Prehospital Management of Bronchiolitis

Respiratory distress is a common cause of 9-1-1 calls for children. In infants and young children, bronchiolitis is one of the most frequent causes of respiratory distress. 

Bronchiolitis is a viral disease process that triggers inflammation and edema of the lower airway. It also increases mucus production, which can cause nasal obstruction and respiratory distress. Associated symptoms include runny nose, cough, wheezing, and rales. 

Research in the past two decades has led to important updates in the care of bronchiolitis. Specifically, the American Academy of Pediatrics recommends against the routine use of nebulized albuterol or epinephrine in mild to moderate disease. Supportive care, including nasal suctioning, is the treatment of choice.

Introduction

One reason pediatric patients are such an important subset of prehospital patients is because they differ anatomically and physiologically from adults. Respiratory distress is the most common identifiable reason for EMS transports in children.¹

Bronchiolitis is the most common cause of lower respiratory infection in children under 2 years of age and the most common reason for hospitalization in children under 1.^2,3 Children 30–60 days old are at the highest risk for hospitalization;³ those born prematurely are at increased risk of hospitalization, respiratory failure, and apnea. Because of the high incidence of disease, EMS professionals will frequently care for children with bronchiolitis and should be aware of current recommendations from the American Academy of Pediatrics (AAP). 

Bronchiolitis is caused by a viral infection, with respiratory syncytial virus (RSV) being the most regularly identifiable. In one cohort of inpatient and outpatient subjects, RSV was identified in 76% of cases. Rhinovirus was the second-most common cause at 18%. Other implicated viruses include influenza, parainfluenza, and human metapneumovirus.⁴ Bronchiolitis is a disease of seasonal and some geographic variation, with most cases occurring between December and March.⁵ 

The disease typically infects the upper respiratory tract, then spreads to the lower respiratory tract. Viral replication in the cells lining the airway causes cell death and release of inflammatory mediators, leading to edema and increased mucus production. The edema, increased mucus, and cellular debris cause narrowing of the airways, resulting in symptoms of airway obstruction and decreased ventilation.^6,7

Signs and Symptoms

Bronchiolitis classically begins with an upper respiratory infection prodrome before progressing to lower respiratory disease. Symptoms typically include rhinorrhea, cough, and fever. Increased mucus production in infants can lead to obstruction of the nasal passage, causing mild to moderate respiratory distress. Infants are more susceptible to symptoms due to their relatively small nasal passages and being obligate nose breathers.⁶ 

On exam the child may be tachycardic and tachypneic, and have wheezing and/or rales on auscultation. In severe cases bronchiolitis may lead to significant respiratory distress and/or periods of apnea. Risk factors for severe disease and apnea include prematurity (less than 37 weeks’ gestation), age less than 12 weeks old, history of cardiac or lung disease, and immunodeficiency.^6,7

Signs of respiratory distress include retractions, nasal flaring, grunting, and hypoxia. During the winter months these symptoms in a child under age 2 are highly suspicious for bronchiolitis.

Treatment

Treatment of children with bronchiolitis centers primarily on the airway, breathing, and circulation algorithm. Because increased mucus production leads to upper-airway obstruction, nasal suctioning may be helpful in cases with signs of obstruction or significant respiratory distress. Bulb suction is a quick and easy way to provide relief. However, evidence on deep (invasive) nasal suctioning is inconclusive, and it is not routinely recommended.⁶ 

Over the past two decades, research into the appropriate treatment for bronchiolitis has advanced.⁷ In 2014 the AAP published its latest clinical policy on bronchiolitis and recommended against routine administration of albuterol or nebulized epinephrine to children with it.

Between the AAP’s first clinical policy statement in 2006 and 2014, multiple systematic reviews found the administration of beta-agonists in this population did not improve objective outcome measures of disease resolution, the need for hospitalization, hospital length of stay, or pulse oximetry readings.^7,8 A 2009 Cochrane review of children under 2 with a history of recurrent wheezing also found no benefit from beta-agonist administration.⁹ 

Children with severe respiratory distress or failure were generally excluded from the studies, so the above recommendations should not be applied in such cases. In cases of severe respiratory distress, there may be a role for nebulized albuterol and epinephrine but attempt nasal suctioning first.

Some wheezing infants may have been diagnosed with reactive airway disease or even asthma—if this is a part of their history, beta-agonists may be part of their treatment plan. Advanced respiratory-support interventions may be necessary in some cases.^6,7 Use BVM assistance for periods of apnea, and intubate very rarely. Never intubate because of an arbitrary number on a respiratory rate—this is a way to potentially injure a child.

Assess pulse oximetry intermittently with adequate saturation level being 90% or better. In cases of sustained desaturation below 90%, deliver supplemental oxygen via nasal cannula.⁷

Less Is More

As with any patient in respiratory distress, performing a primary assessment with the ABCs is paramount to the management of bronchiolitis. Assessing the infant for retractions, nasal flaring, respiratory rate, skin color, and pulse oximetry will yield insight into the severity of respiratory distress. Evaluate their mental status and use the pediatric assessment triangle to ensure you’re keeping up with the child’s physiologic needs. Less is better when considering interventions.

The hallmark of treatment is supportive care, and administration of nebulized albuterol and epinephrine is not routinely recommended. 

References

1. Drayna PC, Browne LR, Guse CE, et al. Prehospital pediatric care: Opportunities for training, treatment, and research. Prehosp Emerg Care, 2015 Jul–Sep; 19(3): 441–7.

2. Gong C, Byczkowski T, McAneney C, et al. Emergency department management of bronchiolitis in the United States. Pediatr Emerg Care, 2017 Apr 24.

3. Hall CB, Weinberg GA, Blumkin AK, et al. Respiratory syncytial virus-associated hospitalizations among children less than 24 months of age. Pediatrics, 2013; 132(2): e341–8.

4. Miller EK, Gebretsadik T, Carroll KN, et al. Viral etiologies of infant bronchiolitis, croup and upper respiratory illness during 4 consecutive years. Pediatr Infect Dis J, 2013; 32(9): 950–5.

5. Mullins JA, Lamonte AC, Bresee JS, Anderson LJ. Substantial variability in community respiratory syncytial virus season timing. Pediatr Infect Dis J, 2003; 22(10): 857–62.

6. Shefrin A, Busuttil A, Zemek R. Wheezing in Infants and Children. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th ed. New York, NY: McGraw-Hill Education, 2016.

7. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: The diagnosis, management, and prevention of bronchiolitis. Pediatrics, 2014; 134(5): e1,474-1,502.

8. Gadomski AM, Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev, 2014 Jun 17; (6): CD001266.

9. Chavasse R, Seddon P, Bara A, McKean M. Short acting beta agonists for recurrent wheeze in children under 2 years of age. Cochrane Database Syst Rev, 2002; (3):CD002873.

Michael Supples, MD, EMT-I, is an emergency medicine resident at Wake Forest Baptist Medical Center in Winston-Salem, N.C. He attended medical school at Eastern Virginia Medical School and previously worked as an EMT-I in Durham, N.C. Reach him at msupples1@gmail.com. 

Adam Johnson, MD, is a pediatric emergency medicine physician and assistant professor of emergency medicine at Wake Forest Baptist Medical Center in Winston-Salem, N.C. He attended medical school at the University of Florida and completed his residency in pediatrics at the University of Alabama at Birmingham, and fellowship in pediatric emergency medicine at the University of Colorado.