1. Bronchiolitis Clinical Practice: An Evidence-Based Approach
William Schneider, DO, MA, FACEP
Medical Director, Pediatric Emergency Services
Banner Thunderbird Medical Center
EPIP Conference November 3rd and 4th, 2011

2. Case Presentation 7 month old uncircumcised male gasping for air
Low grade fever, cough and rhinorrhea for 2 days
Now wheezing, grunting, with mod-severe retractions
Unable to feed since this afternoon
Hx of wheezing in past – parents are treated for asthma
UTD with immunizations, ex-premie at 34 weeks gestation
VS: BP 92/60, HR 132, RR 55, Temp 39.1̊C (R), POx 87% RA
Moderately irritable and difficult to console
Nasal flaring with intercostal and substernal retractions
Diffuse expiratory wheezing

3. Work Up Asthma vs. Bronchiolitis pathway? Respiratory Score?
Suction vs. SVN?
Albuterol vs. Epinephrine SVN?
Oxygen?
Steroids?
CBC, BCx, UA, C&S, LP, CXR, viral studies?
Nasal CPAP vs. Heliox vs. both combined?
Risk factors?
Severe Bronchiolitis
Apnea
What is Your
Work Up?

4. Objectives Bronchiolitis
Review the current literature and the AAP recommendations for the diagnosis and management of Bronchiolitis
Become familiar with the Bronchiolitis respiratory scoring tool used in the assessment of the severity of Bronchiolitis
Explore the risk factors for Severe Bronchiolitis and Apnea
Discuss the new Bronchiolitis Protocol using the Respiratory Scoring Tool to be implemented within Banner Health

5. Introduction Bronchiolitis
Bronchiolitis is the most common lower respiratory tract infection in patients < 2 years of age
Peak age: 2-8 months
Male predominance (1.5:1)
200,000 visits to EDs annually
19% admission rate
Cost $700 million annually

6. Definition AAP Bronchiolitis
“…rhinitis, tachypnea, wheezing, cough, crackles, use of accessory muscles, and/or nasal flaring in a child younger than 24 months.”

7. Pathophysiology Bronchiolitis
Virus invades the nasopharynx and spreads by cell to cell transfer to the lower tract within a few days
Viral infection of the lower respiratory tract
Increased mucous secretion, cell death and sloughing of the bronchial ciliated epithelial cells
Clumps of necrotic epithelium and mucus decrease diameter of the bronchiolar lumen causing turbulent air flow particularly on expiration
Peribronchiolar lymphocytic infiltrate and submucosal edema
Narrowing, air trapping, and obstruction of small airways:
Hyperinflation and atelectasis
Ventilation/perfusion mismatch
↓ lung compliance and ↑ work of breathing
Smooth muscle constriction has limited role

8. Recovery Bronchiolitis
Degree of obstruction may vary as some of the airways clear resulting in rapidly changing clinical severity
Epithelial cells recover after 3 – 4 days
Cilia regenerate after 2 weeks
Median duration of illness ~ 12 days
Symptoms may persist for 3 (18%) to 4 (9%) weeks

9. Etiology Bronchiolitis
RSV (50 – 80%):
November to March
Nearly all children (95%) infected within first 2 years of life
4 to 6 day incubation period precedes URI symptoms
Spread through direct contact with secretions
Human Metapneumovirus (3 – 19%)
Parainfluenza Virus Type 3
Influenza
Adenovirus
Rhinovirus (common in asthma)

10. Differential Diagnosis Bronchiolitis
LIFE-THREATENING CAUSES
Infection: pneumonia, Chlamydia, Pertussis (apnea)
Foreign body: aspirated or esophageal
Cardiac anomaly: congestive heart failure, vascular ring
Allergic reaction
Bronchopulmonary disorder exacerbation (CLD)
NON-LIFE THREATENING CAUSES
Congenital anomaly: tracheoesophageal fistula, bronchogenic cyst, laryngotracheomalacia
Gastroesophageal reflux disease
Mediastinal mass
Cystic fibrosis

