So what puts children at
risk for bronchiolitis?
Well, we talked about
Children with congenital heart disease
are more likely to have severe disease
and more likely to be hospitalized.
Children with chronic lung disease of
prematurity are more likely to be hospitalized.
Kids with cystic fibrosis are at
increased risk for severe bronchiolitis.
Children with immunodeficiency and
particularly severe immunodeficiencies,
such as severe combined
immunodeficiency or SCID,
are at increased risk
And as we stated, children who
have been exposed to smoking
are at increased risk for
hospitalization for bronchiolitis.
So you’ve got the patient,
you’ve diagnosed bronchiolitis based
on your clinical exam and history.
What are you going to do
in terms of treating them?
Well, first as you can see on this slide,
you are not going to give
this child albuterol.
As tempting as it may be,
if this is bronchiolitis,
albuterol does not
does not decrease the likelihood of
being hospitalized in the first place,
and it does make
So it’s generally ineffective.
Some people are concerned that there
may be a small percent of children
who would respond to albuterol and who
like to then give a trial of albuterol.
The latest American Academy of
Pediatrics guideline says not to do that
because we’re going to end
up overusing the drug
and causing so many
people to become jittery
and not helping anyone in terms of
their length of stay in the hospital.
Steroids have no role in bronchiolitis.
If you suspect the patient
you should not
They do not shorten length
of stay in the hospital,
they do not reduce rates of
readmission to the hospital.
They really have no benefit.
So what does work?
The most important thing to do
in a child with bronchiolitis
is superficial suctioning
with saline drops.
Before feeding or before
initiation of any treatments,
if they are warranted
and as needed,
you’re going to give saline
into the nasal passage
and you’re going to teach the
parents how to suck it out.
Notice I said this is a great opportunity
to teach and empower the parents.
We are shifting our paradigm in the
last ten years away from drugs
in the management
of this condition
and we still need to empower parents
to help their children get better,
and teaching them to adequately suction
their child is a mainstay of therapy.
It is extremely effective
at reducing symptoms.
In one study in Cincinnati,
children who are superficially
suctioned every four hours
also had a shorter
length of stay.
You want to avoid deep nasopharyngeal
suctioning with a catheter
because it’s irritating, extremely
painful, can cause bleeding,
and if repeated frequently
can cause trauma.
However, in the acute setting of
a severe respiratory distress,
it’s absolutely indicated because it
can help in the emergent setting.
So superficial suctioning, we used
to use those little blue bulbs
and this new device is
taking the world by storm.
There are self-administered suction devices
for parents to use on their children.
One end is applied to the nose
and the other end the
parent sucks in vigorously
to apply that suction
force into the nose area.
So first they give the saline
drops, then, they suck it out.
It’s common for having to --
You have to teach the
families how to do this.
What’s key here is that the
mucus that’s being sucked out
will not get into the parent’s mouth
and it’s important to tell them that.
My experience is almost all parents
who try this once will never
go back to the blue suction bulb,
which is largely ineffective.
So one thing that we
worry about in children
with bronchiolitis is
their pulse oximetry.
We worry about, are they
getting enough oxygen.
And I want to rethink this paradigm because
there are a lot of people who worry
about oxygen and that fear of oxygen
is driving actually unnecessary care
and unnecessary hospitalization.
So keep in mind a baby in utero is
around 60% to 65% saturated hemoglobin,
so below 65 is
I would not recommend that.
At 18,000 feet, if you were to
climb right now up a mountain,
your normal pulse oximetry
would be around 75%.
You wouldn’t be dead, but you’d certainly
be a little hurting for oxygen.
So certainly, 75 is not a zone where I
feel comfortable with a baby hanging out.
But nobody really knows
what is safe for an infant
and infants routinely and
normally desaturate all the time.
The average desaturation
for an infant who is well,
who is less than four months, who has
a pulse ox probe left on their finger
for 27 hours is well into the mid-80s,
so normal babies will desaturate.
And we need to be careful
about measuring too
much oxygen and worrying
too much about it.
This may be a child who is not
actually having a problem.
So keep in mind if we were to take the
oxygen-hemoglobin dissociation curve,
and if you recall, this is a
curve which has on one axis
the pressure of oxygen
that’s available in the room
and on the other axis what percentage of
hemoglobin molecules are actually saturated,
and we start in a situation where
all of the hemoglobin molecules
and we start reducing
the amount of oxygen,
it’s like this car is
going along for a while
and then suddenly takes
a dive down the hill.
Once a pulse ox machine
gets down to around 90%,
further reduction in available oxygen is going
to cause a much more rapid deceleration,
and that’s why most hospitals
use 90% as a safe level.
So how else should we
manage these children?
Well, it’s key in the hospital setting
that we should engage in handwashing
and we should gown, glove, and mask
to prevent spread of the illness.
In the United States, 30% to 40% of
children hospitalized during the RSV season
for another reason get RSV
while they’re in the hospital.
The risk of infection is related
to their length of stay,
and high-risk children are more
likely to be in the hospital anyway.
So in the hospital setting when
you’re seeing these patients,
we need to wash our hands,
gown, glove, and mask.
When do we decide it’s
safe for them to go home?
Well, we generally decide when
their respiratory rate is safe
keeping in mind that, especially with RSV,
they can have a sort of happy tachypnea,
where they’re not in distress and breathing
a little bit faster in the 50 to 60 range.
Those children may
be okay to go home.
They should have no increased
work of breathing,
no accessory muscle use, no
retractions, flaring, or grunting.
They should be feeding
well, they should not
need IV fluids or NG
fluids to stay hydrated,
and the parents should know
how to suction effectively.
And when they have met these criteria,
they’re probably safe to go home.
Preventing bronchiolitis is key.
And so we encourage families to breastfeed
because that will improve the likelihood
that the child has
a minimal sickness
when they’re exposed to the virus
that their mother is also exposed to.
We would love for children to not
be exposed to secondhand smoke
And in the home, alcohol-based hand sanitizer
can help prevent spread of illness
to children and infants who are
prone to more severe bronchiolitis.
There is some emphasis on medical
prevention of bronchiolitis
and this is because it is the number one
cause of hospitalization in children.
This isn’t a death
such as the influenza vaccine
or the measles vaccine.
This is really more to prevent
use of hospital resources.
So one drug that’s been made available and
is being used currently in the United States
is palivizumab, which is an
antibody designed against the RSV.
This drug is
It costs roughly $10,000 for a child to
go through the winter season and get it.
It is very safe, but
it’s not cost-effective.
In other words, we have to spend about
$300,000 to prevent one hospitalization,
which costs on average $10,000,
and because it doesn’t
prevent mortality from RSV,
this drug is likely to go away
in the next several years.
Right now, it’s restricted for use
in severely premature infants
and infants with
congenital heart disease.
However, even in these populations,
this drug is not cost-effective.
It’s effective, it’s
So there are some new
medications that are coming out
and I don’t know which ones
of these are likely to be
promulgated and accepted
in the United States.
There is an oral anti-RSV agent
that is being worked on currently.
There is nasally administered immunoglobulin
that’s currently being studied.
And also, there is
a maternal vaccine
where they would then also give
a booster vaccine to the baby.
All of these therapies are
geared towards reducing
the rate at which children are
hospitalized in the United States.
The goal is to reduce cost, but
not necessarily to save lives.
We’ll see where this goes.
This is an active area
of research right now.
Thanks for your attention.