Acute Bronchiolitis: Assessment and Management in Urgent Care

Table of Contents

 

About This Course

Bronchiolitis is the most common lower respiratory tract infection in infants and children aged <2 years. Although it is a mild illness in most patients, the variability of the disease course and the difficulty of distinguishing bronchiolitis from reactive airway disease and asthma in young children can present challenges for the urgent care clinician. This issue reviews risk factors for severe bronchiolitis and apnea, provides guidance for differentiating between bronchiolitis and asthma, and provides evidence-based recommendations for the management and disposition of pediatric patients who present to urgent care with acute bronchiolitis. In this issue, you will learn:

Which viruses cause the majority of cases of bronchiolitis

Signs and symptoms that can help differentiate bronchiolitis from other conditions that cause wheezing in young children

Risk factors for apnea and severe bronchiolitis

When diagnostic studies are warranted

How to determine when patients require supplemental oxygen or hydration

Which treatments and therapies are most effective and generally recommended, and which are not recommended

CHARTING & CODING: How to appropriately document a patient encounter for acute bronchiolitis

1. About This Course
2. Abstract
3. Case Presentations
4. Introduction
5. Pathophysiology
6. Etiology
7. Differential Diagnosis
   1. Asthma
8. Urgent Care Evaluation
   1. Personal Protective Equipment
   2. Initial Assessment
   3. History of Present Illness
   4. Past Medical History
      1. Risk Factors for Severe Bronchiolitis
      2. Risk Factors for Apnea
   5. Physical Examination
      1. Respiratory Rate
      2. Oxygen Saturation
9. Diagnostic Studies
   1. Radiographic Imaging
   2. Viral Testing
10. Treatment
    1. Oxygen Supplementation
    2. Fluid Administration
    3. Nasal Suction
    4. Bronchodilators
       1. Albuterol/Salbutamol
       2. Epinephrine
    5. Corticosteroids
    6. Combination Treatment With Epinephrine and Corticosteroids
    7. Anticholinergic Agents
    8. Hypertonic Saline
11. Controversies and Cutting Edge
    1. Leukotriene Receptor Antagonists
    2. Bronchiolitis and Vitamin D Deficiency
    3. Bronchiolitis and Asthma
12. Disposition
    1. Risk Factors for Unscheduled Return Visits
    2. Discharging Children with Bronchiolitis
13. Summary
14. Risk Management Pitfalls in Urgent Care Management of Pediatric Bronchiolitis
15. 5 Things That Will Change Your Practice
16. Critical Appraisal of the Literature
17. Case Conclusions
18. Clinical Pathway for Assessment and Management of Acute Bronchiolitis in Urgent Care
19. Charting & Coding: What You Need To Know
20. References

Abstract

Acute bronchiolitis is the most common lower respiratory tract infection in young children that leads to acute care visits and hospitalizations. Bronchiolitis is a clinical diagnosis, and diagnostic laboratory and radiographic tests play a limited role in most cases. Studies have demonstrated a lack of efficacy for bronchodilators and corticosteroids in most cases of bronchiolitis. Frequent evaluation of the patient’s clinical status, including respiratory rate, work of breathing, oxygen saturation, and the ability to take oral fluids, is important in determining safe disposition. This issue reviews the literature to provide evidence-based recommendations for effective evaluation and treatment of pediatric patients with acute bronchiolitis in the urgent care setting.

Case Presentations

A mother brings in her 9-month-old daughter, whom she describes as “gasping for air”...

• The infant has had a runny nose and cough for a few days as well as a low-grade fever, but now she is breathing rapidly and wheezing, with lower intercostal retractions and nasal flaring.
• The mother states that the infant has had wheezing in the past, and asks if the baby might have asthma since “it runs in the family.” She also indicates that in the last 12 hours, the baby has not taken her usual amount of fluids.
• The infant's oxygen saturation level is 89% on room air.
• You begin to think: Should I treat this as reactive airway disease, asthma, or bronchiolitis? Should I give the patient albuterol, nebulized epinephrine, or oxygen? Does this infant need steroids?
• You also wonder whether this patient should be transferred to a higher level of care and if so, what mode of transport would be appropriate…

A 6-week-old boy presents with rhinorrhea and poor feeding for the last 2 days…

• The mother states that he is not breastfeeding as well as usual due to his congestion. She says there is no family history of respiratory problems.
• The boy was born prematurely at 33 weeks' gestation, requiring admission to the NICU for 2 weeks for respiratory support.
• His oxygen saturation level is 91% to 92% on room air.
• Should you give supplemental oxygen? Should you send respiratory viral panels? Does this infant need to be admitted to the hospital?

