Fever, common cold and cough in pediatric age groups are common. Acute bronchiolitis is a diagnostic term used to describe the clinical picture produced by several different lower respiratory tract infections in infants and very young children (younger than 1yr ,some clinicians extend it to the age of 2 yr). Pneumonia defined as inflammation of lung parenchyma. It is the leading infectious cause of death globally among children younger than 5 yr. The introduction of antibiotics and vaccine against measles , pertussis ,haemophilus influenzae type b and PCV vaccine reduces the pneumonia related mortality over past 15 yr.

1. ACUTE BRONCHIOLITIS AND
VIRAL PNEUMONIA
SPEAKER -Dr Chayanika Mishra
Pediatric Resident, Kolkata

2. ACUTE BRONCHIOLITIS:
 Introduction
 Risk factors
 Etiology
 Patho physiology
 Clinical manifestation
 Diagnosis
 Management
 Complication

3. INTRODUCTION:
 Diagnostic term used to describe the clinical picture produced
by several different lower respiratory tract infections in infants
and very young children (younger than 1yr ,some clinicians
extend it to the age of 2 yr.)

4. RISK FACTORS:
HOST RELATED RISK FACTORS:
 Prematurity, especially < 32 weeks of gestation
 Low birth weight
 Age < 6-12 weeks
 Chronic lung disease including BPD
 Hemodynamically significant CHD ( Moderate to
severe PH, cyanotic heart disease, or CHD that
requires medication to control heart failure)
 Immunodeficiency
 Neuromuscular disorders
ENVIRONMENTAL RISK FACTORS:
 Having older siblings
 Passive smoke
 Household crowding
 Child care attendance
 Lower socioeconomic status

5. ETIOLOGY:
 RSV most common virus isolated in about 75% (30-70 % in Indian studies)
 Rhinovirus
 Parainfluenza
 Adenovirus
 Human metapneumo virus
 Bocavirus
 Mycoplasma is more frequently implicated in older children with bronchiolitis

6. PATHOPHYSIOLOGY:

7. Severity of bronchiolitis:
Mild Moderate Severe
Feeding ability Normal ability to
feed
Appear short of breath
during feeding
May be reluctant or unable to feed
Respiratory distress Little or no
respiratory
distress
Moderate distress with
some chest wall
retractions and nasal
flaring
Severe distress with marked chest
wall retractions, nasal flaring and
grunting ;
Can have frequent and prolonged
apnea
Saturation Saturation >92% Saturation < 92%,
correctable with oxygen
Saturation < 92%,may or may not
be correctable with oxygen

8. Differential diagnosis:
 Pneumonia: Fever >39°C with persistent focal crackles ;
 Episodic viral wheeze: Persistent wheeze without crackles, or recurrent episodes
with or without a family history of atopy

9. Management:
 Treatment is focused on symptomatic relief and maintaining hydration and oxygenation.
 Fever should be controlled with paracetamol.
 Nose block should be cleared with saline nasal drops and gentle suctioning.
 Child should be made to lie in a propped up or head end elevated positioning.
 Orogastric tube feeding may be indicated in admitted patients. Intravenous (IV) fluids in children with
impending respiratory failure or who do not tolerate orogastric/nasogastric (OG/NG) fluids.
 Suctioning of the upper airway in children with apnea, respiratory secretions, and feeding difficulties due to
upper airway secretions.
 Supplemental oxygen in children with SpO2 below 90% (>6 weeks) or below 92% ( < 6 weeks or with
underlying health issues).
 Drugs with questionable value might reduce need for admission or length of hospital stay, but broad
consensus is lacking.
 • Nebulized hypertonic saline: In children hospitalized for >3 days
 • Nebulized adrenaline: 0.1–0.3 mL/kg/dose of 1:1,000 as a potential rescue medication; however inconsistent
and short-lived improvement
 • Beta-agonists: Optional single trial; may be continued if there is clinical response (a trial of bronchodilator
therapy may be initiated, but should be discontinued if there is no objective improvement.

