Preparing for a Bronchiolitis Epidemic

This has been well covered by DFTB so have a wander over there.

The key bits are that it’s mostly a self-limiting viral infection in babies, causing shortness of breath. Symptoms peak at day 3-4. Treatment is generally supportive. It’s most commonly caused by RSV which is really infectious.

Many people worry about whether their diagnosis is right or not. Is it bronchiolitis or is it viral-induced wheeze? With practice you’ll get better at diagnosing. Generally, the younger the child, the less likely they are to have bronchospasm. Wheeze in babies under 1 year of age is usually caused by the oedema and mucus of bronchiolitis narrowing the airways. No amount of bronchodilator will help with that. Children over the age of 2 are more likely to have bronchospasm, so their wheeze comes on more quickly (hours not days) and is more likely to respond to bronchodilators. In that middle group, aged 1-2 years, if you’re not sure, a trial of inhalers is not evidence based, but may help you make the diagnosis. Make sure that the same person listens before and then again 10-15 minutes after treatment. Plenty of things can confound this, a child who screams through 10 puffs of salbutamol may well shift that mucus plug causing their wheeze and falsely reassure you that it was your treatment that helped, so keep an open mind.

Focal crepitations and lack of wheeze suggest pneumonia rather than bronchiolitis or viral wheeze – if the child’s well, the treatment is the same anyway. If the child requires intubation, you’ll be getting an x-ray (most respiratory conditions in children do not need an x-ray, including bronchiolitis unless very unwell. We do far too many x-rays and national audit standards  are that we should be x-raying <10% of children with pneumonia. It doesn’t change management other than to increase unnecessary antibiotic prescribing.).

Newborns may present with apnoeas. Starting high-flow won’t help with these. Get PICU and senior paeds help and consider caffeine IV if they are pre-term.

Keep in mind that just because your practice is evidence based, doesn’t mean that everyone else’s is. You are likely to see variations on the practice outlined here, and it is always good to (politely) question accepted norms. Some departments are much better at this than others.

Edward Snelson @sailordoctor describes assessment and decision-making in bronchiolitis really nicely here and talks about wheeze and the causes at different ages here.

• Infection control precautions
• Give oxygen if saturations are persistently less than 92% (not just a one off!), usually via nasal cannulae
• Escalate to high-flow humidified nasal oxygen (Optiflow, Airvo, Vapotherm) if saturations can’t be maintained on “normal” oxygen.
• Consider CPAP for impending respiratory failure, with discussion with PICU or your local retrieval service. Next step is intubation and ventilation.
• We don’t recommend nasal or upper airway suctioning; babies just make more snot and there is a risk of trauma. Saline nasal drops are great immediately prior to a feed, but the effect doesn’t last long.
• Fluid balance – if taking less than 50% of their usual feeds, nasogastric feeding may be needed (also helps them concentrate on breathing and saving their energy).  Children requiring high flow O2 can still have NG feeds. Isotonic fluids intravenously may be needed for impending respiratory failure or those unable to tolerate NG.

No antibiotics are needed, and although bacterial infection can co-exist, these children generally aren’t given antibiotics. Don’t give bronchodilators, adrenaline nebulisers, hypertonic saline, steroids, Montelukast and most importantly, no trial of inhalers (see also gppaedstips.)

It’s tempting to want to know a blood gas on a patient who appears in respiratory distress
Wouldn’t a CXR be helpful in knowing what is actually going on?
It’s a fine line in bronchiolitis between deciding when to intervene and when to let the child settle and give them a break from handling.
If the clinical exam shows bilateral diffuse crackles and wheeze, and there are no focal signs, it is far more likely to be a bronchiolitis than a LRTI. Routine blood gases and CXRs are not recommended. This will only anger the baby and make their work of breathing much harder, plus there’s the whole exposure to radiation to think about, and the ALARA principle (As Low As Reasonably Achievable). More on chest x-rays here and investigations here.

Do a blood gas in patients who require escalation of care to NIV (to some, all kids with bronchiolitis look unwell). There is no evidence to support CO2 monitoring in these kids, if oxygen saturations are normal then I don’t think CO2 should change management.
If you’re considering a cannula, don’t upset the child by doing a cap gas first.

To do a cap gas, follow the instructions here or watch this video from DFTB – remember to analyse it immediately as unlike adult samples, it clots quickly!

When interpreting, remember it’s a mixed sample so the pO2 and pCO2 aren’t 100% reliable but everything else should be. For more information look at the RCEMLearning blood gas article.

When to consider high-flow, humidified nasal cannula oxygen (HFNC)? DFTB look at the evidence here and here. Basically, if you’re struggling to keep the oxygen saturations above 92% on standard oxygen therapy, try HFNC (with appropriate infection control considerations, and senior support). There are several types of machines from a variety of manufacturers, but they all do a similar job.

