Bronchiolitis: Everything you need to know

Bronchiolitis, otherwise known as Respiratory Syncycial Virus (RSV), is a condition common in children that has symptoms very similar to asthma, and is most common between November and April.

It’s more common in children because their airways are smaller and more susceptible to narrowing. Usually it occurs within the first two years, with it’s peak at 3-6 months.This condition presents nearly identical with asthma, and is often treated or misdiagnosed as such.

In fact, according to “Allergy and Asthma: Practical Diagnosis and Management,” it is “clinically indistinguishable from bronchial asthma.”Yet the course of treatment for bronchiolitis is different from that of asthma.

For instance, while corticosteroids and bronchodilators work great to reverse airway obstruction caused by asthma, these medicines do little for bronchiolitis (or RSV). So it’s important to be able properly diagnose RSV from asthma.

According to Allergy and Asthma, “there are laboratory studies designed to identify viral antigens to pinpoint any of the six different viruses that can cause acute bronchiolitis.” This test starts by the RN, RT or lab technician performing a nasal swab to retrieve cells from the nasal passage.

A viral swab won’t rule out asthma, but it can rule in RSV so proper treatment can be
determined. Other viruses that might cause bronchiolitis are: Adenovirus, enterovirus, Influenza virus and Chlamydia pneumoniae.

So, technically speaking, RSV is common cause of bronchiolitis, and not a synonym for it. Yet the two are usually linked hand in hand.

We know that asthma is a disease that causes airway narrowing due to increased secretions and inflammation of the air passages in the lungs (bronchioles) due to exposure to asthma triggers. This results in bronchospasm that is reversible with time or, when more severe, bronchodilators such as Albuterol. Corticosteroids are used to treat the inflammation.

Bronchiolitis, on the other hand, is inflammation of the bronchioles due to a virus. (click here for a good picture of this). Narrowing of the airways can occur, resulting in air trapping and hypoxia.
Another complication of this is increased secretions. Bronchospasm is not a complicaiton of bronchiolitis, and therefore bronchodilators are of little use.

Bronchodilators are of little use for bronchiolitis because this medicine does not treat inflammation, it treats bronchospasm.

However, if asthma is suspected to be exacerbated by a virus (and viruses are the #1 cause of asthma exacerbations), bronchodilators should be ordered prn, or as needed.

I have heard of some doctors prescribing Atrovent for bronchiolitis. Our Pediatricians seldom use this, however our ER doctors do.

However, according to Glenn Campell, RRT and Respiratory Clinical Specialist at Children’s Hospital in New Orleans, Atrovent should rarely be used to treat asthma and bronchiolitis because “it has been our experience that Iprotropium Bromide (Atrovent) will actually exacerbate the issue by possibly causing mucus plugs secondary to “thickening of secretions”.

This, however, is also controversial.

Since there isn’t much we can do to treat viruses, the main treatment is supportive measures.

Usually patients with this don’t need to be admitted, and usually those admitted for it are obligate nose breathers and are dehydrated due to the child being unable or unwilling to take in fluids, such as refusing to breast feed, or refusing the bottle. So IV fluids is usually indicated.

Antibiotics usually are of little use unless a bacteria is the suspected cause (which is rare).

Otitis media may, however, be treated with antibiotics.

Studies show that bronchodilators should be tried, but if no improvement is observed these should be stopped.

Corticosteroids are also often used to treat this condition, however most studies show they have little to no effect on bronchial inflammation due to a virus.

However, some studies show that racemic epinepherine and dexamethasone have shown to be beneficial.

Still, most of the above therapies other than supportive measures remain controversial.

Supportive care may include oxygen and humidity, keeping the head upright, fluid intake (IV may be indicated), and constant monitoring of pulse oximetry to maintian an SpO2 between 91 and 94%.

One of the most effective therapies for bronchiolitis is simply clearing the airway of secretions, . A bulb syringe works nice, although in the hospital booger be gones work very well. Many times, if the SpO2 drops, suctioning alone will resolve the problem.

Nasal Steroid and Neosynephrine also work well to help keep the nasal passages open.For decreased sats and increased respiratory distress, suctioning should always be attempted before a breathing treatment, and many times suctioning alone will resolve the crisis. According to emedicine, the following are common symptoms of RSV:

• Runny nose


• Cough


• Low grade fever


• Increased work of breathing


• Wheezing


• Cyanosis


• Grunting


• Noisy breathing


• Vomiting, especially post-tussive


• Irritability


• Poor feeding or anorexia


• Increased Respiratory rate (50-60 breaths per minute)


• Increased heart rate


• Diffuse expiratory wheezing


• Nasal flaring


• Cyanosis


• Inspiratory crackles


• Ear infection (otitis media)

There is evidence that children who experience RSV are at an increased risk to develop asthma later in life. For more information, check out the following links:

National Guideline Clearinghouse: Guidelines for management of bronchiolitisRC Journal: Respiratory Care of Bronchiolitis Patients: A Proving Ground for Process ImprovementSeattlechildrens.org: Bronchiolitis

Here"s how to know if you need asthma specialist

I’ve received many questions from asthmatics who were having difficulty managing their disease and were wondering what to do next. Often the answer is to seek an asthma specialist. Recently I wrote a post at MyAsthmaCentral.com regarding this topic.

