Ep 177 Bronchiolitis – Diagnostic Challenges and Management Pitfalls

This fall and winter of 2022 has seen a huge rise in pediatric respiratory illness in North America as well as increased admission for children with bronchiolitis. This was totally predictable. In a previous EM Quick Hit segment Dr. Sarah Reid warned us of the upcoming tsunami of coughing kids. There are many viruses abound: RSV, COVID, Influenza, Parainfluenza, Enterorhinovirus, Adenovirus. In Canada we’ve seen an early RSV surge in the 0-5 year old age group especially - so lots more bronchiolitis. Influenza A is far above expected levels as well, generally in the 5-11 year old age group. In this podcast Anton discusses with world expert and bronchiolitis researcher Dr. Suzanne Schuh, the challenges of the diagnosis and management of bronchiolitis during a time of crisis in pediatric emergency medicine and offers some evidence-based solutions to improving outcomes while minimizing valuable resources, as part of our 'Best of University of Toronto EM' series. Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Anton Helman, December 2022 Cite this podcast as: Helman, A. Bronchiolitis - Diagnostic Challenges and Management Pitfalls. Emergency Medicine Cases. December, 2022. https://emergencymedicinecases.com/bronchiolitis-diagnostic-challenges-management-pitfalls. Accessed September 17, 2024 Résumés EM Cases Clinical assessment and diagnosis of bronchiolitis Bronchiolitis is a clinical diagnosis based on patient age, time of year and clinical presentation. The typical patient with bronchiolitis is a child under 12 months of age who has a URTI prodrome and then develops LRTI symptoms with increased work of breathing, crackles and wheezes. It is important for clinicians and families to understand that acute symptoms generally last for approximately 10 days but can last up to 3 weeks. Neonates may present with apnea and/or cyanosis. Clinical presentations that should alert us to either an alternative diagnosis or additional diagnosis include:  * Prolonged wheeze (≥3 weeks) * Failure to thrive * Recurrent feeding issues, choking with feeds * Previous bacterial pneumonia * Critically ill Distinguishing bronchiolitis from asthma with URI, COVID and pneumonia Multiple wheezing episodes at any age increases the likelihood of asthma. The diagnosis of asthma can be tentatively made in otherwise healthy children as early as 12 months of age. A presumptive diagnosis of asthma can be made with the following criteria: * ≥ 2episodes wheeze OR * ED presentation needing treatment * Reversibility of respiratory distress after therapy * 1st time wheeze with response to therapy * Atopy is not necessary for diagnosis The early diagnosis of asthma is important because literature suggests that a subset of these patients will develop abnormal lung function at the age of 5 years and long term lung disease (COPD), and that this can be prevented with use of coriticosteroids. It is currently recommended that pre-school children with a presumptive diagnosis of asthma receive not only oral corticosteroids, but 3 months of inhaled corticosteroids following an acute exacerbation. Thankfully, the majority of infants with asthma improve by school age. Pearl: A subset of pre-school children with asthma will develop chronic abnormal lung function and COPD, which can be prevented by treating acute exacerbations not only with oral corticosteroids, but 3 months of inhaled corticosteroids.