Full colour PDF of the ‘Winter Ills’ pages as they appeared in ‘best practice’.
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Full colour PDF of the ‘bronchiolitis’ pages as they appeared in ‘best practice’.
Printer friendly PDF of the ‘bronchiolitis’ pages.
Most infants presenting with wheeze in the first year of life have bronchiolitis. Most cases of bronchiolitis occur between 2 and 5 months of age, in airways with very small calibre.
Bronchiolitis is usually caused by Respiratory Syncytial Virus, but can also be caused by rhinovirus, adenovirus, influenza and parainfluenza viruses. It starts with 2-3 days of coryzal symptoms and progresses to cough and wheeze with fever and tachypnoea.
Wheezes and crackles are usually heard throughout the chest. Focal chest signs suggest alternative diagnoses such as pneumonia or aspiration.
Infants with bronchiolitis often get worse for the first 72 hours of their illness and then start to improve. Symptoms may take several weeks to resolve, with a median duration of approximately 12 days. Children and parents need support during this time.
Bronchiolitis has a 1-2% mortality rate and infants with hypoxaemia related to small airways obstruction may need treatment with racemic epinephrine and steroids in addition to oxygen, intravenous fluids and nasogastric feeding.
Management of bronchiolitis is mostly supportive
Interventions such as bronchodilators, adrenaline, steroids and antibiotics have not been shown to be beneficial in uncomplicated bronchiolitis. Management is supportive but may include the need for oxygen, nasogastric feeding or intravenous fluids. Primary care clinicians need to know the features of moderate to severe bronchiolitis so that they can manage it appropriately but also so that they can educate the parents of children with bronchiolitis about recognising deteriorating illness.
Assessment of severityGet a PDF of tables 1,3,4,6 here
|Under 2 months >60/min||>60/min||>70/min|
|2-12 months >50/min|
|Chest wall indrawing||None/mild||Moderate||Severe|
|Feeding||Normal||Less than usual
Quantity >1/2 normal
Quantity <1/2 normal
|History of behaviour||Normal||Irritable||Lethargic|
Any criterion in the severe category designates the child as severely ill
Recognising severe illness in children
Reference: Bone J. Recognising the very ill child NZ Doctor 14 Mar 2007.
When to refer with acute bronchiolitis
As a general rule refer infants earlier rather than later: if in doubt get specialist advice.
Refer all infants immediately with; severe illness (see Table 1), progressive dehydration, where there is clinical concern about hypoxia or a history of apnoea.
Management of bronchiolitis at home
Most infants with bronchiolitis can be safely managed at home. Supportive care plus careful observation for signs of deterioration are the keys.
Supportive care may include:
Written instructions will help caregivers to keep an eye on feeding patterns and behaviour and to monitor for:
Infants with a moderate episode of bronchiolitis need to be reviewed within 24 hours and a firm appointment (time, place, person) helps to ensure the child is seen. (For an example of written instructions for caregivers see here)
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