11. Risk Factors For Severe Illness In Hospitalized Patients
PICNIC network (Pediatric Investigators Collaborative Network on Infections in Canada 1995):
689 hospitalized children < 2 years:
6 out of 689 patients died (0.9%)
4 out of 6 had underlying disease (congenital heart disease, chronic lung disease, immunocompromised)
2 were either premature or < 6 weeks old
None of 372 pts died if older than 6 weeks and without other risk factors for severe disease (95% CI 0-0.8%)

12. Risk Factors for Severe Bronchiolitis History
Age < weeks
Prematurity < weeks gestation
Underlying chronic respiratory illness such as CF, CLD or BPD
Significant congenital heart disease
Immune deficiency including human immunodeficiency virus, organ or bone marrow transplants, or congenital immune deficiencies
Prior intubation
First 48 hours of illness

13. Risk Factors for Severe Bronchiolitis Physical Examination
General appearance: ill appearing
Oxygen saturation level < % on room air
5 fold increase in likelihood of hospitalization
Respiratory rate > breaths per minute
Increased work of breathing - moderate to severe retractions and/or accessory muscle use
Dehydration
Male

14. Risk Factors for Apnea Full-term birth and < 1 month of age
Preterm birth (< 37 weeks gestation) and age < 2 months post conception
History of Apnea of prematurity
Emergency Department presentation with apnea
Apnea witnessed by a caregiver

15. Bronchiolitis Scoring Tool
Assist in clinical decision-making within a protocol
Objective and subjective reproducible clinical parameters
Be applicable to its particular pathophysiology (LRTI)
Validity: score relates to disease severity
Good inter-rater reliability >80%
Responsiveness: detect changes over time
Apply to patients < 2 years of age
Easily adopted by the provider, RT, RN, started in the ED and continued on the floor and/or PICU
Goals:
↓ LOS, ↓ cost & ↓admission rate
↑Consistency, ↑efficiency, and ↑quality
Reflect AAP recommendations

16. AAP Clinical Practice Guideline (Pediatrics 2006;118:1774)
“Physical examination findings of importance include respiratory rate, increased work of breathing as evidenced by accessory muscle use or retractions, and ausculatory findings such as wheezes or crackles”
“Pulse oximetry has been rapidly adopted into clinical assessment of children with Bronchiolitis on the basis of data suggesting that it can reliably detect hypoxemia that is not suspected on physical examination”
“The lack of uniformity of scoring systems make comparison between studies difficult”

17. Bronchiolitis Respiratory Score (Liu, 2004)1 2 3
Respiratory Rate
0-6 mo < 50
6mo – 1yr < 40
1 yr < 30
0-6 mo < 60
6mo – 1yr < 50
1 yr < 45
0-6 mo < 70
6mo – 1yr < 60
1 yr < 60
0-6 mo > 70
6mo – 1yr > 60
1 yr > 60
SaO2
≥ 90 %
> 88 %
> 86 %
≤ 85 %
General Appearance
Calm
No distress
Mildly irritable; easy to
console
Moderately irritable; difficult to console
Extremely irritable; cannot be comforted
Retractions and nasal flaring (NF, SS, IC, SC)
None
1 of 4
2 of 4
3 or more
Auscultation
Clear
Scattered wheezes
Diffuse expiratory wheezing
Biphasic wheezing or very poor air movement

18. Diagnostic Studies - CXR Bronchiolitis
Schuh S, Lalani A, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007; 150(4):
Prospective Cohort study of 265 infants 2-23 months old
Only 2 CXR inconsistent with bronchiolitis
Lobar consolidation
More likely to treat with antibiotics
Pre-radiography: 7 infants (2.6%) identified for antibiotics
Post-radiography: 39 infants (14.7%) identified for antibiotics
Not routinely recommended
Reserved for clinical deterioration or unclear presentation

