01Approach to the Critical Patient/attcp64

Immediate priorities

›First look triage

›Apnea

›Cyanosis

›Severe work of breathing

›Altered mental status

›Poor perfusion

›Immediate escalation triggers

›Recurrent apnea

›SpO2 persistently <90% on room air

›Exhaustion with rising CO2

›Airway and breathing

›Positioning

›Sniffing position for infant

›Head tilt chin lift if obstructed

›Suction strategy

›Nasal suction prior to feeds

›Deep suction only if obstruction not relieved and deterioration

›Oxygenation targets

›SpO2 goal 90% or higher for most infants

›Higher target if significant cardiopulmonary disease

›Ventilatory support escalation

›If persistent hypoxemia, low flow nasal cannula

›If persistent distress, high flow nasal cannula

›If failure of noninvasive support, CPAP or intubation

›Circulation and hydration

›Hydration assessment

›Intake reduction

02History/hx37

Presentation pattern

›Typical course

›Upper respiratory prodrome

›Rhinorrhea

›Cough

›Low grade fever

›Progression to lower respiratory symptoms

›Wheeze or crackles

›Increased work of breathing

›Feeding difficulty

›Peak severity day 3 to 5

›Worst work of breathing

›Highest risk of dehydration

›Red flag symptoms

›Apnea episodes

›Cyanosis

›Lethargy

›Poor feeding with minimal urine output

›Persistent vomiting with dehydration

›Exposure context

›Sick contacts

›Daycare exposure

›Household smoke exposure

Risk factors and comorbidities

›Host risk

›Age under 12 weeks

›Prematurity history

›Prior ICU admission for respiratory illness

03Physical Exam/exam42

Respiratory severity

›Work of breathing

›Nasal flaring

›Intercostal retractions

›Subcostal retractions

›Head bobbing

›Grunting

›Respiratory rate and pattern

›Tachypnea

›Periodic breathing

›Apnea

›Auscultation

›Diffuse crackles

›Wheeze

›Prolonged expiration

›Diminished air entry

›Oxygenation and ventilation

›Room air SpO2

›Central cyanosis

›Signs of hypercapnia

›Somnolence

›Poor respiratory effort

General and hydration

›General appearance

›Alertness

›Consolability

›Toxic appearance

›Hydration indicators

04Differential Diagnosis/ddx35

Life threatening and must not miss

›Critical alternatives

›Bacterial pneumonia ICD-10 J13 to J18

›Focal crackles

›High fever

›Toxic appearance

›Sepsis ICD-10 A41.9

›Hypothermia or fever

›Poor perfusion

›Lethargy

›Congenital heart disease with heart failure ICD-10 Q20 to Q28

›Hepatomegaly

›Poor weight gain

›Diaphoresis with feeds

›Foreign body aspiration ICD-10 T17

›Sudden onset

›Unilateral wheeze

›Asymmetric breath sounds

›Upper airway emergencies

›Croup ICD-10 J05.0

›Barky cough

›Stridor

›Epiglottitis ICD-10 J05.1

›Drooling

›Tripod posture

Mimics and overlaps

›Wheezing illnesses

›Early childhood asthma ICD-10 J45

05Laboratory Tests/lt28

Routine testing strategy

›Default approach

›No routine labs for typical mild to moderate bronchiolitis

›Testing driven by severity and alternative diagnosis concern

›Viral testing limited utility for routine management

›Consider if cohorting or high risk admission decisions

›Sepsis evaluation triggers

›Age under 28 days with fever

›Toxic appearance

›Hemodynamic instability

Targeted labs when indicated

›Hydration and metabolic

›Serum electrolytes for significant dehydration

›Sodium for free water and feeding issues

›Potassium for vomiting or poor intake

›Glucose for lethargy or poor feeding

›Hypoglycemia risk in young infants

›Blood gas for severe disease

›Capillary or venous blood gas if impending failure

›Rising PaCO2 surrogate

›Acidemia trend

›Oxygenation assessment limited on venous sample

›Arterial blood gas if ventilation strategy decisions critical

›PaCO2 in mmHg

›PaO2 in mmHg

›Infection evaluation if bacterial concern

›Complete blood count for toxic appearance

›Limited discrimination for viral vs bacterial

06Diagnostic Tests/dt60

Scoring Systems

›Severity scoring overview

›Purpose

›Structured severity tracking

›Communication across teams

›Limitations

›Scores do not replace clinical trajectory

›Variable interrater reliability

›Wang bronchiolitis severity score

›Components

›Respiratory rate

›Wheeze

›Retractions

›General condition

›Interpretation

›Higher score correlates with more severe disease

›Respiratory Distress Assessment Instrument

›Components

›Wheeze phase

›Wheeze location

›Retractions sites

›Use case

›Clinical trials

›Serial bedside documentation

›Modified Tal score

›Components

›Respiratory rate

›Wheeze

07Disposition/dispo27

Level of care decisions

›Disposition framework

›Mild disease criteria

›SpO2 90% or higher on room air

›Minimal work of breathing

›Adequate oral intake

›Reliable caregivers

›Ward admission criteria

›Need for supplemental oxygen

›Moderate work of breathing

›Poor feeding requiring NG or IV fluids

›High risk comorbidities

›ICU criteria

›Apnea

›Rapidly escalating oxygen or respiratory support

