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Bronchiolitis

Definition
Bronchiolitis is an inflammatory condition primarily affecting the small airways or bronchioles, often characterized by acute viral infection in infants and young children.
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Pathophysiology
The pathophysiology of bronchiolitis involves the infection of the epithelial cells lining the small airways, predominantly by the RSV. This infection leads to cell damage, increased mucus production, and inflammation, resulting in airway obstruction.
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Epidemiology
It is estimated that 33 million cases of RSV-associated acute lower respiratory infections occurred globally in children < 5 years old in 2019.
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Disease course
Clinically, bronchiolitis typically begins as an upper respiratory tract infection, progressing to lower respiratory symptoms such as cough, wheezing, and respiratory distress.
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Prognosis and risk of recurrence
The prognosis of bronchiolitis is generally good, with most cases being self-limiting and resolving without complications.
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Key sources
The following summarized guidelines for the evaluation and management of bronchiolitis are prepared by our editorial team based on guidelines from the French Group for Pediatric Intensive Care and Emergencies (GFRUP 2023), the American Academy of Family Physicians (AAFP 2023), the Center for Disease Control (CDC 2023), the National Advisory Committee on Immunization (NACI 2022), the Canadian Paediatric Society (CPS 2021), the American Academy of Pediatrics (AAP 2020; 2018; 2014), the Paediatric Research in Emergency Departments International Collaborative (PREDICT 2019), the The Thoracic Society of Australia and New Zealand (TSANZ 2018), the American College of Chest Physicians (ACCP 2018), the Royal Australasian College of Physicians (RACP 2017), and the Society of Hospital Medicine (SHP 2013).
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Guidelines

1.Screening and diagnosis

Diagnosis: as per CPS 2021 guidelines, diagnose bronchiolitis clinically based on history and physical examination.
E
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2.Classification and risk stratification

Risk assessment: as per PREDICT 2019 guidelines, regard the following as risk factors for more serious illness:
gestational age < 37 weeks
chronological age at presentation < 10 weeks
indigenous ethnicity
breastfeeding for < 2 months
exposure to cigarette smoke
failure to thrive
chronic pulmonary, heart, or neurological disease.
B

3.Diagnostic investigations

Clinical assessment: consider using clinical scores (such as the modified Wood's Clinical Asthma Score, the Wang score, and the Critical Bronchiolitis Score) for the initial assessment and follow-up.
E

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  • CXR

  • Chest ultrasound

  • Laboratory tests

4.Respiratory support

Oxygen monitoring: as per GFRUP 2023 guidelines, consider monitoring the trend of respiratory parameters and/or clinical scores to assess disease evolution. Avoid obtaining systematic monitoring of pCO2 (and tcpCO2).
E

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  • Supplemental oxygen

  • Noninvasive ventilation

  • Invasive ventilation

5.Medical management

Setting of care, hospital admission: decide on hospital admission based on clinical judgment, factoring in the risk for progression to severe disease, respiratory status, ability to maintain adequate hydration and the family's ability to cope at home.
E

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  • Setting of care (pediatric ICU admission)

  • Supportive care

  • Nebulized hypertonic saline

  • Nebulized epinephrine

  • Bronchodilators

  • Corticosteroids

  • Antibiotics

  • Therapies with no evidence for benefit

6.Nonpharmacologic interventions

Chest physiotherapy: as per AAFP 2023 guidelines, do not offer chest physiotherapy for the treatment of RSV bronchiolitis.
D

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  • Nasal suctioning

7.Patient education

General counseling: ask about the exposure of the infant or child to tobacco smoke when assessing infants and children for bronchiolitis.
B
counsel caregivers about exposing the infant or child to environmental tobacco smoke and smoking cessation when assessing infants and children for bronchiolitis.
B
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8.Preventative measures

Nirsevimab prophylaxis
Offer one dose of nirsevimab in all infants aged < 8 months born during or entering their first RSV season (50 mg for infants weighing < 5 kg and 100 mg for infants weighing ≥ 5 kg).
E
Offer one dose of nirsevimab (200 mg, administered as two 100 mg injections given at the same time at different injection sites) in infants and children aged 8-19 months at increased risk for severe RSV disease and entering their second RSV season.
E

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  • Palivizumab prophylaxis (general principles)

  • Palivizumab prophylaxis (prematurity)

  • Palivizumab prophylaxis (multiple birth)

  • Palivizumab prophylaxis (congenital heart disease)

  • Palivizumab prophylaxis (immunodeficiency)

  • Palivizumab prophylaxis (cystic fibrosis)

  • Palivizumab prophylaxis (Down syndrome)

  • Palivizumab prophylaxis (other comorbidities)

  • Palivizumab prophylaxis (prevention of wheezing or asthma)

  • Palivizumab prophylaxis (prevention of healthcare-associated RSV infection)

  • Palivizumab prophylaxis (remote communities)

  • Palivizumab prophylaxis (regimens)

  • Hand hygiene

9.Follow-up and surveillance

Discharge from hospital
As per PREDICT 2019 guidelines:
Take into account oxygen saturations, adequacy of feeding, age (< 8 weeks), and lack of social support at the time of discharge as a risk for representation.
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Consider discharging infant patients at low risk for severe bronchiolitis, after a period of observation, on home oxygen with a clear return-to-hospital advice.
C

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  • Management of chronic cough