10.  No role of:
• Chest physiotherapy • Antibiotics
• Antivirals • Montelukast
• Ipratropium bromide • Systemic or inhaled steroids
• Steam inhalation
• RSV polyclonal immunoglobulin/palivizumab (no roll in acute management but
useful in prophylaxis)
• Inhaled furosemide/inhaled interferon alfa-2a/inhaled recombinant human
deoxyribonuclease (DNase) ;
 Interventions which are possibly effective for most severe cases:
1. CPAP
2. Surfactant
3. Heliox
4. Aerosolized ribavirin

11. Prevention:
 Breastfeeding: Three-fold greater risk in non-breastfed infant ;
 Hand hygiene ;
 Avoid passive smoking ;
 Immune prophylaxis:
 Palivizumab: Monoclonal antibody, monthly injections during seasonal epidemics.
 Indication: Infants < 12 months with prematurity < 29 weeks; CLD of prematurity;
hemodynamically significant heart disease.
 Palivizumab is administered intramuscularly at a dose of 15 mg/kg monthly (every 30
days) during the RSV season. A maximum of five doses is generally sufficient
prophylaxis during one season.
 Nirsevimab: On trial; single dose for 5 months
 Motavizumab, a second-generation mAb, and Numax-YTE, a third-generation mAb—
under trial

12. Complications:
 Acute respiratory distress syndrome (ARDS) ;
 Myocarditis ;
 Congestive heart failure ;
 Arrhythmias ;
 Bronchiolitis obliterans ;
 Secondary bacterial infection ;
 Predisposition to childhood asthma

13. VIRAL PNEUMONIA :
 Introduction
 Risk factors
 Etiology
 Pathogenesis
 Clinical manifestations
 Diagnosis
 Treatment
 Prognosis
 Complications

14. INTRODUCTION :
Pneumonia defined as inflammation of lung parenchyma.
It is the leading infectious cause of death globally among
children younger than 5 yr.
The introduction of antibiotics and vaccine against measles ,
pertussis ,haemophilus influenzae type b and PCV vaccine
reduces the pneumonia related mortality over past 15 yr.

15. RISK FACTORS :
Low birth weight
SAM
Vitamin A Deficiency
Lack of breast feeding
Overcrowding
Indoor air pollution
History of bronchitis
Immunodeficiency

16. ETIOLOGY :
INFECTIOUS:
 Bacterial
 Viral
 Fungal
 Rickettsial
 Mycobacterial
 Parasitic
 NONINFECTIOUS:
Hypersensitive reaction
Drug induced
Radiation induced
Aspiration_food /gastric acid/ hydrocarbons / foreign body

17. VIRAL:
Common
RSV Bronchiolitis
Parainfluenza types 1-4 Croup
Influenza A & B High fever, winter months
Adenovirus Can be severe, often occurs between Jan - April
Human metapneumovirus Similar to RSV
Uncommon:
Rhinovirus Rhinorrhea
Enterovirus Neonates
Herpes simplex Neonates, Immunocompromised persons
CMV Infants, Immunocompromised persons (HIV)
Measles Rash, coryza, conjunctivitis
Varicella Unimmunised, Immunocompromised persons
Hanta virus Rodents
Corona viruses COVID-19, SERS, MERS

18. Age group Frequent pathogens
Neonates (< 3 wks) Gr B Streptococcus > E. Coli > other Gm –ve bacilli > S.
pneumoniae > H. influenzae
3 wks – 3 months RSV > other respiratory viruses (Rhinovirus, Human
Parainfluenza, Influenza, Human metapneumovirus, Adeno) >
S. pneumoniae > H. influenzae. If patient is afebrile consider C.
trachomatis.
4 months- 4 years RSV > other respiratory viruses (Rhinovirus, Human
Parainfluenza, Influenza, Human metapneumovirus, Adeno) >
S. pneumoniae > H. influenzae > M. pneumoniae
≥5 years M. Pneumoniae > S. pneumoniae > Chlamydophila.
pneumoniae > H. influenzae > Influenza > Adeno > other
respiratory viruses > Legionella