19. Normal With Possible Hyperinflation

20. RUL Atelectasis

21. Mild RML Perihilar Markings With Peribronchial Cuffing

22. Worse Bilateral Perihilar Infiltrates With Flattened Diaphragms

23. Diagnostic Studies – Labs/Viral Swab Bronchiolitis
Rapid viral testing:
Direct Fluorescent Antibody (DFA) is the Gold standard (99% sensitive)
More sensitive than Enzyme Immunoassay (EIA) and Cx (thermo labile virus)
Most viruses have similar presentation
Results have minimal effect on management
May be considered in infants <3 months of age
Limit further lab testing
Limit unnecessary antibiotics
Not routinely recommended
Routine CBC, BMP and blood cultures are not recommended
Febrile neonate (> 38.0̊ C) with RSV and/or clinical bronchiolitis
Requires septic workup and admission

24. RSV in Febrile Infants Study Information Bronchiolitis
Study: The Risk of Serious Bacterial Infections in Young Febrile Infants with RSV Infections
Pediatric Emergency Medicine Collaborative Research Committee of the AAP
Authors: D Levine, S Platt, P Dayan, C Macias, J Zorc, W Krief, J Schor, D Bank, K Shaw, M Stein, C Jacobstein, N Fefferman and N Kuppermann and The Multicenter RSV- SBI Study Group
Pediatrics 2004; 113;1728

25. Background: RSV in Febrile Infants Bronchiolitis
Young febrile infants are at substantial risk of SBI
Clinical assessment may be difficult
Unclear whether viral infection alters the risk of bacterial disease in this age

26. Methods: RSV in Febrile Infants Bronchiolitis
Prospective, multi-center, cross sectional study:
Eight Pediatric Emergency Departments
October-March,
1,248 patients enrolled
Inclusion:
Age < 60 days
Rectal temp > 38.0oC
Exclusion:
Received antibiotics w/in 48 hrs

27. Evaluation: RSV in Febrile Infants Bronchiolitis
Clinical:
History and physical examination
Yale Observation Scale and Pulmonary Score
Diagnostic Testing:
Rapid RSV antigen
Fever evaluation: urine, blood, CSF
Stool culture - if symptomatic
Chest radiograph
Treatment / Disposition at discretion of physician
Telephone follow-up

28. Categorization: RSV in Febrile Infants Bronchiolitis
RSV Status:
“Indeterminate” considered Negative
Clinical Bronchiolitis:
Wheezing or retractions with URI
No lobar infiltrate on chest radiograph
URI: history/presence of cough or Rhinorrhea

29. RSV in Febrile Infants Positive vs Negative NP Swab Results
3 RSV (+) with Bacteremia were neonates

30. RSV in Febrile Infants Clinical Bronchiolitis (CB) Results

31. Conclusion: RSV in Febrile Infants Bronchiolitis
Young febrile infants with RSV or clinical Bronchiolitis are at lower risk of SBI than febrile infants without these findings
Routine RSV testing not necessary
Risk of UTI, however, remains significant

32. Treatment Bronchiolitis
Suctioning – First line therapy
Nasal suction:
BBG nasal aspirator
Age-appropriate bulb suction
Use prior to:
Feeds
SVN trials or therapy
Deep posterior nasal-pharyngeal suctioning:
Reserved for mod-severe respiratory distress from significant airway obstruction
Data does not support routine use
May induce bronchospasm from irritation and /or agitation
Normal saline nose drops may be used prior to suctioning

33. Treatment Bronchiolitis
Oxygen - First line therapy
Supplemental oxygen administered if POx consistently < 90%:
After nasal suctioning, airway positioning and POx probe repositioning
Titrate 02 to keep POx > 90% while awake or > 88% while sleeping
Consider using continuous pulse oximetry
Significant respiratory distress
First 12 to 24 hours
High risk infants < 2 months of age
Hx of prematurity
RS > 10
Until patient is clinically improving

