Bronchiolitis Part VII: Hey PEEPs! Let’s talk respiratory support

[toggle_box] [toggle_item title=”Nasal suctioning” active=”false”]The goal of nasal suctioning is to clear secretions (despite the fact that they’ll be back). This can reduce airway resistance and the work of breathing. In general it provides transient relief, and may make the patient temporarily feel/feed better. It also helps with your exam in decreasing some of the transmitted upper airway sounds. However, in the clinical trials I read there is no definite impact on respiratory score, risk of hospitalization, or inpatient length of stay. The benefit is purely short-lived. There is no strong data for deep suctioning – so I say stick to the bulb or the BBG. [/toggle_item] [toggle_item title=”Chest physiotherapy” active=”false”]I’ll be brief, chest PT/percussive therapy is not recommended for bronchiolitis. The babies appreciate you not ordering it.[/toggle_item] [toggle_item title=”Heliox” active=”false”]In theory helium-oxygen decreases resistance to gas flow in conditions where there is turbulence (airway edema).  In a randomized study Cambonie et al, Chest, 2006 noted that in both term and preterm infants with bronchiolitis that respiratory score and wheezing were improved to a greater degree in those that received heliox. This study was confined to a PICU setting and only included 20 infants all less than 3 months. A study by Liet J Pediatrics, 2012 noted no significant benefit for need for mechanical ventilation, intubation, or improvement in clinical score. Though promising, availability of heliox can vary based on clinical and geographical location – so this obviously limits the generalizability. I do not use it in my routine practice in the ED.[/toggle_item] [toggle_item title=”CPAP” active=”false”]Continuous positive airway pressure is something that we may initially apply to bronchiolitics with apnea or severe respiratory distress. This therapy makes sense, since it stents open the airways by maintaining PEEP. Thia et al Archives of Disease in Childhood, 2008 noted in a crossover design RCT that their 31 patients under the age of 12 months with bronchiolitis benefitted from CPAP via a reduction in PCO2. The earlier it is used the better per their findings. Studies combining CPAP and Heliox see similar benefit. I will use CPAP transiently in the ED, and occasionally I will employ it as a bridge to the PICU in order to avoid intubation, but other therapies (see the next item) have gained favor.[/toggle_item] [toggle_item title=”High-flow nasal cannula” active=”false”]Yes, they make HFNC for the little ones as well. The theoretical physiologic benefits include; provide flow to overcome the resistance and dead space of nasopharynx, providing positive airway pressure, and providing warmed/humidified gas. In general it helps with lung recruitment. McKiernan et al J Pediatrics, 2010 found that HFNC used on patients admitted to the PICU resulted in decreased respiratory rate, intubation, and PICU length of stay. Schibler et al, Intensive Care Med, 2011 noted increased use from 2005-2009 and a 30% decrease in intubation rate over the same time period (37% to 7%) when HFNC was used. In patients with viral bronchiolitis they found that the HR and RR can decrease by 20% after 90 minutes of therapy. The nasal cannula of high-flow also seems to be better tolerated by infants. It isn’t without potential downsides, since the FiO2 needed is still dependent on minute ventilation. Nevertheless, as you’ll see in the next treatment, HFNC has distinct benefits, and though studies focus on problems in the PICU, I start it as early as possible in the ED, knowing that it can take an hour and a half to see the full benefit. If intubation is prevented, then it is worth it. [/toggle_item] [toggle_item title=”Endotracheal intubation” active=”false”]It can be gratifying for ED providers to secure the airway in tenuous situations, but as those of you that have rotated through the PICU can attest, intubating a bronchiolitic is asking for trouble. In general patients >12 months of age, and intubated for longer than 3 days have the greatest risk for complications. These are illustrated nicely in a study by Jorgensen et al in Otolaryngol Head Neck Surg, 2007. Between 2000 and 2005 they looked at 144 intubated infants with bronchiolitis. The mean duration of intubation was 5.5 days. 40% had post intubation complications including wheezing, stridor, retractions, and reintubation. In general I try to avoid intubating bronchiolitics, favoring a trial of HFNC. Obviously if that fails, or if they are in extremis I will readily place tracheal plastic. My overall goal is to get the sickest babies with bronchiolitis to the ICU as fast as possible for optimal care.[/toggle_item]

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Stay tuned for the thrilling conclusion to the bronchiolitis series – when we bring it all home literally. Because we’ll be focusing on discharging home from the ED you see.

Thanks again to Todd Florin, MD, MSCE.