19. Recurrent Pneumonia:
Differential Diagnosis of Recurrent Pneumonia
HEREDITARY DISORDERS Cystic fibrosis
Sickle cell disease
DISORDERS OF IMMUNITY HIV/AIDS
Bruton agammaglobulinemia
Selective immunoglobulin G subclass
deficiencies
Common variable immunodeficiency
syndrome
Severe combined immunodeficiency
syndrome
Chronic granulomatous disease
Hyperimmunoglobulin E syndromes
Leukocyte adhesion defect
Defined as 2 or more episodes in a single year or 3 or more episodes ever with
radiological clearing between occurrences.

20. DISORDERS OF CILIA Primary ciliary dyskinesia
Kartagener syndrome
ANATOMIC DISORDERS Pulmonary sequestration
Lobar emphysema
Congenital cystic adenomatoid
malformation
Gastroesophageal reflux
Foreign body
Tracheoesophageal fistula (H type)
Bronchiectasis
Aspiration (oropharyngeal incoordination)
Aberrant bronchus

21. Pathogenesis:
 Lower respiratory tract has number of defence mechanism which protect against
infections-coughing ,mucociliary clearance ,macrophages ,secretory Ig A.
 Pneumonia results from:
 Disruption of a complex lower respiratory ecosystem that is site of dynamic interaction
between
1. Potential pathogens ,
2. Resident microbial community
3. Host immune defences.

22. Pathogenesis:
Results in- Atelectasis, Interstitial edema, Hypoxemia from V-Q mismatch, Secondary bacterial
infection
Airway obstruction from swelling, abnormal secretions and cellular debris
Direct injury of respiratory epithelium
Spread of infections along airway

23. Secondary bacterial infection:
Bacteria Mechanism of lung parenchymal involvement
M. pneumoniae As is seen in viral pneumonia.
S. pneumoniae Local edema that aids in the proliferation of organisms and their
spread into adjacent portions of lung, often resulting in the
characteristic focal lobar involvement
Group A
streptococcus
Results in more diffuse lung involvement with interstitial
pneumonia and involvement of lymphatic vessels & pleura.
S. aureus confluent bronchopneumonia, characterized by extensive areas
of hemorrhagic necrosis and irregular areas of cavitation,
resulting in pneumatoceles, empyema, and, at times,
bronchopulmonary fistulas.

24. Clinical Manifestations:
 Prodromal symptoms- Preceded by several days of symptom onset.
 Fever- Low grade compared to bacterial pneumonia.
 Tachypnea- Most consistent manifestation.
 Features of increased work of breathing- Chest retraction & nasal flaring.
 Children may lie on one side with the knees drawn up to the chest- splinting on the
affected side to minimize pleuritic pain and improve ventilation.
 Abdominal pain- common in lower-lobe pneumonia.
 In infants, there may be a prodrome of URTI and poor feeding, leading to the abrupt
onset of fever, restlessness, apprehension, and respiratory distress.

25. Physical findings:
 Tachypnea- Most consistent manifestation
 Diminished breath sounds, scattered crackles, and rhonchi are commonly heard over the
affected lung field.
 With the development of increasing consolidation or complications of pneumonia such as
pleural effusion or empyema, dullness on percussion is noted and breath sounds may be
diminished.
 Abdominal distention may be prominent because of gastric dilation from swallowed air or
ileus.
 The liver may seem enlarged because of downward displacement of the diaphragm
secondary to hyperinflation of the lungs or superimposed congestive heart failure.
 It is often not possible to distinguish viral pneumonia (especially adenovirus) clinically from
disease caused by Mycoplasma and other bacterial pathogens.

28. ThankYou