34. Treatment Bronchiolitis
Albuterol nebulized therapy:
Controversial
Inconsistent results in studies
Gadomski, et al. Bronchodilators for bronchiolitis. Cochrane Collaboration Database Syst rev. 2006;(3):CD001266:
Small short term clinical improvements at best (14%)
Do not affect rate of hospitalization or length of hospital stay
Slightly more effective in those patients with history of wheezing or Atopy
Routine use not recommended:
Consider SVN trial to determine effectiveness in individual patients

35. Treatment Bronchiolitis
Epinephrine nebulized therapy:
Hartling L, et al. Epinephrine for Bronchiolitis. Cochrane Collaboration Database Syst Rev. 2004;(1): CD003123:
Slightly better clinical effect when compared with placebo or Albuterol
Short-term improvements in clinical scores, POx, and respiratory rates
The improvements possibly related to the alpha effect of vasoconstriction
Should be reserved for mod-severe disease
No reduction in the admission rates or length of hospital stay
Anticholinergic agents (Ipratropium):
Everad M, et al. Anticholinergic drugs for wheeze in children under the age of two years. Cochrane Collaboration Database Syst Rev. 2009:
Review of 6 trials involving 321 infants
No significant clinical improvement
Not justified if used alone or in combination with B-adrenergic agents

36. AAP Treatment Recommendation Bronchiolitis
“Bronchodilators should not be used routinely in the management of Bronchiolitis”
“A carefully monitored trial of alpha-adrenergic or beta- adrenergic medication is an option. Inhaled Bronchodilators should be continued only if there is a documented positive clinical response to the trial using an objective means of evaluation.”

37. Treatment - Corticosteroids: Bronchiolitis
Patel H. et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Collaboration Database syst rev. 2004;(3):CD
13 studies with 1,198 patients
No significant difference between steroid & placebo treatment groups:
Clinical scores
Oxygen sats
Admission rates
Length of stay
Return visits

38. Corticosteroids Treatment Bronchiolitis
Corneli HM, et al. A Multicenter Randomized, Controlled Trial of Dexamethasone for Bronchiolitis. N Engl J Med ;357: (Bronchiolitis study group of the Pediatric Emergency Care Applied Research Network):
600 patients with first episode of bronchiolitis
2 – 12 months of age with mod-severe disease
2004 – 2006 / 20 medical center Eds
Dexamethasone 1 mg/kg vs. placebo: Measure outcome at 4 hours:
No significant difference in clinical respiratory scores
No difference in admit rates (39.7% vs. 41%)
No difference in readmission rates or hospital LOS
Conclusion: Did not improve outcomes ED
Hospital

39. Corticosteroids Treatment AAP Recommendation
“Corticosteroid medications should not be used routinely in the management of Bronchiolitis.”

40. Treatment Bronchiolitis
Inhaled steroids:
2 small studies
Showed no benefit in the course of the acute disease
Nebulized Hypertonic 3% Saline:
Improves mucociliary clearance in cystic fibrosis
Kuzik, et al. Nebulized hypertonic saline in the treatment of viral bronchiolitis in infants. J Pediatr 2007; 151:
Multi-center trial of 96 patients admitted
3% saline vs. normal saline SVN
26% reduction in hospital length of stay (2.6 vs. 3.5 days)
Chaudhry K, Sinert R. Is nebulized hypertonic saline solution an effective treatment for bronchiolitis in infants? Annals of Emerg. Med ; 55 (1): :
No significant clinical outcome in ED or admission rate

41. Treatment Bronchiolitis
Nasal Continuous Positive Airway Pressure (CPAP):
Noninvasive humidified high flow nasal cannula (1L/kg/min)
Decreases inspiratory muscle work load
Relieves atelectasis
Prevents airway collapse
Improves ventilation
Bridge to intubation
Severe respiratory distress
Apnea spells
Heliox alone or in addition to nasal CPAP:
Helium + 21% oxygen  mixed gas 1/3 as dense as air
Reduces gaseous flow resistance
Improves gaseous exchange and alveolar ventilation
Increases C02 elimination
Response seen within first hour

