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Bronchiolitis  Clinical Practice:  An Evidence-Based Approach Bronchiolitis  Clinical Practice:  An Evidence-Based Approach

Bronchiolitis Clinical Practice: An Evidence-Based Approach - PowerPoint Presentation

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Bronchiolitis Clinical Practice: An Evidence-Based Approach - PPT Presentation

Bronchiolitis Clinical Practice An EvidenceBased Approach William Schneider DO MA FACEP Medical Director Pediatric Emergency Services Banner Thunderbird Medical Center EPIP Conference November 3 ID: 766700

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Bronchiolitis Clinical Practice: An Evidence-Based Approach William Schneider, DO, MA, FACEPMedical Director, Pediatric Emergency ServicesBanner Thunderbird Medical CenterEPIP Conference November 3rd and 4th, 2011 1

Case Presentation 7 month old uncircumcised male gasping for airLow grade fever, cough and rhinorrhea for 2 daysNow wheezing, grunting, with mod-severe retractionsUnable to feed since this afternoonHx of wheezing in past – parents are treated for asthmaUTD with immunizations, ex-premie at 34 weeks gestationVS: BP 92/60, HR 132, RR 55, Temp 39.1̊C (R), POx 87% RAModerately irritable and difficult to console Nasal flaring with intercostal and substernal retractionsDiffuse expiratory wheezing2

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 BronchiolitisApnea3What is Your Work Up?

ObjectivesBronchiolitis Review the current literature and the AAP recommendations for the diagnosis and management of BronchiolitisBecome familiar with the Bronchiolitis respiratory scoring tool used in the assessment of the severity of BronchiolitisExplore the risk factors for Severe Bronchiolitis and ApneaDiscuss the new Bronchiolitis Protocol using the Respiratory Scoring Tool to be implemented within Banner Health4

Introduction Bronchiolitis Bronchiolitis is the most common lower respiratory tract infection in patients < 2 years of agePeak age: 2-8 monthsMale predominance (1.5:1)200,000 visits to EDs annually19% admission rateCost $700 million annually5

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

PathophysiologyBronchiolitis Virus invades the nasopharynx and spreads by cell to cell transfer to the lower tract within a few daysViral infection of the lower respiratory tractIncreased mucous secretion, cell death and sloughing of the bronchial ciliated epithelial cellsClumps of necrotic epithelium and mucus decrease diameter of the bronchiolar lumen causing turbulent air flow particularly on expirationPeribronchiolar lymphocytic infiltrate and submucosal edemaNarrowing, air trapping, and obstruction of small airways:Hyperinflation and atelectasisVentilation/perfusion mismatch↓ lung compliance and ↑ work of breathingSmooth muscle constriction has limited role 7

RecoveryBronchiolitis Degree of obstruction may vary as some of the airways clear resulting in rapidly changing clinical severity Epithelial cells recover after 3 – 4 daysCilia regenerate after 2 weeksMedian duration of illness ~ 12 daysSymptoms may persist for 3 (18%) to 4 (9%) weeks8

EtiologyBronchiolitis RSV (50 – 80%):November to MarchNearly all children (95%) infected within first 2 years of life4 to 6 day incubation period precedes URI symptomsSpread through direct contact with secretionsHuman Metapneumovirus (3 – 19%)Parainfluenza Virus Type 3InfluenzaAdenovirusRhinovirus (common in asthma) 9

Differential DiagnosisBronchiolitis LIFE-THREATENING CAUSESInfection: pneumonia, Chlamydia, Pertussis (apnea)Foreign body: aspirated or esophagealCardiac anomaly: congestive heart failure, vascular ringAllergic reactionBronchopulmonary disorder exacerbation (CLD)NON-LIFE THREATENING CAUSESCongenital anomaly: tracheoesophageal fistula, bronchogenic cyst, laryngotracheomalaciaGastroesophageal reflux diseaseMediastinal massCystic fibrosis10

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 oldNone 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 BronchiolitisHistory Age < 6 - 12 weeksPrematurity < 34 - 37 weeks gestationUnderlying chronic respiratory illness such as CF, CLD or BPDSignificant congenital heart diseaseImmune deficiency including human immunodeficiency virus, organ or bone marrow transplants, or congenital immune deficienciesPrior intubationFirst 48 hours of illness12

Risk Factors for Severe BronchiolitisPhysical Examination General appearance: ill appearingOxygen saturation level < 92 - 94% on room air5 fold increase in likelihood of hospitalizationRespiratory rate > 60-70 breaths per minuteIncreased work of breathing - moderate to severe retractions and/or accessory muscle useDehydrationMale13

