RSV has settled in for the season in the UK – cue the annual ‘nebulised-saline vs salbutamol vs TLC’ debate on every ward round. Well, this year we have a new bronchiolitis guideline from NICE which should help put the old arguments to bed – and remind us how few interventions actually do any good for this condition. Time to get comfortable doing nothing…
I’ve picked out a few highlights from the guideline, but as always, please consume FOAMed responsibly – when treating a sick child do follow your local guideline from the source.
1.1 ‘Assessment and diagnosis’
A few good points to remember:
- Symptoms usually peak between 3 and 5 days, and that cough resolves in 90% of infants within 3 weeks
- Fevers occur in around 30% of children with bronchiolitis, usually below 39 degrees (if higher than 39 degrees, think about other diagnoses i.e. pneumonia)
- Young infants (under 6 weeks) might present with apnoeas ONLY, without other clinical signs of bronchiolitis.
1.2 ‘When to refer’
When bronchiolitis is diagnosed in primary care, the kid earns an immediate ambulance ride to hospital if any of the following are seen: severe respiratory distress (RR over 70/min or marked recessions), apnoeas (reported or observed), cyanosis, or saturations persistently under 92%.
Special cases: Some children are at higher risk of severe symptoms developing and the guideline recommends taking these factors into account (having a lower threshold for referral whether or not severe clinical signs are seen at presentation) –
- chronic lung disease,
- congenital heart disease,
- ex-prems (especially if born <32 weeks),
- babies under 3 months old,
- children with neuromuscular disorders, and
- children with immunodeficiency.
1.3 ‘When to admit’
If your patient can’t keep their sats above 92% in air, they’re getting admitted. Likewise if they are clinically dehydrated, or taking less than 50-75% of their normal amount of fluid, they’ll need feeding support – NG or OG tube is recommended, with IV fluids for those who won’t tolerate their NG (naughty toddlers!) or have impending respiratory failure. Again when thinking about admission, consider the ‘special cases’ – kids who are at higher risk of severe symptoms developing (as listed above).
STOP – hands off that nebuliser. Most things that have gone in and out of fashion for ‘treating’ bronchiolitis don’t have good evidence behind them, and are now officially off the menu. To quote directly:
‘Do not use any of the following to treat bronchiolitis in children:
- hypertonic saline
- adrenaline (nebulised)
- ipratropium bromide
- systemic or inhaled corticosteroids
- a combination of systemic corticosteroids and nebulised adrenaline’
So essentially – give oxygen (if needed) support feeding (if needed), leave the baby alone and provide plenty of reassurance to the parents that things will take their natural course.
When those measures aren’t enough – i.e. if there are recurrent apnoeas, or signs of exhaustion (listlessness, decreased respiratory effort) or the kid is desaturating despite oxygen, it’s time for CPAP. Interestingly there is no mention of humidified high-flow nasal cannula (HHFNC – Vapotherm or Optiflow etc) – I assume this is because although many units are already using these devices, the ‘official’ evidence for their use is still emerging.
1.5 ‘When to discharge’
Once feeding is back to 50-75% of normal and oxygen sats have stayed over 92% in air for 4 hours, including a period of sleep – it’s home time.
NICE makes it clear that along with explaining the ‘red flag’ symptoms to watch out for (grunting, nasal flaring, marked chest recession; fluid intake 50–75% of normal or no wet nappy for 12 hours; apnoea or cyanosis; lethargy or reduced responsiveness) – we have a responsibility to tell parents that smoking at home increases the risk of more severe bronchiolitis symptoms.
…no excuses to avoid the ‘quit smoking’ chat any more.
Are any of these points different from your unit’s current guidance? Or are you already letting your bronchy babies mind their own business while they get better?