Pediatric Respiratory Distress (Bronchiolitis)

Table of Contents

(Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based Guideline Model Process)

Aliases

None noted

Patient Care Goals

  1. Alleviate respiratory distress
  2. Promptly identify respiratory distress, failure, and/or arrest, and intervene for patients who require escalation of therapy
  3. Deliver appropriate therapy by differentiating other causes of pediatric respiratory distress

Patient Presentation

Inclusion Criteria

Child less than 2 yo typically with diffuse rhonchi or an otherwise undifferentiated illness characterized by rhinorrhea, cough, fever, tachypnea, and/or respiratory distress

Exclusion Criteria

  1. Anaphylaxis
  2. Croup
  3. Epiglottitis
  4. Foreign body aspiration
  5. Submersion/drowning
  6. Asthma

Patient Management

Assessment

  1. History
    1. Onset of symptoms
    2. Concurrent symptoms (e.g. fever, cough, rhinorrhea, tongue/lip swelling, rash, labored breathing, foreign body aspiration)
    3. Sick contacts
    4. History of wheezing
    5. Treatments given
    6. Number of emergency department visits in the past year
    7. Number of admissions in the past year
    8. Number of ICU admissions ever
    9. History of prematurity
    10. Family history of asthma, eczema, or allergies
  2. Exam
    1. Full set of vital signs (T, BP, RR, P, O2 saturation)
    2. Air entry (normal vs. diminished)
    3. Breath sounds (wheezes, crackles, rales, rhonchi, diminished, clear)
    4. Signs of distress (grunting, nasal flaring, retracting, stridor)
    5. Weak cry or inability to speak full sentences (sign of shortness of breath)
    6. Color (pallor, cyanosis, normal)
    7. Mental status (alert, tired, lethargic, unresponsive)
    8. Hydration status (+/- sunken eyes, delayed capillary refill, mucus membranes moist vs. tacky, fontanel flat vs. sunken)

Treatment and Interventions

  1. Pulse oximetry and end-tidal CO2 (ETCO2) should be routinely used as an adjunct to other forms of respiratory monitoring
  2. Perform EKG only if there are no signs of clinical improvement after treating respiratory distress
  3. Airway
    1. Give supplemental oxygen – escalate from a nasal cannula to a non-breather mask as needed, in order to maintain normal oxygenation
    2. Suction the nose and/or mouth (via bulb, Yankauer®, or suction catheter) if excessive secretions are present
  4. Inhaled Epinephrine should be administered to children in severe respiratory distress with bronchiolitis (e.g. coarse breath sounds) in the prehospital setting if other treatments (e.g. suctioning, oxygen) fail to result in clinical improvement. Choose one of the following:
    1. Racemic Epinephrine: Nebulize 0.5 ml (11.25 mg) & 3 mL of Normal Saline together
    2. Cardiac Arrest Epinephrine: Nebulize 5 mL of 0.1 mg/mL (0.5 mg)
  5. Utility of IV placement and fluids – IVs should only be placed in children with respiratory distress for clinical concerns of dehydration, or when administering IV medications 

  6. Steroids are generally not efficacious, and not given in the prehospital setting
  7. Improvement of oxygenation and/or respiratory distress with non-invasive airway adjuncts
    1. Bag-valve-mask ventilation should be utilized in children with respiratory failure
  8. Extraglottic devices and intubation
    1. Extraglottic devices and intubation should be utilized only if bag-valve-mask ventilation fails
    2. The airway should be managed in the least invasive way possible

Notes – Pediatric Respiratory Distress (Bronchiolitis)