42. Ineffective Treatments
Ribavirin: No role (Randolph 1996 Arch Ped Adoles Med)
Antibiotics:
< 2% have concurrent bacterial infection
(Purcell 2002 Arch Ped Adoles Med)
No difference in hospitalization with or without antibiotics
(Friis 1984 Arch Dis Child)
Antihistamines, Decongestants, Singulair
Inhaled Interferon -2a
Nebulized Furosemide
Chest Physiotherapy

43. Criteria for Hospitalization Bronchiolitis
Persistent respiratory distress after treatment (RS > 5)
POx consistently < 92%
Dehydration with inadequate po intake
Significant risk factors for Apnea:
< 1-2 month old with hx of prematurity < 35 weeks gestation
Unreliable caretaker
Witnessed Apnea by caretaker or ED personnel
Febrile neonate
Respiratory rate > 60 breaths per minute after treatment
Continual need for deep NP suctioning
Physician discretion

44. Criteria for PICU Admission Bronchiolitis
Intubation
Nasal CPAP (HHNC/Heliox)
Apnea
RS > 10
Sepsis
Frequent bronchodilator SVN less than 2 hours apart
Physician discretion

45. Criteria for Discharge Bronchiolitis
Oxygen sats consistently > 92%
No respiratory distress (RS < 5)
No apnea or significant risk factors
Respiratory rate < 60 breaths per minute
Adequate oral intake
Family education complete
Adequate bulb suctioning
Physician discretion
Caretaker comfortable and reliable

46. Risk Factors for ED Return Visit Bronchiolitis
% ED return rate:
65% within 2 days
Norwood A, Mansbach JM, Clark S, et al. Prospective multi- center study of bronchiolitis: predictors of an unscheduled visit after discharge from the emergency department. Acad. Emerg Med Apr;17(4): [722 patients younger than 2 years of age]:
OR p-value
< 2 months of age:
Sex: male:
History of hospitalizations:
Prematurity (< 35 weeks):

47. Conclusion Bronchiolitis
Bronchiolitis is mainly a clinical diagnosis
Diagnostic laboratory and radiographic tests play a limited role
Bronchodilators and steroids lack significant clinical effectiveness
Supplemental oxygen indicated if POx < 90% consistently
Assess patients for risk factors when making final disposition decisions
Respiratory tool and protocol aid in treatment and disposition decisions
Most patients recover with suction, O2 & fluids only

48. Bronchiolitis Protocol Process Flow
ED and Inpatient

49. Bronchiolitis Protocol Process Flow (ED and Inpatient)
ASSESS & SCORE using Respiratory Scoring Tool (“Assess – Suction – Assess” process)
Bronchiolitis Protocol Process Flow (ED and Inpatient) No
Supportive Care Orders
Observation or Admit if admission criteria met
Patient meets Discharge Criteria?
RS > 5
(AFTER Suction) No
Yes
Discharge with Supportive Care and Family Education
Yes
History of wheezing, atopy, or FH of asthma? No
Yes
DISCHARGE
Trial of Racemic Epinephrine SVN
<5kg: 5.63mg (0.25ml)
>5kg: 11.25mg (0.5ml)
Trial of Albuterol Nebulizer (2.5 mg/3cc) or MDI 4 puffs
Albuterol Responder:
Supportive Care
Alb MDI or Neb Q4 hours
Epi Responder:
Before D/C: Monitor for Minimum of 60 minutes post treatment for rebound (RS>5)
Non Bronchodilator Responder:
Family Education
Yes
Score improved >3 points?
Score improved >3 points? No
Yes No
Yes
Classified as
Epi Responder
Albuterol Responder:
Supportive Care Orders
Alb MDI or Neb Q4 hours prn for RS >5
ED: Q1 hour prn
Alb MDI or Neb Q2 hours prn for RS >7
ED: Q30 minutes prn
Notify MD if on Q2 hours
Epi Responder:
Racemic Epi Q4 hours prn for RS >5
Racemic Epi Q2 hours prn for RS >7
Non Bronchodilator Responder:
Notify MD for RS >7
Classified as
Non-Bronchodilator Responder
Classified as Albuterol Responder
ADMIT
Patient meets Discharge Criteria? No

