Bronchiolitis

Original Author: Hannah Murray and Dr Matt Hurley
Last Updated: 18th August 2018
Revisions: 19

Introduction

Bronchiolitis is a viral infection of the bronchioles, the smallest air passages in the lungs. It is most commonly caused by respiratory syncytial virus (RSV) (1).

Epidemiology

Bronchiolitis is a common disease that usually affects children under the age of 2. About 1/3 of children will develop clinical bronchiolitis in their first year of life (2), although up to 50% may have have encountered RSV by this time.  It mainly occurs during the winter and spring months (3). In recent years, hospital admissions due to bronchiolitis have increased (4).

Pathophysiology

Bronchioles are airways in the lungs which are less than 2mm wide and do not contain cartilage or submucosal glands. There are several physiological changes which occur in response to viral infection:

  • Proliferation of goblet cells causing excess mucus production
  • IgE-mediated type 1 allergic reaction causing inflammation
  • Bronchiolar constriction
  • Infiltration of lymphocytes causing submucosal oedema
  • Infiltration of cytokines and chemokines

The combination of mucus, oedema and increased cells in the bronchioles leads to a ball-valve effect resulting in hyperinflation, increased airway resistance, atelectasis (lung collapse) and ventilation-perfusion mismatch, which together result in the clinical features typically seen in bronchiolitis (1).

Risk factors

  • Being breast fed for less than 2 months
  • Smoke exposure (eg. parents’ smoke)
  • Having siblings who attend nursery or school (increased risk of exposure to viruses)
  • Chronic lung disease due to prematurity (5)

Clinical features

History

The typical history is one of increasing symptoms over 2-5 days, usually consisting of:

  • Low-grade fever
  • Nasal congestion
  • Rhinorrhoea
  • Cough
  • Feeding difficulty

On examination

  • Tachypnoea
  • Grunting
  • Nasal flaring
  • Intercostal, subcostal or supraclavicular recessions
  • Inspiratory crackles
  • Expiratory wheeze
  • Hyperinflated chest
  • Cyanosis or pallor (6)

Differential diagnosis

  • Pneumonia
  • Croup
  • Cystic fibrosis
  • Heart failure – VERY IMPORTANT not to miss this, and it can be difficult to diagnose
  • Bronchitis (7)

Investigations

Laboratory tests

  • Nasopharyngeal aspirate or throat swab – RSV rapid testing and viral cultures
  • Blood and urine culture if child is pyrexic
  • FBC
  • Blood gas (ABG) if severely unwell – this may detect respiratory failure and the need for respiratory support, but should not be done routinely

Imaging

  • CXR (only if diagnostic uncertainty or atypical course) – features seen are:
    • Hyperinflation
    • Focal atelectasis
    • Air trapping
    • Flattened diaphragm
    • Peribronchial cuffing (8)

Management

The first decision is whether the child should be managed at home or in hospital. This should be based on any comorbidities the child may have and any factors which may affect the carer’s ability to look after a child with bronchiolitis. Most can be managed at home with supportive measures eg. fluids, good nutrition and temperature control (8).

An urgent referral to hospital should be made if any of the following features are seen (4):

  • Apnoea
  • Child looks seriously unwell
  • Severe respiratory distress eg. grunting, marked recessions, respiratory rate >70
  • Central cyanosis
  • Oxygen sats < 92%

Hospital referral should be considered if any of the following are seen (4):

  • Respiratory rate > 60
  • Inadequate fluid intake (50-75% of usual volume)
  • Clinical dehydration

In hospital, the following management steps should be taken (4):

  • Give oxygen if sats < 92% in room air
  • Give fluids via nasogastric or orogastric tube if inadequate oral intake
  • Consider CPAP if there is impending respiratory failure
  • Perform upper airway suctioning if there are upper airway secretions or apnoea

Discharge can be considered when the child is:

  • Clinically stable
  • Taking adequate oral fluids
  • Maintaining sats > 92% for more than 4 hours

 

It is worth noting that there is no role for antibiotics, steroids or bronchodilators in the treatment of bronchiolitis.

Complications

These complications can occur following bronchiolitis (8, 9):

  • Hypoxia
  • Dehydration
  • Fatigue
  • Respiratory failure
  • Persistent cough or wheeze (very common and parents should be counselled that their child may cough for several weeks)
  • Bronchiolitis obliterans – Airways become permanently damaged due to inflammation and fibrosis (10)

Prognosis

Bronchiolitis usually lasts 7-10 days (11). Most children who require hospital admission can cough for up to 6 weeks, whereas those cared for at home will have a more minor ‘common cold’.

References

(1) Nizar F Maraqa, “Bronchiolitis”, Jan 2017. [Online]. Available: http://emedicine.medscape.com/article/961963-overview [Accessed July 2017]
(2) NICE, “Bronchiolitis in Children: Diagnosis and Management”, June 2015. [Online] Available: https://www.nice.org.uk/guidance/ng9/chapter/Introduction [Accessed July 2017]
(3) Denny, AM Collier, FW Henderson, WA Clyde, “The Epidemiology of Bronchiolitis”, Paediatric Research, Vol 11, p. 234-236, 1977.
(4) Green, D. Yeates, A. Goldacre, C. Sande, R. Parslow, P. McShane, A. Pollard, M. Goldacre, “Admission to hospital for bronchiolitis in England: trends over five decades, geographical variation and association with perinatal characteristics and subsequent asthma”, Archives of Disease in Childhood, Published online September 2015
(5) NHS Choices, “Bronchiolitis- Causes”, Oct 2015. [Online]. Available: http://www.nhs.uk/Conditions/bronchiolitis/Pages/causes.aspx [Accessed July 2017].
(6) Meissner, “Viral Bronchiolitis in Children”, The New England Journal of Medicine, Vol 374. P. 62-72, 2016
(7) Nizar F Maraqa, “Bronchiolitis Differential Diagnoses”, Jan 2017. [Online]. Available: http://emedicine.staging.medscape.com/article/961963-differential [Accessed July 2017]
(8) NHS Choices, “Bronchiolitis – Complications”, Oct 2015. [Online]. Available: http://www.nhs.uk/Conditions/Bronchiolitis/Pages/Complications.aspx [Accessed July 2017].
(9) Embarrassing Bodies Kids, “Bronchiolitis Complications”, Oct 2015. [Online]. Available: http://embarrassingbodieskids.channel4.com/men-in-white-coats/bronchiolitis/complications/. [Accessed July 2017].
(10) Rezaee and Y. Weerakkody, “Obliterative Bronchiolitis”, [Online]. Available at https://radiopaedia.org/articles/obliterative-bronchiolitis. [Accessed July 2017].
(11) Knott, “Bronchiolitis”, June 2013. [Online]. Available: https://patient.info/doctor/bronchiolitis-pro [Accessed July 2017]

 

Authors:

1st Author: Trainee Doctor Hannah Murray

Senior Reviewer: Dr Matthew Hurley (Senior respiratory paediatric registrar)

Student Reviewer: Luke Austen

Quiz

Question 1 / 5
In a sample of 600 children, how many would you expect to have had bronchiolitis during their first year of life?

Quiz

Question 2 / 5
Which of these features is NOT consistent with a diagnosis of bronchiolitis?

Quiz

Question 3 / 5
Which of these features is an absolute indication for referral of a child with suspected bronchiolitis to hospital?

Quiz

Question 4 / 5
You are the FY2 doctor prescribing for an 18 month-old baby with uncomplicated bronchiolitis. What should you give?

Quiz

Question 5 / 5
Which of the following is not a risk factor?

Results

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