›Persistent hypoxemia despite high flow support

›Hypercapnia with fatigue

›Hemodynamic instability

›Transfer criteria

›Need for pediatric ICU unavailable locally

›Need for intubation or advanced ventilation

›High risk infant with worsening trajectory

Discharge readiness

›Safe discharge elements

›Stable on room air with SpO2 90% or higher

›Feeding adequate for hydration

›Caregiver comfort with nasal suction and feeding plan

›Return precautions understood

08Treatment/t76

Supportive care core

›Support bundle

›Nasal suction

›Before feeds and sleep

›Avoid aggressive deep suction if causing trauma

›Oxygen therapy

›Low flow nasal cannula starting point

›Wean to room air when SpO2 stable 90% or higher

›Avoid continuous monitoring in stable improving mild cases

›Hydration and nutrition

›Small frequent feeds

›NG feeds if safe and persistent poor intake

›IV isotonic fluids if unable to tolerate enteral

›Fever control

›Acetaminophen 15 mg per kg PO or PR every 4 to 6 hours

›Maximum 75 mg per kg per day

›Maximum 4000 mg per day

›Ibuprofen 10 mg per kg PO every 6 to 8 hours if age 6 months or older

›Maximum 40 mg per kg per day

›Airway and ventilation escalation

›High flow nasal cannula

›Initiate for persistent moderate to severe distress

›Weight based flow per local protocol

›Titrate flow and FiO2 to SpO2 goal

›Failure signals

›Rising FiO2 requirement

›Worsening retractions

›Rising PaCO2 on blood gas

09Special Populations/sp32

Pregnancy

›Special population notes

›Bronchiolitis definition primarily pediatric

›Adult RSV lower respiratory infection may mimic bronchiolitis pattern

›Pregnancy respiratory physiology

›Reduced functional residual capacity

›Lower tolerance for hypoxemia

›Medication cautions

›Avoid unnecessary medications

›Oxygenation target individualized for maternal fetal status

Geriatric

›Special population notes

›Bronchiolitis uncommon as a diagnostic label in older adults

›RSV lower respiratory infection considerations

›Higher risk of hypoxemia

›Higher risk of decompensation with COPD or CHF

›Disposition sensitivity

›Lower threshold for admission with comorbidity burden

Pediatrics

›Pediatric specific management

›Weight based dosing for all medications

›Feeding safety

›Avoid oral feeds if severe tachypnea with aspiration risk

›NG feeds as preferred over IV when feasible

›Apnea risk

›Highest risk in young infants

›Higher risk with prematurity

›High risk comorbidities

10Background/b39

Epidemiology

›Population burden

›Most common lower respiratory infection in infants

›Peak incidence in first year of life

›Seasonal clustering in winter months in many regions

›Viral causes

›RSV as leading cause

›Rhinovirus

›Human metapneumovirus

›Parainfluenza

›Influenza

›Risk stratification

›Highest hospitalization rates in young infants

›Prematurity increases severity risk

›Smoke exposure increases severity risk

Pathophysiology

›Airway level mechanisms

›Bronchiolar epithelial infection

›Mucosal edema

›Mucus plugging

›Impaired mucociliary clearance

›Gas exchange consequences

›Ventilation perfusion mismatch

›Air trapping

›Atelectasis

›Increased work of breathing

›Apnea mechanism

›Immature respiratory control in young infants

11Patient Discharge Instructions/pdi24

copy discharge instructions

›Home care plan

›Nasal saline drops with gentle suction before feeds and sleep

›Small frequent feeds

›Maintain hydration with usual milk or formula

›Fever comfort care with acetaminophen as directed by weight

›Smoke free environment

›Expected course

›Cough and congestion can last 1 to 2 weeks

›Worst breathing often occurs around days 3 to 5

›Return to ED now

›Trouble breathing

›Fast breathing that is worsening

›Skin pulling in between ribs or under ribs

›Grunting or head bobbing

›Blue lips or face

›Pauses in breathing

›Too sleepy to feed

›Fewer than half normal wet diapers

›Signs of dehydration

›Very dry mouth

›No tears when crying

›Follow up

›Primary care visit in 24 to 48 hours if symptoms not improving

›Earlier follow up for infants under 3 months or high risk conditions

12References/r14

Guidelines and evidence sources

›Clinical guideline set

›American Academy of Pediatrics bronchiolitis guideline

›National Institute for Health and Care Excellence bronchiolitis guideline

›Canadian Paediatric Society bronchiolitis guidance

›Evidence summaries

›Systematic reviews on bronchodilators in bronchiolitis

›Systematic reviews on corticosteroids in bronchiolitis

›Trials and meta analyses on high flow nasal cannula in bronchiolitis

›Coding and terminology references

›ICD-10 bronchiolitis J21.0 RSV bronchiolitis

›ICD-10 bronchiolitis J21.1 human metapneumovirus bronchiolitis

›ICD-10 bronchiolitis J21.8 other specified organisms

›ICD-10 bronchiolitis J21.9 unspecified bronchiolitis

›SNOMED CT bronchiolitis disorder concept mapping for problem list use

Evidence & Review

Evidence & Review