Risk Factors for Apnea Full-term birth and < 1 month of agePreterm birth (< 37 weeks gestation) and age < 2 months post conceptionHistory of Apnea of prematurityEmergency Department presentation with apneaApnea witnessed by a caregiver14

Bronchiolitis Scoring Tool Assist in clinical decision-making within a protocolObjective and subjective reproducible clinical parametersBe applicable to its particular pathophysiology (LRTI) Validity: score relates to disease severityGood inter-rater reliability >80%Responsiveness: detect changes over timeApply to patients < 2 years of ageEasily adopted by the provider, RT, RN, started in the ED and continued on the floor and/or PICUGoals:↓ LOS, ↓ cost & ↓admission rate↑Consistency, ↑efficiency, and ↑qualityReflect AAP recommendations15

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) 01 2 3 Respiratory Rate 0-6 mo < 50 6mo – 1yr < 40 1 yr+ < 30 0-6 mo < 60 6mo – 1yr < 50 1 yr+ < 45 0-6 mo < 70 6mo – 1yr < 60 1 yr+ < 60 0-6 mo > 706mo – 1yr > 601 yr+ > 60 SaO2≥ 90 %> 88 %> 86 %≤ 85 %General AppearanceCalmNo distressMildly irritable; easy to consoleModerately irritable; difficult to consoleExtremely irritable; cannot be comforted Retractions and nasal flaring (NF, SS, IC, SC)None1 of 42 of 43 or moreAuscultationClearScattered wheezesDiffuse expiratory wheezingBiphasic wheezing or very poor air movement17

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 oldOnly 2 CXR inconsistent with bronchiolitisLobar consolidationMore likely to treat with antibioticsPre-radiography: 7 infants (2.6%) identified for antibioticsPost-radiography: 39 infants (14.7%) identified for antibioticsNot routinely recommendedReserved for clinical deterioration or unclear presentation18

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 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 presentationResults have minimal effect on managementMay be considered in infants <3 months of ageLimit further lab testingLimit unnecessary antibioticsNot routinely recommendedRoutine CBC, BMP and blood cultures are not recommendedFebrile neonate (> 38.0̊ C) with RSV and/or clinical bronchiolitis Requires septic workup and admission23

RSV in Febrile Infants Study Information BronchiolitisStudy: The Risk of Serious Bacterial Infections in Young Febrile Infants with RSV InfectionsPediatric 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 24

Background: RSV in Febrile InfantsBronchiolitis Young febrile infants are at substantial risk of SBIClinical assessment may be difficultUnclear whether viral infection alters the risk of bacterial disease in this age25

Methods: RSV in Febrile InfantsBronchiolitis Prospective, multi-center, cross sectional study: Eight Pediatric Emergency DepartmentsOctober-March, 1998-20011,248 patients enrolledInclusion:Age < 60 daysRectal temp > 38.0oC Exclusion:Received antibiotics w/in 48 hrs 26

Evaluation: RSV in Febrile InfantsBronchiolitis Clinical:History and physical examinationYale Observation Scale and Pulmonary ScoreDiagnostic Testing:Rapid RSV antigenFever evaluation: urine, blood, CSFStool culture - if symptomaticChest radiograph Treatment / Disposition at discretion of physicianTelephone follow-up 27

Categorization: RSV in Febrile Infants BronchiolitisRSV Status:“Indeterminate” considered NegativeClinical Bronchiolitis:Wheezing or retractions with URINo lobar infiltrate on chest radiographURI: history/presence of cough or Rhinorrhea 28

RSV in Febrile Infants Positive vs Negative NP Swab Results3 RSV (+) with Bacteremia were neonates29

RSV in Febrile InfantsClinical Bronchiolitis (CB) Results30

Conclusion: RSV in Febrile InfantsBronchiolitis Young febrile infants with RSV or clinical Bronchiolitis are at lower risk of SBI than febrile infants without these findingsRoutine RSV testing not necessaryRisk of UTI, however, remains significant31

TreatmentBronchiolitis Suctioning – First line therapyNasal suction:BBG nasal aspiratorAge-appropriate bulb suctionUse prior to:FeedsSVN trials or therapyDeep posterior nasal-pharyngeal suctioning:Reserved for mod-severe respiratory distress from significant airway obstructionData does not support routine useMay induce bronchospasm from irritation and /or agitationNormal saline nose drops may be used prior to suctioning32