Do You Need An Asthma Specialist?
By Rick Frea, Tuesday, May 25, 2010, @ MyAsthmaCentral.com

So, when is a good time to see an asthma specialist? That is a good question, and a common one.

Thanks to modern science and the National Heart, Blood and Lung Institute’s asthma guidelines, most doctors are able to treat most asthmatics, and treat them well.

Yet, from time to time, there comes along an asthmatic whose asthma is difficult to control. When this occurs it’s time for your doctor to call in the reinforcements: the asthma specialist or other specialist.

In my opinion, a wise person — wise doctor in this case — is one who knows the boundaries of his study, and knows when it’s time to refer his patients to a specialist.

1. Asthma Specialists: According to the asthma guidelines, this constitutes:

• An Allergist: Specially trained in allergy and asthma


• A Pulmonologist: Specially trained in lung disease


• Ear, nose and throat doctor: They specialize in these areas


• Other: Any doctor who has extensive training and specializes in asthma

Thankfully, in today’s medical world, doctors can refer to the asthma guidelines for a little help. The asthma guidelines (see page 71) recommend your physician refer you (or your asthmatic child) to an asthma specialist when:

• You had a life-threatening asthma attack


• You aren’t meeting goals of asthma therapy after three to six months of treatment


• You have difficult-to-manage asthma (hardluck asthma)


• Your signs and symptoms of asthma are atypical


• Your doctor has trouble diagnosing your asthma
  


• Other conditions complicate your asthma, like allergies, sinusitis, nasal polyps, and severe rhinitis, GERD or COPD.


• Additional diagnostic testing is needed, such as allergy testing, scope of your nose (rhinoscopy), pulmonary function studies, or scope of your lungs (bronchoscopy)


• You need additional education or guidance. Let’s face it, sometimes it’s hard to adjust to this disease. You may need help learning what your asthma triggers are or how to avoid them. You also may need help remembering to take your medicines, or taking them correctly.


• Your doctor thinks you might benefit from allergy testing or allergy shots (immunotherapy)


• Your doctor suspects you need more than just typical asthma care, or need closer managing or specialized asthma medicines.


• You needed more than two bursts of corticosteroids within one year, or you needed to be hospitalized for your asthma


• Your asthma is being caused by something you inhaled at work or other environmental inhalant that is complicating your asthma or treatment.

2. Psychological and Social Specialists: Another thing that can complicate asthma are social or psychological circumstances. These, among other things, may trigger asthma or complicate your (or your childs) ability to care for yourself:

• Anxiety


• Depression


• Stress


• Substance abuse


• Marital problems


• Abusive spouse or parents


• Poverty

In this case, your doctor will want to refer you (or your child) to specialists such as a psychologist or social worker.

When I was 15 in 1985 my asthma was so bad that my doctor referred me to the specialists at National Jewish Health (NJH). While getting my asthma under control, my doctors realized anxiety was triggering my asthma and complicating my ability to care for myself.

I ended up staying at this asthma hospital for six months while they treated all these problems, and I have to admit, what I learned there still benefits me to this day.

While at NJH I also met kids who were addicted to cigarettes or — believe it or not — drugs. As you can imagine, these things complicated their asthma.

I also met a couple kids who had terrible home circumstances. One kid had alcoholic parents, the other abusive parents.

Thankfully there were, and are, specialists to help us get our lives and our asthma under control despite these exceptional circumstances.

3. Family Counseling: Sometimes family members, especially parents, need to see a specialist to learn how they can better take care of their family members, particularly their children.

The following are some examples of when family members might need help from a specialist:

• General guidance in how to manage asthma


• Parents of children with hardluck asthma


• Parents of children with anxiety or depression


• Parents in abusive homes


• Substance abuse in home


• Cigarette smoke in home

My parents received counseling before I left NJH to teach them what my asthma triggers were, and to show them how to make their home more asthma friendly. They also learned how to better help me manage my asthma.

While specialty hospitals like NJH are still around to help asthmatics and asthmatic parents, their programs are mostly outpatient orientated. Also, doctors are better educated today so most of us can get the care we need by specialists close to our homes.

And, while most doctors know when it’s time to refer you to a specialist, sometimes you may need to nudge your doctor. After all, doctors are only human.

If you think you or your child needs to see a specialist, don’t be afraid to talk to your doctor.