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Clinical Pathway for Assessment and Management of Acute Bronchiolitis in Urgent Care

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

3. * Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502. (Clinical practice guideline) DOI: 10.1542/peds.2014-2742

4. * Mansbach JM, Espinola JA, Macias CG, et al. Variability in the diagnostic labeling of nonbacterial lower respiratory tract infections: a multicenter study of children who presented to the emergency department. Pediatrics. 2009;123(4):e573-e581. (Retrospective study; 928 patients aged <2 years) DOI: 10.1542/peds.2008-1675

23. United States Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic. Accessed December 10, 2022. (CDC interim guidance)

24. American Academy of Pediatrics. Use of personal protective equipment (PPE) for pediatric care in ambulatory care settings during the SARS-CoV-2 pandemic. Updated December 8, 2022. Accessed December 10, 2022. (Interim clinical guidance)

35. * Willwerth BM, Harper MB, Greenes DS. Identifying hospitalized infants who have bronchiolitis and are at high risk for apnea. Ann Emerg Med. 2006;48(4):441-447. (Retrospective review; 691 patients aged <6 months) DOI: 10.1016/j.annemergmed.2006.03.021

44. * Mansbach JM, Clark S, Christopher NC, et al. Prospective multicenter study of bronchiolitis: predicting safe discharges from the emergency department. Pediatrics. 2008;121(4):680-688. (Prospective multicenter study; 1456 patients aged <2 years) DOI: 10.1542/peds.2007-1418

45. * Mallory MD, Shay DK, Garrett J, et al. Bronchiolitis management preferences and the influence of pulse oximetryand respiratory rate on the decision to admit. Pediatrics. 2003;111(1):e45-e51. (Cross-sectional study) DOI: 10.1542/peds.111.1.e45

46. * Ross PA, Newth CJ, Khemani RG. Accuracy of pulse oximetry in children. Pediatrics. 2014;133(1):22-29. (Prospective multicenter observational study; 255 patients aged <18 years) DOI: 10.1542/peds.2013-1760

53. * Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics. 2004;113(6):1728-1734. (Multicenter prospective cross-sectional study; 1248 patients aged 60 days) DOI: 10.1542/peds.113.6.1728

57. * House SA, Marin JR, Hall M, et al. Trends over time in use of nonrecommended tests and treatments since publication of the American Academy of Pediatrics Bronchiolitis Guideline. JAMA Netw Open. 2021;4(2):e2037356. (Retrospective cohort; 602,375 encounters) DOI: 10.1001/jamanetworkopen.2020.37356

63. * Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-718. (Multicenter randomized clinical trial; 229 infants) DOI: 10.1001/jama.2014.8637

64. * Principi T, Coates AL, Parkin PC, et al. Effect of oxygen desaturations on subsequent medical visits in infants discharged from the emergency department with bronchiolitis. JAMA Pediatr. 2016;170(6):602-608. (Prospective cohort study; 118 patients) DOI: 10.1001/jamapediatrics.2016.0114

66. * Schondelmeyer AC, Dewan ML, Brady PW, et al. Cardiorespiratory and pulse oximetry monitoring in hospitalized children: a delphi process. Pediatrics. 2020;146(2):e20193336. (Review of recommendations) DOI: 10.1542/peds.2019-3336

76. National Collaborating Centre for Women's and Children's Health (UK). Bronchiolitis: Diagnosis and Management of Bronchiolitis in Children. Published June 1, 2015. Updated August 9, 2021. Accessed December 10, 2022. (Clinical guidelines)

80. * Gadomski AM, Bhasale AL. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2006;(3):CD001266. (Systematic review; 30 trials, 1992 infants with bronchiolitis) DOI: 10.1002/14651858.CD001266.pub2

91. * Schuh S, Coates AL, Binnie R, et al. Efficacy of oral dexamethasone in outpatients with acute bronchiolitis. J Pediatr. 2002;140(1):27-32. (Double-blind randomized placebo-controlled trial; 70 patients aged 2-24 months) DOI: 10.1067/mpd.2002.120271

92. * Corneli HM, Zorc JJ, Mahajan P, et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med. 2007;357(4):331-339. (Double-blind randomized trial; 600 patients aged 2-12 months) DOI: 10.1056/NEJMoa071255

126. *Norwood A, Mansbach JM, Clark S, et al. Prospective multicenter study of bronchiolitis: predictors of an unscheduled visit after discharge from the emergency department. Acad Emerg Med. 2010;17(4):376-382. (Prospective cohort multicenter study; 722 patients aged <2 years) DOI: 10.1111/j.1553-2712.2010.00699.x

128. American Medical Association. CPT^® evaluation and management (E/M) office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99417) code and guideline changes. 2021. Accessed December 10, 2022. (Summary of coding guidelines)

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Keywords:  bronchiolitis, acute bronchiolitis, bronchiolitis guidelines, wheezing, wheeze, lower respiratory tract infection, LRTI, respiratory syncytial virus, RSV, asthma, apnea, oxygen supplementation, nasal suction, bronchodilators, epinephrine, corticosteroids, hypertonic saline, bronchiolitis treatment