PEM fellow Dr. Michelle Vazquez presents a case of: A 6 month old boy comes to the ED with an elevated respiratory rate and lots of wheezing on exam. He had a tactile fever at home and in the ED his temperature is measured at 100.4F. His oxygen saturation is 90% on room air.
There is no family history of asthma. The mother had a recent cold. Vaccines are up to date.
You briskly take a history and physical. The baby is tachypneic (breathing in the 60s) and is mildly tachycardic and has some diffuse wheezing. The exam is otherwise non-contributory.
You are getting ready to put the child on a trial of supplemental oxygen, some hypertonic saline nebs, albuterol, and some corticosteroids and maybe even get an X-ray because that’s what people seem to do for cases of suspected bronchiolitis. You also consider racemic epinephrine if things go badly.
But what do the guidelines say? Which of these is supported for use in the EMERGENCY DEPARTMENT according to the most recent clinical guideline from the combined “Bronchiolitis board group” (General Pediatrician, Family Physician, Pediatric Hospitalists, Emergency Physicians, Neonatologists, Pediatric Infectious Disease)?
Amazingly, none of these other than supplemental oxygen, but only if the baby has an oxygen saturation of 90% on room air or less. A new set of guidelines was published in 2014 to reflect this, and the management recs may surprise you (note: the WikEM phone app section on bronchiolitis does in fact have this updated!)
Wait so does that mean that these other interventions don’t work? Not exactly. Albuterol has been shown in meta-analysis to improve symptoms. But it didn’t decrease time of illness or hospitalization rate or length of stay. Racemic Epi may decrease length of stay to 7 days (i.e. severe cases, it may help). Hypertonic saline decreases length of stay by one day but the recommendations state not to give in the ED. Corticosteroids should not be given (Level A recommendation) as it does not reduce admissions and prolongs viral shedding.
So what can you do?
-parent education
-encourage breast feeding to 6 months
-hand washing.
oxygen if saturation is 90% of less.
-assess tobacco exposure
-and of course, RSV will not respond to antibiotics. So no need for empiric antibiotics unless other suspicion arises.
Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S 3rd, Hernandez-Cancio S. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis.Pediatrics. 2014 Oct 27. pii: peds.2014-2742.
Thanks to Dr. Vazquez from the Sinai Peds EM Department for this talk and these pearls!
