November 28, 2022
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Respiratory Syncytial Virus [RSV], is the most common causative agent behind acute bronchiolitis and each winter, the lower respiratory pathogen tends to make headlines across the Northern Hemisphere. Of note, it can frequently co-circulate with the flu. Most often it affects our youngest populations (those < 2 years of age) and while most times, self-care at home is the best remedy because its self-limiting, on occasion, hospital admissions are warranted. Complex care will likely be needed for children < 6 weeks, those who have congenital disease or those who were born premature. This year, in the U.S., we are peaking (cases/hospitalizations) about 3 months earlier than usual. [See Figure 2 – CDC]
Figure 2. Source: CDC
Personally, my 6-month-old daughter required such a hospitalization at Cincinnati Children’s in 2013!! My wife and I watched the ball drop over Times Square from the ED as we rang in 2014 with a bang. Her secretions were copious, wheezing, grunting was present, her oxygen saturations were in the low-80’s as it transitioned into a RLL pneumonia in short order. Fortunately, she recovered pretty quickly, and she was discharged in about 36 hours. Due to the fact, she wasn’t immunocompromised and was relatively healthy; she was able to avoid some controversial measures like anti-viral drugs, steroids, IV immunoglobulin therapy, and aggressive ventilatory support like CPAP & intubation. It’s amazing what oral hydration, wall suction, bronchodilators, and 0.5L of supplemental humidified oxygen can do. None the less, a scary time for the parents.
Additionally, many lung diseases are restrictive in nature, meaning air cannot get in, but in the case of RSV, the patients simply can’t get the air out (they trap it). Bronchiolitis represents just one form of obstructive lung disease and its important to call out that this can also affect young adults and the elderly. However, for pediatrics like my daughter, acute bronchiolitis tends to show off in a seasonal fashion from October – March. In adults, the causative agent can be a little more complicated (think chronic vs. acute): with interstitial lung disease, occupational exposures post organ transplant (check out bronchiolitis obliterans), or autoimmune diseases like RA driving the obstructive pathology.
PEARLS for Bronchiolitis:
•Trust your gut instincts
•Lean on/Leverage the Pediatric Assessment Triangle (PAT)
•Be proactive against hypoxia with suctioning and oxygenation – less invasive measures first!
•Maintain normal hydration/fluid status
•Recall - symptoms peak around days 3-5 (if you encounter them on Day 2 – you can expect them to get worse before they get better) - Hospitals will use this to guide their disposition decisions
•Elderly adults can also be affected
Figure 3. Source: Getty Images provided by CNET from www.msn.com