Alfonso Belmonte MD Objectives After the lecture the learner should be able to 1 Describe the pathophysiology of wheezing 2 List 23 features that differentiate bronchiolitis asthma foreign body and left to right heart lesions with heart failure ID: 934407
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Slide1
Bronchiolitis
8/9/17
UNM Family and Community Medicine Residency School
Alfonso Belmonte, MD
Slide2Slide3Objectives
After the lecture the learner should be able to:
1) Describe the pathophysiology of wheezing
2) List 2-3 features that differentiate bronchiolitis, asthma, foreign body and left to right heart lesions with heart failure
3) Discuss AAP policy on
Diagnosis
Risk Factor assessment
Treatment
4
) Discuss UNM policy and practices for bronchiolitis
Slide4Objectives
After the lecture the learner should be able to:
1) Describe the pathophysiology of wheezing
2) List 2-3 features that differentiate bronchiolitis, asthma, foreign body and left to right heart lesions with heart failure
3) Discuss AAP policy on
Diagnosis
Risk Factor assessment
Treatment
4
) Discuss UNM policy and practices
Slide5Wheezing asthma
Slide6Wheezing asthma
Distal
Wheezing Airway
obstruction
Slide7Extra-luminal compression
-interstitial edema
-smooth muscle contraction
Intra-luminal obstruction
-mucus/cellular debris
-foreign body
Slide8Asthma= extra-luminal compression
Slide9Bronchiolitis=intra-luminal obstruction
Slide10Foreign Body=intra-luminal obstruction
Slide11Pulmonary Edema=intra
and extra luminal
obstruction
Slide12Wheezing asthma
Distal
Wheezing Airway
obstruction
Slide13Questions?????
1) Describe the pathophysiology of wheezing
Slide14Objectives
After the lecture the learner should be able to:
1) Describe the pathophysiology of wheezing
2) List 2-3 features that differentiate bronchiolitis, asthma, foreign body and left to right heart lesions with heart failure
3) Discuss AAP policy on
Diagnosis
Risk Factor assessment
Treatment
4
) Discuss UNM policy and practices
Slide15Common Symptoms
Wheezing
Tachypnea / resp. distress
Hypoxemia
Poor Feeding
Pulmonary crackles
Cough
Slide16Foreign Body
Asthma
Bronchiolitis
Heart Failure in Left to right shunts
Common Symptoms
Wheezing
Tachypnea / resp. distress
Hypoxemia
Poor Feeding
Pulmonary crackles
Cough
Slide17Foreign Body
-FOCAL wheezing
-Hyper-acute onset
-no preceding URI
-abnormal bilateral lateral decubitus
Asthma
-Older (>4) OR
-Younger than 4 with + asthma predictive index
-Family History
Bronchiolitis
-Younger (<2)
- URI progressing to LRI
- Sick contacts
-Older than 2 with
neg
API
Heart Failure in Left to right shunts
-cold forehead sweat -weak pulses
-cardiomegaly -failure to thrive
-6-12 weeks of age -no rhinorrhea
-murmur, gallop
-cough absent
Common Symptoms Wheezing Tachypnea / resp. distressHypoxemia Poor Feeding Pulmonary crackles Cough
Slide18Questions????????
2) List 2-3 features that differentiate bronchiolitis, asthma, foreign body and left to right heart lesions with heart failure
Slide19Objectives
After the lecture the learner should be able to:
1) Describe the pathophysiology of wheezing
2) List 2-3 features that differentiate bronchiolitis, asthma, foreign body and left to right heart lesions with heart failure
3) Discuss AAP policy on
Diagnosis
Risk Factor assessment
Treatment
4
) Discuss UNM policy and practices
Slide202014 AAP policy on Bronchiolitis
Inclusion
1-24 months old
Exclusion
Immunocompromised
Recurrent wheezing
Bronchopulmonary dysplasia aka chronic neonatal lung disease
Cystic fibrosis
Congenital heart disease
Neuromuscular disease
Slide21Bronchiolitis Diagnosis
Based on History and Physical (strong rec)
Xray
and labs should NOT be routinely obtained (moderate rec)
Slide22History
Sick contacts
URI (rhinorrhea, congestion, cough) progressing to LRI (hypoxemia, retractions, rales, wheezing, nasal flaring)
Usually worst 3-7 days after URI starts
Slide23Physical
URI
LRI: diffuse findings is key
Clinical pearl:
Children are obligate nasal breathers till age 6 months
Retractions may improve with simple nasal suction
Evaluate for FULL 1 minute
6 Months
Slide24X-ray
If done
Lead to more antibiotics without improved outcomes
Should be saved for PICU admissions or suspected complications (pneumothorax)
Slide25Viral testing?
