006 [viewed 02 March 2014]. Available from: http://sign.ac.uk/pdf/sign91.pdf
  2. GANONG, William F. Review of medical physiology. 22nd ed. Singapore: McGraw-Hill, 2005.
  3. GOZAL, D., M. JAFFE, A. A. COLIN, L. KAHANA, Z. HOCHBERG. The water-electrolyte endocrine balance in infants with bronchiolitis. Pediatric research [Online]. International Pediatric Research Foundation.1988, 24, 545–545 [viewed 05 March 2014]. Available from: doi:10.1203/00006450-198810000-00188.
  4. KHUMAN, P. Ratan, Lourembam SURBALA, Priyanka MEHTA, Ankita MAKWANA. Infant with bronchiolitis and chest physical therapy: A case report. Scholars Journal of Medical Case Reports [online]. Scholars Academic and Scientific Publishers. 2014, 2(1):3-6 [viewed 02 March 2014]. Available from: http://saspjournals.com/sjmcr
  5. KLEIGMAN, Robert M, Richard E. BEHRMAN, Hal B. JENSON, Bonita F. STANTON. Nelson textbook of paediatrics. 18th ed. Philadelphia,PA: Elsevier, 2007.
  6. KLEIGMAN, Robert M, Richard E. BEHRMAN, Hal B. JENSON, Bonita F. STANTON. Nelson textbook of paediatrics. 18th ed. Philadelphia,PA: Elsevier, 2007.
  7. KLEIGMAN, Robert M, Richard E. BEHRMAN, Hal B. JENSON, Bonita F. STANTON. Nelson textbook of paediatrics. 18th ed. Philadelphia,PA: Elsevier, 2007.
  8. KUMAR, Praveen, Michael CLARK. Kumar & Clark's clinical medicine. 7th ed. Spain: Elsevier, 2009.
  9. KUMAR, Praveen, Michael CLARK. Kumar & Clark's clinical medicine. 7th ed. Spain: Elsevier, 2009.
  10. Subcommittee on Diagnosis and Management of Bronchiolitis: American Academy of Pediatrics. Pediatrcs [Online]. American Academy of Pediatrics. 2006, vol. 118, 1774-93 [viewed 02 March 2014]. Available from: DOI: 10.1542/peds.2006-2223.