Bronchiolitis / Wheezing – 3-24 Months

Wheezing is a common complaint on radio traffic. In infants, wheezing is most likely due to bronchiolitis or asthma. Listen carefully for a history of recurrent wheezing in the past as a clue toward asthma. For infants presenting for the first time or with associated stridor, think foreign body. Wheezing in older children should not be diagnosed as “bronchitis” as this is not a disease seen in children. Older wheezing children have asthma, a viral process or pneumonia. Be tuned in to a reported past history that points to undiagnosed bronchiectasis (productive cough greater than 3 months). These children should be seen in Pediatric Clinic for an evaluation.

Diagnosis: based on history and clinical presentation
Demographics: hospitalization rate for Alaska Native children 3x general population in some studies
Signs/Symptoms: cough, rhinorrhea, wheezing, respiratory distress, poor feeding
Risk Factors for Severe Disease:

• less than 12 weeks old
• prematurity <34 weeks
• history of cardiopulmonary disease
• anatomic airway defects
• neuromuscular disease
• immunodeficiency
• tobacco smoke exposure

Risk for Apnea:

• postconception age <48 weeks
• low birth weight
• tachypnea or respiratory depression
• low room air oxygen saturations

Management: see Bronchiolitis/Wheezing YKHC Clinical Guideline
Prevention:

• Good Hand Hygiene
• Encourage breastfeeding for at least 6 months
• discuss Tobacco Cessation when appropriate
• Synagis for infants who qualify

Resources/References

• Bronchiolitis/Wheezing YKHC Clinical Guideline
• Lewis, T. et al. Prevalence of Asthma and Chronic Respiratory Symptoms Among Alaska Native Children. CHEST. 125(5):1665-1673, May 2004. doi.org/10.1378/chest.125.5.1665
• Singleton, Rosalyn J. MD; Bruden, Dana MS; Bulkow, Lisa R. MS Respiratory Syncytial Virus Season and Hospitalizations in the Alaskan Yukon-Kuskokwim Delta, The Pediatric Infectious Disease Journal: November 2007 - Volume 26 - Issue 11 - p S46-S50 doi: 10.1097/INF.0b013e318157da9b
• Respiratory Hospitalizations in the Delta (Powerpoint Presentation by Rosalyn Singleton, MD)
• Martinez, P; Weiss, B. Unchanged asthma prevalence during 1990–1999 in rural Alaska Native. International Journal of Circumpolar Health, 65:4, 341-346, DOI: 10.3402/ijch.v65i4.18119
• Ware, D.N. et al. (2014) Household reporting of childhood respiratory health and air pollution in rural Alaska Native communities. International Journal of Circumpolar Health 73:1.
• Trends in asthma prevalence, hospitalization risk, and inhaled corticosteroid use among Alaska Native and non-Native Medicaid recipients less than 20 years of age. State of Alaska Epidemiology Bulletin, 2004.
• Singleton, R. et al. Asthma Hospitalizations Among American Indian and Alaska Native People and for the General US Population. Chest. 2006, Nov. 130(5):1554-1562. doi.org/10.1378/chest.130.5.1554
• Bruden, D. et al. Eighteen Years of Respiratory Syncytial Virus Surveillance: Changes in Seasonality and Hospitalization Rates in Southwestern Alaska Native Children. Pediatr Infect Dis J. 2015;34(9):945-950. doi:10.1097/INF.0000000000000772
• Ralston, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics November 2014, 134 (5) e1474-e1502; DOI: https://doi.org/10.1542/peds.2014-2742
• Clinical Practice Guideline: Bronchiolitis. AAFP. 2019.
• Kirolos, et al. A Systematic Review of Clinical Practice Guidelines for the Diagnosis and Management of Bronchiolitis. The Journal of Infectious Diseases, Volume 222, Issue Supplement_7, 1 November 2020, Pages S672–S679, doi.org/10.1093/infdis/jiz240
• Kou, et al. Bronchiolitis: From Practice Guideline to Clinical Practice. Emerg. Med. Clin. North. Am., 36 (2018), pp. 275-286, 10.1016/j.emc.2017.12.006
• Roqué i Figuls, Marta et al. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. The Cochrane database of systematic reviews vol. 2,2 CD004873. 1 Feb. 2016, doi:10.1002/14651858.CD004873.pub5
• Condella, Anna et al. Multicenter Study of Albuterol Use Among Infants Hospitalized with Bronchiolitis. The western journal of emergency medicine vol. 19,3 (2018): 475-483. doi:10.5811/westjem.2018.3.35837
• Zhang, Linjie et al. Nebulised hypertonic saline solution for acute bronchiolitis in infants. The Cochrane database of systematic reviews vol. 12,12 CD006458. 21 Dec. 2017, doi:10.1002/14651858.CD006458.pub4
• Hsieh, Chia-Wen et al. Exploring the efficacy of using hypertonic saline for nebulizing treatment in children with bronchiolitis: a meta-analysis of randomized controlled trials. BMC pediatrics vol. 20,1 434. 14 Sep. 2020, doi:10.1186/s12887-020-02314-3
• Hendaus, Mohamed A et al. Pulse oximetry in bronchiolitis: is it needed?. Therapeutics and clinical risk management vol. 11 1573-8. 12 Oct. 2015, doi:10.2147/TCRM.S93176
• Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC), Cloutier MM, et al. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020 Dec;146(6):1217-1270. doi: 10.1016/j.jaci.2020.10.003. Erratum in: J Allergy Clin Immunol. 2021 Apr;147(4):1528-1530. PMID: 33280709; PMCID: PMC7924476.
• RSV in Alaskan Native Infants from the CDC.
• Improving Health for Alaska and Arctic Residents: Arctic Investigations Program through the CDC
• Pediatric Asthma 2019 (PowerPoint Presentation)
• Pediatric Asthma Part 2 2019 (PowerPoint Presentation)
• RSV Infections in adults (PowerPoint Presentation)
• Seattle Children's Hospital Bronchiolitis Pathway

YKHC Clinical Guidelines
Common/Unique Medical Diagnoses