Managing Critical Bronchiolitis

Abstract

Critical bronchiolitis is a common PICU diagnosis. It is a clinical diagnosis made in children younger than 2 years with low-grade fever, respiratory distress, rhinorrhea, cough, and wheezing. Like many experts, we now consider bronchiolitis to be a syndrome in which some children have uncomplicated viral disease, some have reversible bronchospasm and inflammation, and some have secondary bacterial infection. For all children, we routinely obtain a chest radiograph and basic laboratory tests. For most children, we treat them for uncomplicated viral disease with supportive care highlighted by thoughtful respiratory support. For most children, this consists of high-flow nasal cannula oxygen with flows of 1 to 2 L/kg/min and supplemental oxygen to target oxygen saturations of 92% to 97%. We routinely start enteral nutrition while administering oxygen via high-flow nasal cannula. We provide close monitoring and generally are tolerant of episodes of worsening respiratory distress and instability. We trial racemic epinephrine and then escalate to positive-pressure ventilation if refractory hypoxemia, encephalopathy (indicative of hypercarbia), and sustained severe dyspnea with evidence of systemic stress (eg, moderate to severe tachycardia) develop. On occasion, we treat children with profuse evidence of an asthma phenotype with bronchodilators and corticosteroids, although recognize that no reliable way exists to identify such children at the bedside. For children requiring invasive ventilation, we obtain culture samples of the lower airways shortly after intubation, begin empiric antibiotics, and complete a course if bacterial pathogens are identified. Ventilation strategies must be personalized based on ventilator parameters and physical examination findings, because signs of both obstructive and restrictive disease may be present.