Before you start HFNC, check your local guidelines – most places will need this child cared for in HDU, and this has a huge impact on capacity. In many trusts, this is a Consultant Paediatrician decision, because of the implications of starting, or not starting. Also, this is an AGP, so if the child is in your ED and they need to get to paeds, you can’t move them down the corridor on it. Can they transfer first and start NIV in HDU?

Use the airvo2 app to help – even if you’re an experienced optiflow user, it just helps you remember what the buttons do!

Summary of main steps:

Review label on machine or see instruction video here. There’s also a quick reference guide here. The pictures below illustrate the process wonderfully, but we’re not sure where they came from, so are asking forgiveness for reusing them.

1. Install auto fill water chamber remove the blue port caps, unwind the water tube but leave the water bag spike in the plastic bracket so it stays clean. Fit the chamber adaptor firmly on to the chamber ports. Clip the water tube into position. The chamber is ready. Slot the water chamber into the AIRVO 2.

2. Connect water supply hang the water bag and push the tube spike into the fitting. Open the vent cap and watch the water enter the chamber.

3. Check water level is below the mark if the water rises above the mark, the chamber is faulty and must be replaced.

4. Connect the breathing tube the end with the blue sleeve attaches to the AIRVO 2. Slide the sleeve back, and line up the connector with the port on the top of the AIRVO 2. Push the connector on and slide the sleeve down to lock the breathing tube into place.

5. Attach the nasal cannulae see ‘Commencing Therapy’.

Information video available for cleaning and disinfecting available from fphcare.

We thought earlier about when to do a CXR. The same goes for IV access. Think about why you need it. Are you considering a bacterial LRTI and therefore considering IV antibiotics? Or will a cannula just upset a miserable child who can be hydrated using NG feeds?

The official line is admit and consider NG tube feeding for babies taking less than about half of their usual feeds. There’s a feeding calculator available on Twitter. 

In reality if a baby is appearing to have moderate to severe respiratory distress and/or looking tired I would pop an NG down and see how they do with a bottle or breast feed. If it looks like they’re too tired to maintain feeding orally and they aren’t tolerating “little and often” feeds, use that NG tube. It will conserve their energy for respiratory effort and avoids the need for IV fluids.

A survey of parents of children who required both NG and IV insertion reported 80% of parents would select NG over IV rehydration given the choice (Srinivasan 2017). Babies are less likely to feel hungry, so less likely to get unsettled, plus enteral feeding is always a better option, physiologically.

If we are heading towards intubation the NGT will be useful to keep in. Don’t forget, an upset baby will cry and swallow lots of air, which will distend the stomach and splint the diaphragm, making respiratory distress worse – aspirating the NG tube can help with this. Babies needing bag-mask ventilation also benefit from NG aspiration for the same reasons, especially just prior to intubation.

NICE guidelines advise IV fluids in children who do not tolerate NG feeds, or have impending respiratory failure.

For tips on how to put an NG in, look at DFTB and remember, confirm the position according to local policy before starting any feed.

Involve the anaesthetic team early if you are clinically concerned regarding the work of breathing, or if the baby is tiring.

It’s challenging for us as emergency medicine practitioners to call the anaesthetic team without numbers like blood gases, but a trend of observations will give you a really good picture of what’s going on.

Also remember the parents! Compare everything to what the parents say is their baseline and re-evaluate frequently so you can determine if the baby is improving, stable, or deteriorating.

If you are considering intubation, get hold of your retrieval service early.

Nasal swabs are less accurate than aspirate swabs (and adc.bmj.com). But all these children will get swabbed nor for covid so an extended viral swab has become common practice during the pandemic, rather than an NPA. Worth noting that some Trusts/ departments cohort children with specific viruses (normally RSV) and others don’t. POC RSV and flu testing is now common and you may not need a full viral PCR, although local guidance might require this.

Swabs won’t help with clinical management (viral respiratory illnesses all need a similar treatment pathway) but may help with infection control and cohorting of babies with similar causative organisms. universal practice. Some Trusts no longer cohort children with RSV or treat them any differently from those with other viruses. I think post pandemic we will all continue to wear masks at all times for these children, FFP3 preferable if they are on NIV.

We can’t predict who will need admission, although NICE gives some good indicators in NG9, summarised by EUSEM:breaking-evidence-eusem-top-scoring-pem-abstracts-1-3.

RSV does live on hands and surfaces for 4 – 7 hours, so keep up all that hand hygiene. Make sure hand washing is emphasised, and see if you can get an extra cleaner to make sure all surfaces are washed regularly.

Your paediatricians will consider giving at risk children Palivizumab – a monoclonal antibody. Apron and gloves should be worn for all contacts and visitors should be restricted and strongly encouraged not to wander. Consider using our posters – or share your own.

If they are taking >50% feeds (volume for formula fed babies and total time on the breast for BF babies) AND sats are >90% they can go home (this was recently changed – 90% is a new threshold).

