Fall is coming, and with that pediatric respiratory illness. There have been excellent reviews of bronchiolitis on EMRAP with Dr. Sloas, and here is some text your can turn into a dot phrase in Epic to help with your charting and clinical decision making in patients with suspected bronchiolitis. Enjoy!
___________________________________________________________________________________________________________
Patient is a @AGE@ @SEX@ with significant birth history of ***, presents with symptoms of {URI ASSESSMENT:101712} and initial emergency department vital signs of respiratory rate *** and oxygen saturation of ***. The ddx above was considered. Their emergency department workup was remarkable for ***. Initial therapy consisted of ***. Based on the below considerations, they were given *** therapy based on a bronchiolitis score of ***.
The bronchiolitis scoring system was used with the following considerations
Inclusion
Age <2 yrs (peak 3-6mo)
Viral symptoms present and increase with work of breathing & lower respiratory tract symptoms that may include: increased work of breathing, persistent cough, feeding difficulty, +/- wheezing, rapid shallow respirations, +/- fevers
Prematurity and/or age <12 weeks - expect a more severe course of illness
Exclusion (high risk factors)
Hemodynamically significant cardiac disease
Anatomic airway defects
Neurologic disease
Immunodeficiency
Chronic lung disease
General risk factors
Previously healthy infant with sat <95%
Age < 3mo
GA < 34 wks
Respiratory rate >70
variable 0 points 1 point 2 points 3 points
RR
< or = 2mo < or = 60 61-69 > or = 70
2-12 mo < or = 50 51-59 > or = 60
1-2 yr < or = 40 41-44 > or = 45
retractions none subconstal or intercostal 2 of the following: subcostal, intercostal, substernal, or nasal flaring (infant) 3 of the following: subcostal, intercostal, substernal, suprasternal, supraclavicular OR nasal flaring / head bobbing (infant)
dyspnea
0-2 yrs Normal feeding. Vocalizations and activity 1 of the following: difficulty feeding, decreased vocalization or agitation 2 of the following: difficulty feeding, decreased vocalization or agitation Stops feeding, no vocalization or drowsy and confused
auscultation Normal breath sounds, no wheezing present End-expiratory wheeze only expirotory wheez only (greater than end-expiratory wheeze) Inspiratory and expiratory wheeze OR diminished breath sounds OR both
General therapeutic considerations
Suction
Assess for fluid needs
Oxygen if hypoxemic
Consider bronchodilators if history of reactive airway disease or ill appearing
Consider 4ml of 3% hypertonic saline *
Therapy generally not recommended
Albuterol (however reasonable to assess for reactive airway disease component)
Racemic epinephrine
Hypertonic saline *
Steroids
Chest physiotherapy
Inhaled steroids
Routine viral testing
Consider IV fluids if
Poor orally intake
Poor urine output
RS 9-12
Respiratory rate >60
Admission / Transfer considerations (higher risk for apnea)
Ann Emerg Med. 2006 Oct;48(4):441-7
Prior history of pulmonary disease
Hypoxemia
Respiratory rate >40/min
Dehydration requiring IV fluids
Unreliable home situation
<1 mo and febrile
Premature birth and <48 weeks age post conception
Underlying cardiac / lung disease (with judgement)
History of apnea
* considerations with hypertonic saline: there is a discrepancy between Seattle Children's hospital and Marry Bridge Children's hospital in the use of hypertonic saline. There are several studies looking at this, Chaundry in Annals of Emerg Med in Jan of 2010 which showed clinical severity score improves with hypertonic saline, with slight difference in length of stay, but no difference in admit rate for outpatient studies. Also Grewal in Arch Peds Adol Med in Nov of 2009, which did not show any difference in admission or re-visit rates in hypertonic versus regular saline nebulizer therapy.
___________________________________________________________________________________________________________
Patient is a @AGE@ @SEX@ with significant birth history of ***, presents with symptoms of {URI ASSESSMENT:101712} and initial emergency department vital signs of respiratory rate *** and oxygen saturation of ***. The ddx above was considered. Their emergency department workup was remarkable for ***. Initial therapy consisted of ***. Based on the below considerations, they were given *** therapy based on a bronchiolitis score of ***.
The bronchiolitis scoring system was used with the following considerations
Inclusion
Age <2 yrs (peak 3-6mo)
Viral symptoms present and increase with work of breathing & lower respiratory tract symptoms that may include: increased work of breathing, persistent cough, feeding difficulty, +/- wheezing, rapid shallow respirations, +/- fevers
Prematurity and/or age <12 weeks - expect a more severe course of illness
Exclusion (high risk factors)
Hemodynamically significant cardiac disease
Anatomic airway defects
Neurologic disease
Immunodeficiency
Chronic lung disease
General risk factors
Previously healthy infant with sat <95%
Age < 3mo
GA < 34 wks
Respiratory rate >70
variable 0 points 1 point 2 points 3 points
RR
< or = 2mo < or = 60 61-69 > or = 70
2-12 mo < or = 50 51-59 > or = 60
1-2 yr < or = 40 41-44 > or = 45
retractions none subconstal or intercostal 2 of the following: subcostal, intercostal, substernal, or nasal flaring (infant) 3 of the following: subcostal, intercostal, substernal, suprasternal, supraclavicular OR nasal flaring / head bobbing (infant)
dyspnea
0-2 yrs Normal feeding. Vocalizations and activity 1 of the following: difficulty feeding, decreased vocalization or agitation 2 of the following: difficulty feeding, decreased vocalization or agitation Stops feeding, no vocalization or drowsy and confused
auscultation Normal breath sounds, no wheezing present End-expiratory wheeze only expirotory wheez only (greater than end-expiratory wheeze) Inspiratory and expiratory wheeze OR diminished breath sounds OR both
General therapeutic considerations
Suction
Assess for fluid needs
Oxygen if hypoxemic
Consider bronchodilators if history of reactive airway disease or ill appearing
Consider 4ml of 3% hypertonic saline *
Therapy generally not recommended
Albuterol (however reasonable to assess for reactive airway disease component)
Racemic epinephrine
Hypertonic saline *
Steroids
Chest physiotherapy
Inhaled steroids
Routine viral testing
Consider IV fluids if
Poor orally intake
Poor urine output
RS 9-12
Respiratory rate >60
Admission / Transfer considerations (higher risk for apnea)
Ann Emerg Med. 2006 Oct;48(4):441-7
Prior history of pulmonary disease
Hypoxemia
Respiratory rate >40/min
Dehydration requiring IV fluids
Unreliable home situation
<1 mo and febrile
Premature birth and <48 weeks age post conception
Underlying cardiac / lung disease (with judgement)
History of apnea
* considerations with hypertonic saline: there is a discrepancy between Seattle Children's hospital and Marry Bridge Children's hospital in the use of hypertonic saline. There are several studies looking at this, Chaundry in Annals of Emerg Med in Jan of 2010 which showed clinical severity score improves with hypertonic saline, with slight difference in length of stay, but no difference in admit rate for outpatient studies. Also Grewal in Arch Peds Adol Med in Nov of 2009, which did not show any difference in admission or re-visit rates in hypertonic versus regular saline nebulizer therapy.
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