50. Bronchiolitis Protocol
Inclusion criteria:
Diagnosis of bronchiolitis
Less than 2 years of age
Exclusion criteria:
Hx of cystic fibrosis (CF)
Hx of Bronchopulmonary dysplasia (BPD)
Significant or cyanotic congenital heart disease
Immunocompromised
On home oxygen
Has significant comorbid conditions complicating care

51. Bronchiolitis Protocol
Does the patient meet eligibility criteria?
Use Banner Health System (BHS) Bronchiolitis Order Set/RT Bronchiolitis Protocol
Assess & Score using BHS Sheet (Always score before and after intervention):
Allow minutes after each intervention before reassessment and scoring
Document patient past medical history of Atopy, allergies, or wheezing
Document family medical history of asthma:
First degree relatives treated for asthma (parents, siblings)

52. ED and Inpatient Supportive Care Orders
Oral or nasopharyngeal suctioning prn by RT/RN :
Age appropriate suction bulb or BBG nasal aspirator
Reserve deep suction for airway obstruction causing significant respiratory compromise
Scheduled spot check pulse oximetry Q4 hrs (Q1 hrs in ED) and prn:
Consider continuous pulse oximetry in pts in ED or with significant respiratory distress (first hrs), high risk infants <1-2 months of age, hx of prematurity, RS >10)
Begin Oxygen Protocol:
Supplemental O2 begins ONLY when pulse Ox consistently < 90% after suction/repositioning
O2 weaning starts when O2 consistently > 90% while awake or > 88% asleep comfortably
Bronchiolitis assessment: Scoring to be done PRE & POST intervention primarily by the RT (RN if RT not available): (Q minutes and prn in ED)
PRN if post score 0 - 4
Q4 hrs and prn if post score is > 5
Q2 hrs and prn if post score is > 7
Begin family education upon hospital admission or complete at discharge
Notify physician if score > 10, clinical deterioration, or new O2 requirements
Consider nasal CPAP (HHNC/Heliox) if severe respiratory distress or apnea spells
Notify physician when discharge criteria are met

53. Bronchiolitis Protocol Process Flow
ASSESS & SCORE using Respiratory Scoring Tool (“Assess – Suction – Assess” process)
Bronchiolitis Protocol Process Flow
Include: months; Dx Bronchiolitis
Exclude: hx BPD, CHD, home O2, or significant comorbid conditions No
Supportive Care Orders
Observation or Admit if admission criteria met
Patient meets Discharge Criteria?
RS > 5
(AFTER Suction) No
Yes
D/C with Supportive Care & Family Education
Yes
History of wheezing, Atopy, or first degree relative treated for asthma? No
Yes
DISCHARGE CRITERIA:
O2 Sats consistently >92%
No respiratory distress (RS <5)
Feeding adequately
Family comfortable & reliable
Family education complete
Respiratory rate <60
No Apnea or significant risk
Bulb suction adequate
Physician discretion
Trial of Racemic Epinephrine SVN
<5kg: 5.63mg (0.25ml)
>5kg: 11.25mg (0.5ml)
Trial of Albuterol Nebulizer (2.5 mg / 3cc) or MDI 4 puffs
Score improved >3 points? No
Score improved >3 points?

