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Bronchiolitis - PICU admission

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Risk Factors for PICU admission

  • Prematurity
  • Age < 12 wks
  • Underlying chronic illness - congenital cardiac disease, chronic lung disease, home oxygen, tracheostomy

Indications for PICU admission

  • Sats < 90% despite maximal ward oxygen therapy
  • Apnoea /bradycardia
  • Decreased level of consciousness

Bronchiolitis mimics

  • Sepsis - babies < 3mths should receive a septic screen and consideration of IV antibiotics
  • Asthma/reactive airway disease -consider a trial of bronchodilators in infants > 6mths or recurrent wheezy illness, document response to bronchodilators clearly in the notes
  • Pneumonia - secondary bacterial pneumonia not uncommon in bronchiolitis
  • Pertussis - consider screening babies <6wks

Investigations

  • NPA - send early in morning (before 10am) to allow processing of result same day. NPA's are not processed on weekends at Starship, can defer until Monday morning
  • CXR -mandatory in all children unwell enough to require PICU admission
  • Septic Screen - babies < 3mths

General Management

  • Avoid excessive handling
  • Nasogastric tube for decompression of stomach
  • Nasal saline/suction: Babies are obligate nose breathers and benefit from regular nasal toilet with saline if coryzal
  • Fluids/Feeds: Hourly bolus feeds via NG if tolerated (bolus feeds allow venting of stomach in between). Restrict enteral feeds to 90ml/kg/day initially and increase to normal volumes as tolerated.
    IV fluids should be restricted to 70ml/kg/day and must be isotonic saline with added glucose.
    Bolus IV fluids should be avoided unless there are signs of circulatory failure (shock). All babies with moderate bronchiolitis have an increased heart rate - this sign in isolation should not be the trigger for bolus fluid therapy. Fluid boluses remain in the circulation for only a short period of time before shifting and accumulating in the extracellular tissue spaces - this may be harmful for children with respiratory illnesses.
  • Sedation: Enteral feeding may be enough to settle a fractious baby. If remains unsettled Chloral hydrate may be used - Dose 25mg/kg Q4-6H PRN
  • Oxygen therapy: Babies with bronchiolitis do not require sats of 100%. Titrate oxygen to keep sats 92-96%.
  • Caffeine: Consider trial of caffeine in babies with apnoea to prevent intubation - loading dose 20mg/kg caffeine citrate, maintenance 5mg/kg daily
  • Positioning: Prone positioning with bed head raised 300 (in an HDU setting with continuous ECG and saturation monitoring) may improve respiratory mechanics and V/Q mismatch, resulting in decreased work of breathing
  • High flow nasal cannula oxygen:
    2L/kg flow
    Oxygen : start at 50% and titrate to achieve oxygen saturations 92-96%
    Babies will still have visible signs of respiratory effort on high flow
    A reduction in Heart Rate is the best indicator of improving physiology
  • Bubble CPAP:
    Start at 6cmH2O PEEP and titrate PEEP
    Oxygen: start at 50% and titrate to achieve oxygen saturations 95-96%
    Will usually require chloral hydrate sedation to tolerate initiation of CPAP therapy
  • Indications for Intubation and Ventilation:
    Apnoea requiring intervention, that doesn't improve with CPAP +/- caffeine
    Clinical signs of Respiratory Failure - an isolated raised pCO2 on a blood gas is not an indication for ventilation

    Ventilating babies with bronchiolitis is difficult as the disease affects the small airways resulting in gas trapping and V/Q mismatch. Ventilation is best avoided if possible and should only be considered after discussion with the PICU Intensivist. Heavy sedation +/- muscle relaxation is usually required.
  • Initial ventilation settings:
    TV 6ml/kg (peak pressure < 30cmH2O), PEEP 5cmH2O, RR 20-25/min, I time 0.8-1 second, FIO2 0.6.
    Allow permissive hypercapnia (raised pCO2) as long as pH > 7.25
    Titrate oxygen to sats 88-94%

References

  1. Ralston et al. American Academy of Pediatrics Clinical Practice Guideline: The Diagnosis, Management and Prevention of Bronchiolitis. Pediatrics 2014;134:e1474-e1502
  2. Schroeder AR, Mansbach JM. Recent evidence on the management of bronchiolitis. Current Opinion in Pediatrics. June 2014;26:328-333

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Document Control

  • Date last published: 12 June 2015
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Editor: John Beca
  • Review frequency: 2 years