Emergency Medicine

Explanation

Vital signs, particularly heart rate, are reliable indicators that a child is sick. Increased work of breathing, grunting and stridor are important pointers to severe respiratory distress.

Explanation

Bronchiolitis is extremely common in this age group. Bronchiolitis is a descriptive term of symptoms and signs that includes a viral upper respiratory infection, followed by increased work of breathing and wheezing in a child less than two years of age with no other cause of wheezing (such as pneumonia or atopy).

Bronchiolitis may account for up to 60 percent of the cases of LRTI during the first year of life. Bronchiolitis has a peak incidence between two and six months of age and remains a significant cause of respiratory disease during the first five years of life.

While most children will present with a relatively mild version of bronchiolitis that may or may not require admission, children will occasionally present with severe respiratory distress. Bronchiolitis is a leading cause of hospitalization in infants and young children.

Other differentials that need to be considered in this child include non-specific pneumonitis, pneumonia or cardiac failure. These are much less common in this age group. One generally would not expect a septic child to have such obvious respiratory signs. This child is too young to be diagnosed with asthma.

Explanation

Answer:

• Blow-over mask oxygen
• Low flow nasal prongs
• High flow humidified
• Nasopharyngeal CPAP
• Intubation and ventilation

The most important intervention in this case would be to provide oxygen via mask or nasal prongs. The aim is to maintain a saturation >95%. Very young babies can be treated with headbox oxygen. Another treatment option that is sometimes used is a trial of salbutamol in a child older than six months, although is very unlikely to help in children under one year.

Salbutamol is most useful if there is a family history of asthma or atopy. If it is not effective, it should be discontinued. If simple measures fail, CPAP followed by intubation and ventilation is the next treatment option.

Antibiotics are not useful in acute bronchiolitis, although many paediatricians would consider it if there were concerns about possible aspiration and secondary infection. If there is any concern regarding sepsis, antibiotics should be given.

Explanation

This child has severe respiratory distress. The only investigation above that will effect your management in the short term is a venous blood gas. An NPA is only useful to confirm which virus this child has, thus assisting with advice regarding isolation. An NPA may also give you reassurance regarding the diagnosis if there are doubts. While you are likely to perform an NPA in the inpatient setting, it is not going to alter your immediate management.

A chest x-ray is not necessary in the routine evaluation of bronchiolitis. It is unlikely to alter treatment and may lead to inappropriate use of antibiotics due to the presence of upper lobe atelectasis. A CXR is likely to be performed in this case but again, will not alter your immediate management.

Data regarding the utility of routine FBC and blood cultures in bronchiolitis is lacking. It is sometimes used to evaluate the possibility of a secondary or comorbid bacterial infection in children with suspected bronchiolitis and a fever. However, a raised white cell count in bronchiolitis is not predictive of serious bacterial infection and the risk of serious bacterial infection other than urinary tract infection in children with bronchiolitis older than one month is very low (around 1%). This risk is raised in children admitted to the intensive care unit.

Explanation

Metabolic acidosis rather than metabolic alkalosis is an indicator of poor tissue perfusion.

The most common reason for intubation for infants with bronchiolitis is respiratory failure due to fatigue.

Explanation

Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis, followed by rhinovirus. Less common causes include parainfluenza virus, human metapneumovirus, influenza virus, adenovirus, coronavirus and human bocavirus.

Explanation

All of the above: A, B, C, D, E.

Other risk factors include low birth weight, congenital cyanotic heart disease, neurological disease, immunodeficiency and congenital anatomic airway defects. Environmental risk factors include older siblings, twin and other higher order siblings, household crowding and high altitude.

Explanation

RSV occurs in seasonal outbreaks, with peaks over winter months. RSV bronchiolitis tends to follow a very typical course. Symptoms usually peak around day three or four. They begin to improve on day ten of the illness, although the cough may last for a number of weeks.

The majority of children are able to be managed at home following simple advice given to the parents regarding symptom control, fluid intake and warning signs

Explanation

RR >40. As a general rule, children with oxygen saturations <93% when asleep require admission. Children with borderline saturations who are awake when initially seen may need admission for oxygen monitoring if they have significantly increased work of breathing.

A RR >60 generally is associated with poor intake and increased risk of fatigue.

Poor fluid input and output is a common reason for admission. If simple measures such as saline drops to the nares do not work (babies are obligate nasal breathers) or syringing fluid orally do not work, admission for IV or NG rehydration may be required.

Parental anxiety and ability to cope must always be taken into consideration with any child who presents unwell.

For more information, please see the

The Children’s Hospital Westmead: bronchiolitis – parent fact sheet