54. Bronchiolitis Protocol Process Flow continued
Trial of Racemic Epinephrine SVN
<5kg: 5.63mg (0.25ml)
>5kg: 11.25mg (0.5ml)
Trial of Albuterol Nebulizer (2.5 mg/ 3cc) or MDI 4 puffs
ADMISSION CRITERIA:
O2 Sats consistently <92%
RS >5
Feeding poorly or dehydrated
Family unreliable
Respiratory rate >60
Apnea witnessed
Significant risk factors for apnea
Neonatal fever
Bulb suction inadequate
Physician discretion No
Score improved >3 points?
Score improved >3 points?
Yes
Classified as Epi Responder
Yes No
Classified as Albuterol Responder
Classified as
Non-Bronchodilator Responder
PICU CRITERIA:
Intubation
Nasal CPAP (HHNC/Heliox)
RS > 10
Apnea
Frequent bronchodilator <2 hrs
Sepsis
Physician discretion
Patient meets Discharge Criteria?

55. Bronchiolitis Protocol Process Flow continued
Albuterol Responder:
Supportive Care
Alb MDI or Neb Q4 hours prn
Epi Responder:
Before D/C: Monitor for Minimum of 60 minutes post treatment for rebound (RS >5)
Non Bronchodilator Responder:
Family Education
DISCHARGE
Patient meets Discharge Criteria?
Yes
Albuterol Responder:
Supportive Care Orders
Alb MDI or Neb Q4 hours prn for RS >5
ED: Q1 hour prn
Alb MDI or Neb Q2 hours prn for RS >7
ED: Q30 minutes prn
Notify MD if on Q2 hours
Epi Responder:
Racemic Epi Q4 hours prn for RS >5
Racemic Epi Q2 hours prn for RS >7
Non Bronchodilator Responder:
Notify MD for RS >7
ADMIT No

56. Case Conclusion Asthma vs. Bronchiolitis pathway? Respiratory Score?
7 month old male gasping for air:
low grade fever
cough and rhinorrhea for 2 days
now wheezing, grunting, with mod- severe retractions
unable to feed since this afternoon
hx of wheezing in past
parents treated for asthma
UTD with immunizations, uncircumcised
ex-premie at 34 weeks gestation
VS: BP 92/60, HR 132,RR 55, T 39.1̊C (R), POx 87% RA
moderately irritable and difficult to console
nasal flaring with intercostal and substernal retractions
diffuse expiratory wheezing
Asthma vs. Bronchiolitis pathway?
Respiratory Score?
Suction vs. SVN?
Albuterol vs. Epinephrine SVN?
Oxygen?
Steroids?
CBC, BCx, UA, C&S, LP, CXR, viral studies?
Nasal CPAP vs. Heliox vs. both?
Risk factors?
Severe Bronchiolitis
Apnea

57. References
Bronchiolitis Guideline Team, Cincinnati Chi8ldren’s Hospital Medical Center. Evidence-based care guideline for management of cronchiolitis in infants 1 year of age or less with a first time episode. Guideline Htm. Revised November 16, (Clinical guideline).
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Levine D, Shari L, et al. Risk of Serious Infection in Young Febrile Infants With Respiratory Syncytial Virus Infections. Pediatrics 2004;113;1728.

58. References
Kuzik BA, et. al. Nebulized Hypertonic Saline in the treatment of viral bronchiolitis in infants. Journal of Pediatrics. (2007) pp
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Norwood A, et. al., Prospective multicenter study of bronchiolitis: predictors of an unscheduled visit after discharge from the emergency department. Soc for Academic Emerg Med. (2010) Vol. 17, No. 4: pp
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Schuh S, Lalani A, Allen U, Manson D, Babyn P, Stephens D, MacPhee S, Mokanski M, Khakin S, and Dick P, Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. (2007) Apr;150(4): pp
Seiden JA, Scarfone RJ, Bronchiolitis: An Evidence-Based Approach to Management. Clin Ped Emerg Med 10: (2009) pp

59. References
Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and Management of bronchiolitis. Pediatrics (2006); Vol No. 4: pp
Sumner A, et. Al. Cost-effectiveness of Epinephrine and dexamethasone in children with Bronchiolitis. Pediatrics (2010) Vol 126. No. 4: pp
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