TreatmentBronchiolitis Oxygen - First line therapySupplemental oxygen administered if POx consistently < 90%:After nasal suctioning, airway positioning and POx probe repositioningTitrate 02 to keep POx > 90% while awake or > 88% while sleepingConsider using continuous pulse oximetrySignificant respiratory distress First 12 to 24 hoursHigh risk infants < 2 months of ageHx of prematurityRS > 10 Until patient is clinically improving33

TreatmentBronchiolitis Albuterol nebulized therapy:ControversialInconsistent results in studiesGadomski, 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 staySlightly more effective in those patients with history of wheezing or AtopyRoutine use not recommended:Consider SVN trial to determine effectiveness in individual patients 34

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 AlbuterolShort-term improvements in clinical scores, POx, and respiratory ratesThe improvements possibly related to the alpha effect of vasoconstrictionShould be reserved for mod-severe diseaseNo reduction in the admission rates or length of hospital stayAnticholinergic 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 infantsNo significant clinical improvement Not justified if used alone or in combination with B-adrenergic agents35

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.”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 patientsNo significant difference between steroid & placebo treatment groups:Clinical scoresOxygen satsAdmission ratesLength 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 bronchiolitis2 – 12 months of age with mod-severe disease2004 – 2006 / 20 medical center EdsDexamethasone 1 mg/kg vs. placebo: Measure outcome at 4 hours:No significant difference in clinical respiratory scoresNo difference in admit rates (39.7% vs. 41%)No difference in readmission rates or hospital LOSConclusion: Did not improve outcomesEDHospital 38

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

TreatmentBronchiolitis Inhaled steroids:2 small studiesShowed no benefit in the course of the acute diseaseNebulized 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 admitted3% saline vs. normal saline SVN26% 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

TreatmentBronchiolitis Nasal Continuous Positive Airway Pressure (CPAP):Noninvasive humidified high flow nasal cannula (1L/kg/min)Decreases inspiratory muscle work loadRelieves atelectasisPrevents airway collapseImproves ventilationBridge to intubationSevere respiratory distressApnea spellsHeliox alone or in addition to nasal CPAP:Helium + 21% oxygen  mixed gas 1/3 as dense as airReduces gaseous flow resistanceImproves gaseous exchange and alveolar ventilationIncreases C0 2 eliminationResponse seen within first hour41

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, SingulairInhaled Interferon -2aNebulized FurosemideChest Physiotherapy 42

Criteria for HospitalizationBronchiolitis Persistent respiratory distress after treatment (RS > 5)POx consistently < 92% Dehydration with inadequate po intakeSignificant risk factors for Apnea: < 1-2 month old with hx of prematurity < 35 weeks gestationUnreliable caretakerWitnessed Apnea by caretaker or ED personnelFebrile neonateRespiratory rate > 60 breaths per minute after treatmentContinual need for deep NP suctioningPhysician discretion 43

Criteria for PICU AdmissionBronchiolitis IntubationNasal CPAP (HHNC/Heliox)ApneaRS > 10SepsisFrequent bronchodilator SVN less than 2 hours apartPhysician discretion44

Criteria for DischargeBronchiolitis Oxygen sats consistently > 92%No respiratory distress (RS < 5) No apnea or significant risk factorsRespiratory rate < 60 breaths per minuteAdequate oral intakeFamily education completeAdequate bulb suctioningPhysician discretionCaretaker comfortable and reliable 45

Risk Factors for ED Return VisitBronchiolitis 17 - 20% ED return rate: 65% within 2 daysNorwood 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 p-value< 2 months of age: 2.1 0.03Sex: male: 1.7 0.02History of hospitalizations: 1.7 0.02Prematurity (< 35 weeks): 1.6 0.16 46

ConclusionBronchiolitis Bronchiolitis is mainly a clinical diagnosisDiagnostic laboratory and radiographic tests play a limited roleBronchodilators and steroids lack significant clinical effectivenessSupplemental oxygen indicated if POx < 90% consistentlyAssess patients for risk factors when making final disposition decisionsRespiratory tool and protocol aid in treatment and disposition decisionsMost patients recover with suction, O2 & fluids only 47

