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Grand Rounds / Articles

Assessing Bronchiolitis in the Emergency Room

Taken from a presentation at the
Continuing Professional Learning conference:"POGO 2005"
February 3 - 5, 2005
Dr. Vicki Cattell, MD, CRCP(C)

Etiology

An inflammation of the bronchioles caused by viruses, especially Respiratory Syncytial Virus (RSV), in children less than two years of age. It is often the cause of first and second episodes of wheezing in young children.

But...

When child has three or more episodes, especially when there is a family history of atopy, consider asthma as diagnosis.

Management

There is little evidence for many current treatments of bronchiolitis.

?Alupent

Has a role when there is concomitant reactive airways disease but J. Paediatrics, 2003, May:142(5) "Randomized, double blind, placebo controlled trial of oral albuterol in infants with mild to moderate acute bronchiolitis".

Conclusion

The widespread use of oral albuterol in this patient group is not recommended.

?Bronchodilators...Annals of Emergency Medicine Nov 2003, Vol 42#5

"Are bronchodilators effective in bronchiolotis".

Conclusion

Bronchodilators produce modest, short term improvement in some children with bronchiolitis, there is no change in natural course.

?Dexametasone / Glucocorticoids...Paediatric Clinics North America, Volume 44#1, Feb 1977

"Recent advances in the treatment of bronchiolitis and laryngitis".

Conclusion

The use of dexamethasone or other glucocorticoids for children with acute bronchiolitis cannot be supported by the current evidence.

In fact, Don't Just Do Something...Stand There!

Assessment and Frequent Reassessment

The main question to ask it "Is the child coping?".

Chest X-ray

Only in children wheezing for the first time or if the chest signs demonstrate more crackling than wheezing (seven to ten percent have co-morbid bacterial infection).

When to Refer

Summary

No treatment has been shown to be effective in altering the natural course of bronchiolitis.

Focus is on assessing whether or not the child is coping, or if they need oxygen, hydration or suction.

Consider alternate diagnosis if there have been several past episodes of wheezing, or if child is more than two years old.

Reassure parents, but inform parents the need to reassess in presence of warning signs of dehydration, irritability and anxiety.