Transcript Bronchiolitis Scoring Tool

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
V a ria b le
R S V (+ )
R S V (-)
RR
N = 269
N = 979
(9 5 % C I)
Any SB I
1 7 /2 4 4
1 1 6 /9 2 5
UTI
1 4 /2 6 1
9 8 /9 6 6
0 .5
5 .4 %
1 0 .1 %
(0 .3 ,0 .9 )
7 .0 %
B a c te re m ia 3 /2 6 7
1 .1 %
M e n in g itis
(4 .1 ,1 0 .9 % )
(3 .0 , 8 .8 % )
(0 .2 , 3 .2 % )
0 /2 5 1
1 2 .5 %
(1 0 .5 ,1 4 .8 % )
(8 .3 ,1 2 .2 % )
(0 .3 ,0 .9 )
2 2 /9 6 8
0 .5
2 .3 %
(0 .1 ,1 .6 )
(1 .4 , 3 .4 % )
8 /9 3 8
(0 , 1 .2 % )
0 .5
0 .9 %
(0 .4 , 1 .7 % )
0
p
.0 1 3
.0 1 5
.3 3
.2 1
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
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