Episode 59: Bronchiolitis

This EM Cases episode is on the diagnosis and management of Bronchiolitis. Bronchiolitis is one of the most common diagnoses we make in both general and pediatric EDs, and like many pediatric illnesses, there’s a wide spectrum of severity of illness as well as a huge variation in practice in treating these children. Bronchiolitis rarely requires any work up yet a lot of resources are used unnecessarily. We need to know when to worry about these kids, as most of them will improve with simple interventions and can be discharged home, while a few will require complex care. Sometimes it’s difficult to predict which kids will do well and which kids won’t. Not only is it difficult to predict the course of illness in some of these children but the evidence for different treatment modalities for Bronchiolitis is all over the place, and I for one, find it very confusing. Then there’s the sphincter tightening really sick kid in severe respiratory distress who’s tiring with altered LOC. We need to be confident in managing these kids with severe disease.

So, with the help of Dr. Dennis Scolnik, the clinical fellowship program director at Toronto’s only pediatric emergency department and Dr. Sanjay Mehta, an amazing educator who you might remember from his fantastic work on our Pediatric Ortho episode, we’ll sort through how to assess the child with respiratory illness, how to predict which kids might run into trouble, and what the best evidence-based management of these kids is.

BONUS Mini podcast

Dr. Amy Plint, one of Canada's most prominent researchers in Bronchiolitis, the lead author on the landmark 2009 NEJM Bronchiolitis trial looking at the value of nebulized epinephrine and dexamethasone in the management of Bronchiolitis, gives us her approach in choosing medications in the management of Bronchiolitis and the future of research in the controversial area.



Written summary and blog post prepared by Dr Michael Misch and Dr Patrick Prendergast, Jan 2015

Cite this podcast as: Scolnik, D, Mehta, S, Helman, A. Bronchiolitis. Emergency Medicine Cases. January, 2015. https://emergencymedicinecases.com/episode-59-bronchiolitis/. Accessed [date].

Bronchiolitis is the most common lower respiratory tract infection under 2 years of age and the leading cause of hospital admission under 6 months of age. The incidence of hospitalization for bronchiolitis is increasing annually. There is a wide spectrum of illness severity as well as considerable practice variation in the management of Bronchiolitis across North America.

Differentiating Bronchiolitis from Asthma and Pneumonia

 Q: At the bedside, how is bronchiolitis differentiated from pneumonia and asthma (or reactive airways disease)?

While bronchiolitis sometimes presents to the ED in ‘classic’ fashion (a first episode of wheezing in a child less than 2 years of age, after a 2-4 day viral prodrome of fever, cough and nasal congestion, between the months of November and April in Northern climates), it is often not possible to distinguish Bronchiolitis from asthma or pneumonia at first contact in the ED, as their clinical presentations may overlap.

Children with asthma usually presents with recurrent wheezing in a child >2 years old with a personal and/or family history of atopy or a family history of asthma. Environmental or allergic precipitants are often present in older children.

Response to bronchodilators may help to differentiate bronchiolitis from asthma.

Children with bacterial pneumonia often appear ‘toxic’ and tend to have higher grade fevers than those found in bronchiolitis. They may have focal chest findings and usually do not have wheeze.