Bronchiolitis
Treatment
Always attend to A,B,C first, and perform a thorough history and examination
Treatment flowchart
Oxygen
Maintain the oxygen saturation >92% with either nasal cannulae, headbox or mask oxygen. Always try and use humidified oxygen. No need for routine O2 if sats >95%
Criteria for admission
- Requiring oxygen to maintain sats >92%
- Requiring help with hydration
- Family anxiety
- Low threshold for admission if <4 weeks old
Hydration
Increased respiratory distress makes it hard for children to feed and increases the fluid loss by evaporation from their lungs. Hydration can be maintained by trying a variety of tactics:
- Smaller but more frequent feeds. If taking formula, estimate the volume you would expect the child to take 2 hourly and specify that in the notes.
- Nasogastric/orogastric feeds. Useful if the child is too tired to take sucking feeds. Again estimate the expected volume. Theoretically blocking one nostril with an NGT is not ideal in respiratory distress however it is much better tolerated than an OGT. In practise try an NGT first and if this makes things worse revert either to an OGT or iv fluids Back to flowchart
- Intravenous fluids. Required if the child is vomiting the tube feeds or if the tube feeds are making the child’s respiratory distress worse. Aim to supply 80% of maintenance due to the risk of SIADH.
Bronchodilators
3% Saline Nebs for Broncheolitis
Dilution of 30% sodium chloride injection to produce 3%
3% sodium chloride is no longer available.
30% hypertonic sodium chloride available as 10ml amps
(CUH = kept in Misc. drawer in drug cupboard in resus)
Vol of 30% NaCl |
Vol of 0.9% NaCl |
*Final vol of ~3% NaCl |
7.2ml |
92.8ml |
100ml |
18ml |
232ml |
250ml |
36ml |
464ml |
500ml |
* Final concentration produced = 2.9952%
e.g. To produce 100ml of 3% NaCl, withdraw 7.2ml from a 100ml bag of 0.9% NaCl and discard. Then add 7.2ml 30% NaCl to the 100ml bag
There is no conclusive evidence that bronchodilators make any difference to oxygen saturation, admission rates or length of stay and therefore should not be prescribed routinely. Some children, however, may show an improvement in their clinical bronchiolitis scores and occasionally a nebulisor trial may be warranted.
Antibiotics
Should only be prescribed if there is collapse or consolidation on the CXR or there is concern about the diagnosis. If the child is less than 12 months the recommended antibiotics would be:
- Amoxycillin if tolerating oral fluid
- Cefuroxime if requiring intravenous fluids
- Ribavirin is not routinely recommended
Investigations
NPA
If the patient is to be admitted an NPA should be performed. If the patient is admitted out of hours the NPA can be carried out the next morning. It does not alter the management but may help with organising cohort nursing of the RSV+ve patients.
CXR
Does not need to be carried out in every case. It is recommended where there is either concern about the diagnosis, the child is pyrexial (>380) or the child is requiring more than 40% oxygen.
Bloods
Not needed routinely and only required when concern about the diagnosis or if an intravenous cannula is being sited.