Bronchiolitis Protocol Process Flow48 ED and Inpatient

49 History of wheezing, atopy, or FH of asthma? Patient meets Discharge Criteria? Yes Yes 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 RS > 5 (AFTER Suction)NoNoScore improved >3 points? Classified as Epi ResponderClassified as Non-Bronchodilator ResponderNoYesPatient meets Discharge Criteria?Classified as Albuterol ResponderYesSupportive Care Orders Albuterol Responder: Supportive Care Alb MDI or Neb Q4 hoursEpi Responder: Before D/C: Monitor for Minimum of 60 minutes post treatment for rebound (RS>5) Supportive Care Non Bronchodilator Responder: Supportive Care Family EducationBronchiolitis Protocol Process Flow (ED and Inpatient)NoYesAlbuterol Responder: Supportive Care OrdersAlb MDI or Neb Q4 hours prn for RS >5 ED: Q1 hour prnAlb MDI or Neb Q2 hours prn for RS >7ED: Q30 minutes prnNotify MD if on Q2 hoursEpi Responder: Supportive Care OrdersRacemic Epi Q4 hours prn for RS >5ED: Q1 hour prnRacemic Epi Q2 hours prn for RS >7ED: Q30 minutes prnNotify MD if on Q2 hoursNon Bronchodilator Responder: Supportive Care OrdersNotify MD for RS >7 Score improved >3 points?Observation or Admit if admission criteria metNoASSESS & SCORE using Respiratory Scoring Tool (“Assess – Suction – Assess” process) ADMIT DISCHARGEDischarge with Supportive Care and Family Education

Bronchiolitis Protocol Inclusion criteria:Diagnosis of bronchiolitisLess than 2 years of ageExclusion criteria:Hx of cystic fibrosis (CF)Hx of Bronchopulmonary dysplasia (BPD) Significant or cyanotic congenital heart diseaseImmunocompromisedOn home oxygenHas significant comorbid conditions complicating care50

Bronchiolitis Protocol Does the patient meet eligibility criteria?Use Banner Health System (BHS) Bronchiolitis Order Set/RT Bronchiolitis ProtocolAssess & Score using BHS Sheet (Always score before and after intervention):Allow 10-15 minutes after each intervention before reassessment and scoringDocument patient past medical history of Atopy, allergies, or wheezingDocument 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 aspiratorReserve deep suction for airway obstruction causing significant respiratory compromiseScheduled 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/repositioningO2 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 requirementsConsider nasal CPAP (HHNC/Heliox) if severe respiratory distress or apnea spellsNotify physician when discharge criteria are met52

Bronchiolitis Protocol Process Flow 53History of wheezing, Atopy, or first degree relative treated for asthma? Patient meets Discharge Criteria? Yes Yes 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 DISCHARGE CRITERIA: O 2 Sats consistently >92%No respiratory distress (RS <5) Feeding adequatelyFamily comfortable & reliableFamily education completeRespiratory rate <60No Apnea or significant riskBulb suction adequatePhysician discretionRS > 5 ( AFTER Suction)NoNoScore improved >3 points?Score improved >3 points?Include: 0-24 months; Dx BronchiolitisExclude: hx BPD, CHD, home O2, or significant comorbid conditionsSupportive Care OrdersNo ASSESS & SCORE using Respiratory Scoring Tool (“Assess – Suction – Assess” process)Observation or Admit if admission criteria met D/C with Supportive Care & Family Education

Bronchiolitis Protocol Process Flow continued 54 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 Score improved > 3 points? Score improved > 3 points? Classified as Epi ResponderClassified as Non-Bronchodilator ResponderNoYesPatient meets Discharge Criteria? Classified as Albuterol ResponderYesADMISSION CRITERIA:O2 Sats consistently <92%RS >5Feeding poorly or dehydratedFamily unreliable Respiratory rate >60Apnea witnessedSignificant risk factors for apneaNeonatal feverBulb suction inadequatePhysician discretionPICU CRITERIA: IntubationNasal CPAP (HHNC/Heliox)RS > 10ApneaFrequent bronchodilator <2 hrsSepsisPhysician discretion

55 Patient meets Discharge Criteria? 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 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 >7ED: Q30 minutes prn Notify MD if on Q2 hoursEpi Responder: Supportive Care OrdersRacemic Epi Q4 hours prn for RS >5ED: Q1 hour prnRacemic Epi Q2 hours prn for RS >7ED: Q30 minutes prnNotify MD if on Q2 hoursNon Bronchodilator Responder: Supportive Care OrdersNotify MD for RS >7NoBronchiolitis Protocol Process Flow continued ADMIT DISCHARGE

Case Conclusion 7 month old male gasping for air:low grade fevercough and rhinorrhea for 2 daysnow wheezing, grunting, with mod-severe retractionsunable to feed since this afternoonhx of wheezing in pastparents treated for asthma UTD with immunizations, uncircumcisedex-premie at 34 weeks gestationVS: 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 BronchiolitisApnea56

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