Bronchiolitis Clinical Pathway, Emergency Department – Initial Respiratory Assessment: Key Points

Bronchiolitis Clinical Pathway — Emergency Department

Initial Respiratory Assessment: Key Points

Variability The physical exam varies from minute to minute based on physiology and response to treatment as well as the child's position, level of alertness, and cooperation.
Physical Examination Assessment is ideally done with the child upright, awake after suctioning the upper airway, as nasal congestion may transmit to the lungs and simulate wheezing. A reliable assessment often requires repeated examinations over the course of the ED visit.
Progression of Illness Symptoms tend to worsen over the first 3-5 days of illness and then gradually resolve over the following weeks. Assessment of the stage of illness and potential progression is an important factor in the disposition decision.
Pulse Oximetry
  • Hypoxemia is usually due to ventilation-perfusion mismatch from mucus plugging of the airways.
  • Bronchodilator therapy can worsen this effect temporarily.
  • Pulse oximetry is important, as mild hypoxemia may not be apparent on physical exam. However, changes can be transient, the decisions to initiate oxygen should be based on repeated observation of pulse oximetry < 90% after routine measures such as positioning and suctioning.
  • Mild hypoxemia (< 95%) is a predictor of potential progression to severe disease requiring hospitalization, particularly if the child is in the early stages of the illness.
Apnea
  • Apnea is a concern in young and premature infants. Factors predicting very low risk of apnea include:
    • Age > 4 weeks for full-term or 48 weeks post-conception for pre-term (< 37 weeks gestation),
    • Absence of prior history of apneic episode before presentation.

Baseline Assessment and Pathway Status Determination

The highest rating in any category dictates the patient’s current assessment. Key elements including respiratory rate, work of breathing and mental status can be used to assess trend overtime. Albuterol Trial RT: Score-Treat-Score

    Mild (0) Moderate (1) Severe (2)
RR < 3 months 30-60 61-80 > 80
3 - < 12 months 25-50 51-70 > 70
1y – 2y 20-40 41-60 > 60
WOB None or mild Intercostal retractions Nasal flaring, grunting, head bobbing
Mental Status Baseline Fussy or anxious Lethargic or inconsolable
Oxygen Requirement None < 1.5 liters > 1.5 liters
Suctioning Bulb Wall/Bulb Wall
Breath Sounds Clear Crackles, Wheezing Diminished breath sounds or significant crackles, wheezing
Cough Absent or mild Moderate Severe