AAP recommends
RSV testing for children on
S
ynagis
If + stop monthly
Synagis
“Apart from this
setting, routine
virologic testing is not recommended”More in the UNM specific section
Slide26Risk assessment
Essentially the exclusion criteria plus
age <3 months
Immunocompromised
Recurrent wheezing
Bronchopulmonary
dysplasia
aka chronic neonatal lung disease
Cystic fibrosis
Congenital heart disease
Neuromuscular disease
Slide27Treatment
Slide28Asthma= extra-luminal compression
Slide29Bronchiolitis=intra-luminal obstruction
Slide30Treatment
Improve clinical symptom scores
Does NOT alter need for hospitalization or length of stay
Studies excluded severe disease
Slide31EPI
Slide32RCT with placebo
No effects
Pred
Slide33Chest Physiotherapy
Slide34Antibiotics
ONLY if concurrent infection (usually AOM or UTI)
Suggested reading:
1) AAP Policy on Acute Otitis Media
2)
Costs and Infant Outcomes After Implementation of a Care Process Model for Febrile
Infants
.
Pediatrics
July
2012, VOLUME 130 / ISSUE 1
Slide35Hydration / Nutrition
IVF
Typically D5
NS
20KCl
Additional reading:
Isotonic
Versus Hypotonic Maintenance IV Fluids in Hospitalized Children: A
Meta-Analysis. Pediatrics January
2014, VOLUME 133 / ISSUE
1
NGUse expressed breast milk or formula
Slide36IV vs NG
Both Are:
Safe (as long as ISOTONIC fluids are used)
No difference in:
O2 time
LOS
ICU / Intubation
Parental satisfaction
NG
Higher
success rate in placement
IV
Lower
success rate in placement
Slide37Hypertonic Saline
Jury is still out
2014 AAP policy
DON
’
T use in ED
MAY use inpatient
2015 Systematic Review Zhang et al. Pediatrics. October 2015, Volume 136 / Issue 4.
Decrease LOS 11 hours
20% decrease risk of hospitalization
Lots of heterogeneity and inability to run met analysis
Inconsistency in dosing and frequency
Slide38Oxygen / Pulse Ox
ACTUALLY
Not well studied!!!
Makes sense though.
Pulse Ox
“May choose not to use continuous pulse oximetry” –weak recommendation
Pulse Ox:
Poor reliability for 76-90%
Healthy infants can have intermittent hypoxemia from period breathing
Further Reading: Longitudinal assessment
of hemoglobin oxygen
saturation
in healthy infants during
the first 6 months
of
age. J
Pediatr
.
1999;135(5):
580–586
Oxygen Use for sats <90%Poor correlation of hypoxemia and respiratory distress Home O2 on =/< 0.5L is safe High flow nasal cannula can decrease intubation
Slide39Bronchiolitis treatment
Isotonic
Slide40Ouestions
????
3) Discuss AAP policy on
Diagnosis
Risk Factor assessment
Treatment
Slide41Objectives
After the lecture the learner should be able to:
1) Describe the pathophysiology of wheezing
2) List 2-3 features that differentiate bronchiolitis, asthma, foreign body and left to right heart lesions with heart failure
3) Discuss AAP policy on
Diagnosis
Risk Factor assessment
Treatment
4
) Discuss UNM policy and practices
Slide42UNMH
Cohorting
!
Slide43UNMH
Home Oxygen
No need for room air
sats
>90
Room air trial ( Do NOT do till stable on </= 0.5L)
If
sats
>85% on room air for 10 minutes
get Rx in before 3PM
Sleeping??? (depends on your attending, NOT and institutional requirement)
No open flames as heat source, reliable PCP follow up
Slide44UNMH
High Flow Nasal Cannula
Reduces intubation
If still having moderate to severe respiratory distress on 3L
Transfer to Pediatrics as primary
Slide45UNMH
https://sites.google.com/site/unmpedsinpt/protocols
user
name-unmpeds1
password-
unmpeds
!
Tip- if it does not let you log on, log off of your individual google account then try logging in again.
Slide46UNM
Slide47WARM SCORE
-Wheezing
-Air Exchange
-Respirations
-Muscle Use
Slide48UNMH
WARM <4 (mild)
Supportive care
WARM 4 (moderate)
Trial Albuterol, continue only if score improves by 2
WARM 5 (severe)
Trial Albuterol
continue only if score improves by 2
Consider Rapid Response
Slide49Slide50Questions?????
Slide51References
Swingler
GH, Hussey GD,
Zwarenstein
M.
Randomised
controlled trial of
clinical outcome
after chest radiograph in ambulatory
acute lower-respiratory infection in children. Lancet. 1998;351(9100):404–408Nelsons Pedi