Bronchiolitis

-2mo – 2 yo
RFs: < 1mo (prematurity of respiratory center), prematurity (<48w postconceptional age), chronic lung disease (bronchopulm dysplasia, tracheomalacia)*, cardiac disease, immunodeficiency, h/o apnea
-consider dispo to ICU for apnea monitoring and esp if pt has poor respiratory reserve at baseline (chronic lung/cardiac dz)
-ask re FH atopy/asthma and pt h/o eczema. Ask if prior wheezing.
O2 if sat <90%, nasal suctioning (esp if infant / obligate nasal) and O2 +/- trial bronchodilator – albut only (no atrovent). Only continue if positive response.
– RSV+ – higher risk of apnea
– if not severe (tachypnea, hypoxemia <90%, atelectesis or consolidation) or RFs, no labs or cxr
–if bil crackles/whz without URI symptoms, it’s not bronchiolitis! Consider CHF, FB
-there is variation in practice re whether or not to w/u for UTI in febrile pt >2mo with classic bronchiolitis symptoms
– no benefit of steroids or abx (unless high suspicion concomitant infection)
-HFNC at max 2 LPM/kg or bipap for wob. ivf for inability to tolerate feeds due to wob. consider inhaled epi, heliox with cpap.
-give palivizumab for pts <1yo with: hemodynamically significant heart disease or chronic lung disease of prematurity defined as preterm infants <32 weeks, 0 days’ gestation who require >21% oxygen for at least the first 28 days of life
-no need for RSV PCR testing unless diagnosis unclear or if pt in respiratory failure
ARDS salvage therapy: APRV and oscillator
-HFOV / oscillator = vibrating CPAP – TV 1-4mL/kg (very small) – maintains recruitment

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