• Warn parents that bronchiolitis often gets worse before it gets better and that if they are concerned they should seek further review.
• Tell them to look out for feed volumes and work of breathing.
• Provide written parental advice leaflets that contain this information.
• Parents of children under 3 months should know to always seek urgent medical review if their child develops a fever. (Red flags are also important. Children under 3 months with a fever >38.0 are at high risk of serious bacterial infection, even if clinically they look like bronchiolitis. The local protocol for management of these children should always come first, before bronchiolitis management. Parents of children under 3 months should know to always seek urgent medical review if their child develops a fever.)
• There’s good evidence that babies of smokers are at increased risk from bronchiolitis, even if their parents always smoke outdoors or change their clothes after smoking, so this is worth addressing too. Know how to refer parents and family members for smoking cessation support.
• NICE tells us we should warn patients that pollution makes asthma worse. It probably also makes bronchiolitis worse.

Start planning for the epidemic NOW!

• Find and update your bronchiolitis guideline!
• Liase with adult critical care about possibility of taking children >12 years as surge capacity.
• Have discussions about utility of POC testing.

Education

• Train all staff in recognition and treatment of bronchiolitis. There are some fab resources to do this asynchronously from elfh and here on DFTB.
• Familiarise yourself with HFNC, in whichever brand you use locally. Ask staff to download the airvo2 app if appropriate.
• Make sure you have a clear and easily locatable bronchiolitis guideline.
• Consider reaching out to mother and baby groups in your areas to educate them about bronchiolitis and when to worry (and when not to!).
• Consider a patient questionnaire so you can get lots of information from them quickly, without having to ask it. We made an example proforma here – please review it, use it, modify it, and feedback.
• Consider a bronchiolitis clerking pathway, preferably one that enables single clerking. (Send us your clerking examples – #RCEMBronch)

Have discussions about a bronchiolitis follow-up clinic so you can send home your day 3 bronchiolitic baby,  knowing they will get a day 4 and onwards review when they are likely to be at their peak. If anyone does this, please get in touch and let us know how it works!

There’s a nice summary infographic here.

What do you do for patients with bronchiolitis? 🤔 Heres Ed Oakleys #DFTB19 lecture on a page for @doodlemedicine 🖊🎨💻 https://t.co/eAWG6eKNaF

— Charlotte Durand (@char_durand) September 25, 2021

Equipment

• Do you have enough high-flow consumables? How quickly can you get them?
• Does Paeds have enough piped oxygen?
• Do you have enough paediatric non-rebreathe masks and enough nasal cannulae?
• Do you have enough NG tubes and pH strips?

Infection Control 

• Consider infection control posters in all rooms and staff areas.
• Arrange extra cleaning to reduce fomite spread.
• Make sure you have enough aprons and gloves available.
• Educate all staff about the importance of infection control.

Wellbeing

All the links we shared for Covid wellbeing are really important. It’s likely your workforce are tired (yes, paeds were busy and redeployed too). This epidemic is likely to receive less media attention than Covid and this might mean parents are less understanding, especially as children are more emotive. This is going to make it hard. So…

• Arrange regular debrief or Balint groups. Yes you’re busy, but yes they’re important.
• Publicise those wellbeing contact details.
• Get AL and rest in… now.

The CATs webinair: Recorded here.
RCPCH webinair: Recorded here.
Paediatric Critical Care Society: 15th July. Details here.

Guidelines
EMBRACE Generic Guidelines including intubation checklists.

References

• #EM3, Carl Van Heyningenm updated version here, old but discussed version Lightning Learning: Bronchiolitis.
• RCEMLearning, Snelson E. Coughing, Wheezy and Stridulous Children
• RCEM Local Guidelines Paediatric Bronchiolitis
• Henry Goldstein. Bronchiolitis, Don’t Forget the Bubbles, 2013.
• Andrew Tagg. Nasogastric tubes, Don’t Forget the Bubbles, 2018.
• Andrew Tagg. COVID and RSV, Don’t Forget the Bubbles, 2021
• Ben Lawton. Following bronchiolitis guidelines, Don’t Forget the Bubbles, 2021.
• Tessa Davis. Bronchiolitis guidelines, Don’t Forget the Bubbles, 2018.
• RCEMLearning, Abela N, W is for Winter.. and Wheeze: Paediatric Acute Asthma. 2016.
• NICE, Bronchiolitis in children: diagnosis and management. [Guideline NG9].  Published: 01 June 2015. Updated 2021.
• Respiratory Syncytial Virus (RSV) – Guidance for the Management of Ratified by: Infection Control & Decontamination Assurance Group: 3rd August 2017. Review date: March 2022.
• Public Health England, Respiratory syncytial virus (RSV): symptoms, transmission, prevention, treatment. 22 August 2008.
• Intensive Care Society Policy Statement
• DFTB Bronchiolitis

Test Yourself

RCEMLearning, Moore  AM, The Unhappy Wheezer. 2019.