Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Bronchiolitis
BRONCHIOLITIS
Inflammation of the bronchioles in children under 24 months of age
I. Etiology
A. Caused by an infectious agent. Most commonly respiratory syncytial virus (RSV) but also may be caused by parainfluenza, adenovirus, or mycoplasma.
B. Insidious onset often preceded by URI symptoms.
II. Incidence/Epidemiology
A. Peak season is winter and early spring.
B. Humans are the only source of infection and the illness is transmitted by direct or close contact.
III. Incubation
A. 2–8 days
IV. Subjective findings
A. Birth history-prematurity, LBW
B. Past medical history-pulmonary disease, congenital heart disease
C. Rhinorrhea
D. Mild cough
E. Fever below 38.4C
F. Tachypnea
G. Nasal flaring and retractions
H. Feeding difficulties
I. Irritability
V. Objective findings
A. Fine crackles and expiratory wheezes
B. Tachypnea
C. Nasal flaring and retractions
D. Hypoxia: Oxygen saturation below 95%
E. Laboratory data/diagnostics
1. CBC and differential: Normal
2. Blood gas may show respiratory compromise
3. Nasal washing may be positive for RSV
4. X-ray: Hyperinflation and patchy atelectasis
VI. Assessment
A. Differential diagnosis
A. Asthma: Family history, atopy, repeated episodes of wheezing
B. Foreign body: History of choking, foreign body visualized on X-ray
C. Tracheomalacia: Stridor, chronic symptoms
D. Congestive heart failure-murmur, chronic symptoms, growth failure
E. Pneumonia: Seen on X-ray
F. GERD: History of frequent emesis, recurrent symptoms
VII. Plan
A. Treatment is supportive
B. Maintain oxygen saturation above 91%
C. Maintain adequate hydration: Small, frequent feedings may be indicated
D. Control fever: Antipyretics and increased fluid intake
E. Suction to prevent hypoxia: Bulb suction with normal saline if necessary
F. Prevent aspiration: Caution with feedings if tachypnea is present
G. Trial beta-adrenergic agents: May or may not be helpful. If wheezing or respiratory distress, consider home nebulizer therapy.
H. Consider palivizumab if in a high-risk group
I. Ribavirin aerosol treatment is not routinely recommended
J. Consider hospitalization if:
1. Child has a toxic appearance
2. Child is under 6 months of age
3. Child has moderate respiratory distress: RR above 70, O2 saturation is below 95%, nasal flaring, intercostal retractions
4. Child is dehydrated or not able to PO feed
5. Care at home may not be adequate or appropriate
6. Child is in a high-risk group: Child with chronic lung disease, congenital heart disease, neuromuscular disease, or immunodeficiency
VIII. Education
A. Educate regarding signs of respiratory distress
B. Educate regarding signs of dehydration and importance of small, frequent feedings
C. Contact precautions: Good handwashing
D. Saline washes with bulb syringe: Several drops of nasal saline in nare immediately followed by aspiration with the bulb syringe. Avoid overuse as it may increase nasal secretions.
E. Cool mist vaporizer
F. Acetaminophen for fever control; consider ibuprofen if child is over 6 months of age
G. Follow-up to reassess in 24–48 hours; follow-up immediately if child has apnea, cyanosis, poor feeding, increased respiratory rate, or signs of respiratory distress.
H. Child should not be exposed to cigarette smoke.
IX. Complications
A. Apnea
B. Respiratory failure
C. Aspiration pneumonia
D. Secondary bacterial infection
X. Consultation
A. Toxic appearance
B. Premature infant or infant under 3 months of age
C. Hypoxia (O2 sat below 95% on room air)
D. History of chronic illness
E. Tachypnea (RR above 70/minute in infants)