4 bronchiolitis

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4 bronchiolitis

  1. 1. BronchiolitisDr Yog Raj Khinchi
  2. 2. Bronchiolitis• LRI – Leading cause – morbidity & mortality in children• Bronchiolitis – - Most common serious LRTI needing hospital admission - Pediatric burden of illness world wide - Generally self limiting condition
  3. 3. Bronchiolitis: Definition• Clinical Syndrome• Acute onset of resp. symptoms: < 2 yrs age• Initial symptoms: URT viral infections• Fever, coryza, progresses in 4-6 days to LRT involvement: Cough and wheezing
  4. 4. Bronchiolitis: Epidemiology•  incidence due to - More premature infants & children with chronic illnesses• More common in children < 12 months• > 50% affected children: 2 to 7 mo of age• Infants < 6 months are at highest risk of clinically significant disease• 2% to 3% of children require hospital admission• Commonly in late autumn and early spring
  5. 5. Increasing hospitalization Predisposing factors• Infants in day care• Exposure to passive smoke• Crowding in the household• Environmental and genetic factors do contribute to severity of disease
  6. 6. Bronchiolitis: Etiology• Viral Most common: Respiratory syncytial virus (RSV) Others: Influenza, parainfluenza adenovirus, coronavirus, rhinovirus• M. pneumonia: though isolated not recognized as etiological agent
  7. 7. Bronchiolitis: PathophysiologySloughed epithelial cells Airway obstructionneutrophils & lymphocytesComplete / partial plugging of some Atelectasis /airways overdistentionVentilation and perfusion imbalance Hypoxemia Once plugging of airway has occurred, treatment is only respiratory support, O2 and time
  8. 8. Bronchiolitis: Clinical features• Quite variable• Nasal obstruction with or without rhinorrhea• Cough - First irritating  tight cough• Poor feeding after the initial onset of symptoms• Apnea upto 20% in < 12 months with RSV• Fever - higher than 39oC [adenovirus or influenza]
  9. 9. • Nasal flaring  Tachypnea  Chest retraction
  10. 10. Bronchiolitis: Clinical features…• Respiratory distress – Mild, moderate or severe• Clinical features - Nasal flaring, tachypnea, expanded chest, audible wheeze• Auscultation - rales or rhonchi & poor air entry, prolonged expiratory phase• Other features - Conjunctivitis, rhinitis & otitis media• Mild-to-moderate hypoxia - Pulse oximetry or arterial blood gases
  11. 11. Bronchiolitis: Clinical classificationMild, moderate, or severeBased on• Ability to feed• Respiratory effort• Oxygen saturation observed at admission
  12. 12. Investigations: Specific and supportive• Complete blood count• CXR• Nasopharyngeal aspirate (NPA) - RSV and viral culture• Electrolytes – especially if needing IV fluids• Blood culture – if temperature > 38.5°C• Blood gases Usually no lab tests needed in mild bronchiolitis
  13. 13. Chest X-rayCXR shows:• hyperinflation• patchy infiltrates – typically migratory (post-obstructive atelectasis & peribronchial cuffing)
  14. 14. Bronchiolitis: Diagnosis• A clinical diagnosis• Infant with short prodrome of upper RTI• Clinical finding - audible wheezing - wheezing with crackles - respiratory distress with - chest recession
  15. 15. Bronchiolitis: Differential diagnosis• Congenital anomalies vascular ring, congenital heart disease• Gastroesophageal reflux• Aspiration pneumonia• Foreign body aspiration
  16. 16. Management• Supportive care - mainstay of therapy• Moderately ill infants - require supplementary O2• IVF in young infants - tachypnea, partial nasal obstruction & feeding difficulties• Role of bronchodilators - Controversial
  17. 17. Oxygen• Humidified oxygen ideal• Supplemental oxygen if SaO2 <94%, combination of clinically significant respiratory distress, RR > 60/min, feeding difficulty• Maintain SaO2 above 95%• Use nasal prongs / face mask / hood / head box• Hypoxaemia + / - distress, despite high O2 flow, require ventilatory support.
  18. 18. Fluid Therapy• Indications – Nasal flaring, tachypnoea (>60/min), apnoeic episodes, marked retractions, tiring during feeds• Normal maintenance volumes – N/2 or N/4 dextrose saline• Fluid volumes increased up to 20% – if frequent or persistent fever (>38.5°C) and/or markedly increased respiratory effort• Monitor serum electrolytes
  19. 19. Beta-agonist therapy and clinical outcome • RCT - no clear utility for bronchodilators in bronchiolitis
  20. 20. Nebulized epinephrine• Improvement in respiratory symptoms - inconsistent & potentially short-lived• May use nebulized epinephrine as a potential rescue medication who are to be admitted
  21. 21. Systemic Corticosteroids In Bronchiolitis • Data suggest moderate potential efficacy • In higher doses -  hospitalization rates & improve symptoms at 4 hours in ED in patients with mod to severe bronchiolitis
  22. 22. Bronchiolitis: Ribavirin• Ribavirin - considered in severely immuno- compromised developing lab confirmed RSV assoc. bronchiolitis
  23. 23. ICU managementNeeded in the following category• Progression to severe respiratory distress, especially in at- risk group• Apnoeic episodes – Eg. associated with desaturation or > 15 seconds duration or frequent recurrent brief episodes• Persistent desaturation despite oxygen• ABG evidence of respiratory failure – i.e. pO2 < 80mm Hg; pCO2 > 50mm Hg; pH < 7
  24. 24. Bronchiolitis: CPAP• May benefit infants with bronchiolitis by stenting open the smaller airways during all phases of respiration• Prevents air trapping & obstructive disease• As a constant stimulus in infants - propensity to experience apnea• Data though promising, without controlled trials, are inconclusive
  25. 25. Discharge• Minimal respiratory distress• SaO2 > 90% in room air – Except in chronic lung disease, heart disease, or other risk factors• Not received supplemental O2 for 10 hrs• Minimal or no chest recession• Able to take oral feeds
  26. 26. Complications• Respiratory complications - most frequent• Infectious complications - second most common,• Cardiovascular, electrolyte imbalance• Complication rates were higher in - premature infants congenital heart disease other congenital abnormalities• Infants 33-35 weeks GA highest complication rates longer hospital stay
  27. 27. Serious complications• Respiratory failure• Apnea• Pneumothroax – Among former premature infants – congenital abnormalities• Risk of serious bacterial infections in first month of life regardless of RSV + / -
  28. 28. Prognosis• Generally self limiting condition• 2% to 3% of children require hospitalization• Need for supplemental O2 based on SaO2 on admission and predict length of hospital stay• Beware of rapid deterioration in high risk group• Death is uncommon even in high risk group
  29. 29. Prevention• RSV cross-infection is common and serious – but largely preventable• Vaccine development for RSV has been slow• RSV spread from nose/face/hands of another individual – Frequent hand washing by nursing, medical, other staff and parents minimize this problem• Avoid nursing infants with bronchiolitis (RSV positive, or awaiting RSV results) in rooms with high-risk infants• Some studies reveal – Efficacy of palivizumab prophylaxis in prevention of RSV bronchiolitis in severely premature infants with BPD

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