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You get dispatched to a call for a pediatric patient with a chief complaint of respiratory distress. You arrive on the scene to find an ill 18-month-old patient who is in obvious respiratory distress, retracting, using accessory muscles. The patient’s mother states this has been going on for a few days. She reports that the patient has been having intermittent fevers, has no prior medical history and has multiple sick contacts at daycare.

You perform your exam and find diffuse wheezing, with some intermittent crackles, and you reach for the airway and pull out some albuterol, because it’s asthma, right?

Bronchiolitis diagnosis, management

Bronchiolitis is a common pediatric illness often found in children younger than 2 years old [1].

It is most commonly caused by respiratory syncytial virus (RSV), but can be caused by other viruses, including adenovirus, human metapneumovirus, influenza and parainfluenza [1]. RSV mediated bronchiolitis also appears with outbreaks during the winter and early spring, with a peak in January [1]. Pediatric patients who are at the most risk of bronchiolitis are those with complications of infancy, including [1]:

• Preterm birth
• Chronic lung disease
• Congenital heart disease
• Immunocompromise
• Infants less than 3 months old
• Any other underlying chronic illness

Another association has been identified between maternal smoke exposure and the infant’s bronchiolitis severity score [6].

Bronchiolitis often is the sequela of a viral inflammation of the epithelial lining of the bronchioles, causing inflammation, wheezing, increased mucus production, rhonchi and subsequent necrosis of those epithelial cells [2]. Initial presentation of the disease is often viral in nature, presenting with nasal congestion, runny nose and cough. Peak presentation for emergency care is around day 3-5. Tachypnea, accessory muscle usage and retractions are subsequent symptoms of the illness, progressing to respiratory failure in severe cases. In infants, respiratory failure can be recognized with cyanosis, hypoxia, nasal flaring and grunting.

Frequently, bronchiolitis is a clinical diagnosis that is made after completing a thorough history and physical on a patient. The clinical signs and symptoms of this disease are often all that is needed to make the diagnosis. Adjunct testing, including lab work and imaging, is often not required. In patients under 2 years old, bronchiolitis accounts for almost 300,000 emergency room visits each year, of which as many as 40% result in hospitalization [2].

Currently, there is a large variation in the ED management of bronchiolitis leading to a large variation in practice.

Bronchiolitis should be initially managed with supportive treatment. This treatment should include adequate hydration; clearance of the upper airways with suctioning; and close monitoring for signs and symptoms of respiratory failure, and the need for invasion intervention, such as endotracheal intubation and mechanical ventilation [1].

Determining how to treat pediatric respiratory distress in the ambulance

First of all, asking questions may be the best way to determine how to treat the patient. Look at the age. Is the patient’s age measured in months (0-24 months)? If so, there is a good chance it’s not asthma.

Next, ask a family member if the patient has had these respiratory illnesses before. If the answer is yes, then ask if the breathing treatments have been given and helped in the past. If they have not helped in the past, there is a good chance they won’t help this time either.

Inquire about history of this illness: do the signs and symptoms include fevers, runny nose, congestion? This would lean more towards bronchiolitis. Does the patient have a history of eczema or allergies? The presence of these can indicate the atopy triad, which includes asthma.

The following table can help delineate between the two illnesses.

Pediatric asthma treatment options

It should be noted that patients with any degree of asthma severity can have any degree of asthma exacerbation. Even those who are diagnosed with mild intermittent asthma can present with the most severe exacerbation [3]. The EMS provider should be identifying how severe the asthma exacerbation is. Commonly used scoring systems can be used, like the pediatric asthma severity score (PASS) [4].

Pediatric Asthma Severity Score (PASS) based on respiratory rate [4]

Scores are assigned into three categories. Mild respiratory distress is classified as a PASS score of <8, moderate respiratory distress at 8-11 and severe respiratory distress at >11 [4].

Treatment for asthma should almost always include oxygen supplementation, especially for those presenting with hypoxemia, or moderate to severe exacerbation. In addition to oxygen, short-acting beta agonists, such as albuterol, are the mainstay of treatment. An inhaled anticholinergic medication, such as Atrovent, can be given with albuterol for moderate to severe exacerbations and can be given in combined or DuoNeb formulation [2]. Corticosteroids should also be added for any moderate to severe exacerbation [5]. In patients who are experiencing poor aeration, IV magnesium sulfate is a beneficial option. In the most severe cases, where other treatments could be delayed, intramuscular epinephrine can be beneficial [5].

Pediatric bronchiolitis treatment options

Supportive care is the mainstay of treatment in bronchiolitis, ranging from anything the patient needs [1]. Initially, the patient will likely require nasal suctioning, analyzing pulse oximetry and oxygen administration. If this initial set of interventions is not sufficient, additional escalation may be required, including but not limited to positive pressure ventilation and endotracheal intubation. The most recent guidelines published by the American Academy of Pediatrics (AAP) in 2018 only recommend parenteral fluids in patients who are unable to adequately tolerate oral rehydration.

Currently, there is no evidence supporting the use of short-acting beta-agonists, such as albuterol, in patients aged 2 or less [2]. In addition, the AAP guidelines recommend against the use of albuterol, epinephrine, systemic corticosteroids [3].

As this is a viral illness, only time will allow the patient to recover; and as clinicians, it is our responsibility to support the patient through the illness.

Read next: Pediatric patient ABCs: 7 tips for EMTs and paramedics

References

1. Erickson EN, Mendez MD. Pediatric Bronchiolitis. [Updated 2019 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519506/
2. Condella, A., Mansbach, J. M., Hasegawa, K., Dayan, P. S., Sullivan, A. F., Espinola, J. A., & Camargo, C. A., Jr (2018). Multicenter Study of Albuterol Use Among Infants Hospitalized with Bronchiolitis. The western journal of emergency medicine, 19(3), 475–483. doi:10.5811/westjem.2018.3.35837
3. AAP Bronchiolitis treatment guidelines 2018
4. Maue, D. K., Krupp, N., & Rowan, C. M. (2017). Pediatric asthma severity score is associated with critical care interventions. World journal of clinical pediatrics, 6(1), 34–39. doi:10.5409/wjcp.v6.i1.34
5. Øymar, K., & Halvorsen, T. (2009). Emergency presentation and management of acute severe asthma in children. Scandinavian journal of trauma, resuscitation and emergency medicine, 17, 40. doi:10.1186/1757-7241-17-40
6. Bradley JP, Bacharier LB, Bonfiglio J, Schechtman KB, Strunk R, Storch G, Castro M. Severity of respiratory syncytial virus bronchiolitis is affected by cigarette smoke exposure and atopy. Pediatrics. 2005 Jan;115(1):e7-14.