Overview
Definition:
Bronchiolitis is a common acute viral lower respiratory tract infection in infants and young children, characterized by inflammation and edema of the bronchioles
Discharge criteria aim to ensure safe transition from hospital to home, focusing on adequate feeding and stable oxygenation.
Epidemiology:
Primarily affects infants under 2 years, with peak incidence between 2-6 months
Caused predominantly by Respiratory Syncytial Virus (RSV)
It is a leading cause of hospitalization in infants.
Clinical Significance:
Understanding discharge readiness prevents readmissions, reduces healthcare burden, and ensures optimal recovery at home
Inadequate feeding or oxygen support post-discharge can lead to clinical deterioration and re-hospitalization, critical for DNB and NEET SS candidates to grasp.
Clinical Presentation At Discharge
Symptoms:
Resolution of significant tachypnea
Reduced work of breathing
Absence of significant retractions or nasal flaring
Improved feeding tolerance
Decreased frequency/severity of cough
Afebrile or stable temperature.
Signs:
Oxygen saturation consistently >90-92% on room air
Respiratory rate within acceptable limits for age
Absence of significant grunting or accessory muscle use
Good peripheral perfusion
Normal or improving hydration status.
Diagnostic Criteria:
No formal diagnostic criteria for discharge
rather a clinical assessment of stability
Guidelines emphasize clinical improvement in respiratory status, adequate oral intake, and sustained oxygenation.
Discharge Criteria Feeding
Adequate Intake:
Ability to tolerate oral feeds (breastmilk, formula, or solid food) without excessive emesis
Successful completion of at least 2-3 feeds per shift prior to discharge
Demonstrates effective suck-swallow-breathe coordination.
Hydration Status:
Demonstrates adequate urine output (e.g., >3-4 wet diapers per day)
Moist mucous membranes
Good skin turgor
No signs of significant dehydration.
Feeding Challenges:
Consider postponing discharge if infant tires easily during feeds, has persistent vomiting post-feeds, or requires continuous NG/OG support for basic caloric intake
Gradual transition to oral feeds is crucial.
Discharge Criteria Oxygen Stability
Oxygen Saturation:
Oxygen saturation consistently ≥90-92% on room air for at least 24 hours
If supplemental oxygen was required, the infant should be able to maintain target saturation for at least 24 hours on room air
Specific target saturation may vary slightly by institution.
Respiratory Rate:
Respiratory rate normalized for age and age-appropriate for activity levels
Absence of significant distress with minimal or no supplemental oxygen.
Weaning Criteria:
Gradual weaning of supplemental oxygen as clinical status improves
Monitor for desaturation during activity or feeding
If desaturation occurs, reassess feeding tolerance and underlying respiratory status
Home oxygen therapy is rarely indicated for uncomplicated bronchiolitis resolution.
Post Discharge Care And Follow Up
Parent Education:
Educate caregivers on recognizing signs of worsening respiratory distress, fever, feeding difficulties, and dehydration
Provide clear instructions on medication administration (if any)
Emphasize hygiene measures to prevent future infections.
Follow Up Appointments:
Schedule follow-up appointment within 2-7 days, especially for infants with significant risk factors or complex hospital course
Advise immediate return to emergency department for any concerning symptoms.
Supportive Measures:
Encourage upright positioning
Saline nasal drops and gentle suctioning for nasal congestion
Adequate fluid intake
Avoidance of smoke exposure
Prompt vaccination for influenza if season permits.
Key Points
Exam Focus:
The core of DNB/NEET SS questions on bronchiolitis discharge revolves around identifying patients ready for home based on feeding and oxygen stability
Remember target O2 saturation thresholds and signs of adequate hydration.
Clinical Pearls:
Always assess feeding and oxygenation together
An infant requiring high FiO2 may have improved saturation but poor feeding due to respiratory fatigue
Family readiness and understanding are as important as clinical parameters.
Common Mistakes:
Discharging infants with borderline oxygen saturation or poor feeding, leading to readmission
Over-reliance on single parameters without a holistic clinical assessment
Insufficient caregiver education regarding warning signs at home.