It’s getting to that time of year again! The waiting room is full of snotty spluttering children, most of whom just need simple advice and reassurance. But amongst them will be the occasional infant who is more unwell with a cough, most likely bronchiolitis. How confident are you at spotting these patients and sorting them out? NICE have produced new guidance to aid in diagnosing bronchiolitis and knowing when to refer, as well as exploring the evidence-based management (NICE 2015, NG9).

Before we look at the NICE guidelines, here’s some statistics on bronchiolitis:

  • Most common LRTI in infants.
  • 1 in 5 of those
  • Almost exclusively a disease of the under 2s.
  • Peak incidence is 3-6m of age.
  • Up to 3% of patients require hospitalisation.

NICE guidance (NICE 2015, NG9)

Diagnosis

Bronchiolitis is most likely in those

  • Prodromal coryzal illness progressing to acute troublesome cough and increased work of breathing.
  • Tachypnoea +/- chest recession.
  • Wheeze +/- crackles throughout chest.
  • Poor feeding.
  • Fever (only in 30% of cases and usually <39⁰C).
  • Symptoms peak at 3-5d then start to improve.
  • Cough resolves within 3w in 90% infants.
  • Under 6w age, apnoea may be only clinical symptom or sign.

Differential diagnoses to consider include:

  • Bacterial pneumonia (look for focal chest signs and fever >39⁰C).
  • Viral wheeze or early onset asthma (usually older age, recurrent/variable symptoms, no fever).

Assessment

  • Measure oxygen saturations in all infants with suspected bronchiolitis using appropriate equipment.
  • Assess hydration status (pulse rate, capillary refill time, etc.).
  • Assess respiratory distress (count respiratory rate (RR), look for recessions, nasal flaring and grunting).
  • A chest X-ray should not be done as part of the assessment (in primary or secondary care).

Referral

Immediate (999) referral Consider same day referral
Apnoea (observed or reported) RR >60/min
Severe respiratory distress (grunting; marked recession; RR >70/min) Feeding difficulty (<75% usual intake)
Central cyanosis Clinical dehydration
Oxygen saturation <92% in air

Have a lower threshold for referring those with risk factors for severe bronchiolitis:

  • Chronic lung disease.
  • Congenital heart disease.
  • Age <3m.
  • Prematurity (especially if <32w).
  • Neuromuscular disorders.
  • Immunodeficiency.

Also, consider the social circumstances of the child and the ability and confidence of the parents/carers to spot deterioration.

Management

For most children, treatment is supportive and the condition is self-limiting.

Offer the following specific safety-netting advice to those being treated at home on red flags to look out for:

  • Increasing work of breathing or exhaustion.
  • Poor fluid intake (<75% usual or no wet nappies for ≥12h).
  • Apnoea or cyanosis.

Due to lack of evidence of any benefit, DO NOT use any of the following:

  • Antibiotics.
  • Nebulised adrenaline/salbutamol/saline.
  • Inhaled salbutamol/ipratropium bromide/corticosteroids.
  • Oral steroids.
  • Montelukast.

Supplemental oxygen should be given (in hospital and whilst awaiting transfer) to infants with persistently low oxygen saturations <92%.

In secondary care, CPAP, chest physiotherapy and ventilation may be required in the most severe cases, with nasogastric or orogastric tube if needed to maintain oral intake.

This article was first published in the October 2015 edition of the NASGP's The Sessional GP magazine.

Aimee Lettis

Aimee Lettis from the GP Update team gives us short, sharp nuggets of clinical information for sessional GPs. The GP Update team run one-day courses, bringing GPs up to date with all the latest evidence and guidelines.

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