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Bronchiolitis in children

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Bronchiolitis in children

  1. 1. Bronchiolitis in Children Prof. Dr. Saad S Al Ani Senior Pediatric Consultant Head of Pediatric Department Khorfakkan Hospital Sharjah, UAE Saad.alani@moh.gov.ae
  2. 2. Bronchiolitis is caused by a viral infection and is seasonal ,peaking in the winter months. The most common cause is respiratory syncytial virus (RSV) which accounts for 80% of cases Other respiratory viruses that cause bronchiolitis: • Rhinovirus • Adenovirus • Influenza virus • Parainfluenza Bush A. Thomson AH..acute Bronchiolitis.BMJ2007,335(7628):1037-1041 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 2
  3. 3. Bronchiolitis is the most common disease of the lower respiratory tract during the first year of life Children present with : • Cough • Increased work of breathing • Difficulty with feeding About 1 in 3 infants will develop bronchiolitis in the first year of life About 2% -3% of all infants will need admission to hospital Deshpande SA, Northern V.The clinical and health economic burden of respiratory syncytial virus disease among children under 2 years of age in a defined geographical area. Arch Dis Child2003,88(12):1065-9. 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 3
  4. 4. Young infants( especially those under 6 weeks) may present with apnea without other clinical signs) Apnea is considered a ‘ red flag’ symptoms that need emergency care in the hospital National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 4
  5. 5. • Apnea (Observed or reported) • The child look seriously unwell • Severe respiratory distress:  Grunting  Marked chest recessions  Respiratory rate above 70 breaths per minute • Central cyanosis • Oxygen saturations persistently below 92% when breathing air Emergency consideration Scottish Intercollegiate Guidelines Network. Bronchiolitis in children: A national clinical guideline .2006. http://www.sign.ae.uk/pdf/sign91.pdf 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 5
  6. 6. • Most children:  Will have mild disease that is self limiting  Can be managed at home • Some children  Have more severe respiratory distress  Needing treatment • Few children :  Will deteriorate rapidly  Develop severe life threatening bronchiolitis  Need urgent treatment National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 6
  7. 7. Clinical features that may be important predictors of deterioration include: • Length of illness ( a deterioration is more likely in the early stages of the disease) • Heart rate above 97th centile • Respiratory rate above 70 breaths per minute • Fever • Oxygen saturation below 92% • Ability to feed Walsh P,et al.A validated clinical model to predict the need for admission and length of stay in children with acute bronchiolitis. Eur J Emerg Med2004;11(5):265-72 Corneli HM,et al. Bronchiolitis: clinical characteristics associated with hospitalization and length of stay. Pediatr Emerg care 2012;28(2):99-103 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 7
  8. 8. Referral indications to hospital If any of the followings is present in a child with bronchiolitis, referral to hospital is indicated: • Respiratory rate > 60 breath per minute • Difficulty with breastfeeding or inadequate oral intake • Clinically dehydrated • Chronic lung disease • Congenital Heart disease • Age under 3 months • Premature birth(<32 weeks gestation) • A neuromuscular disorder • Immunodeficiency National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 8
  9. 9. Think of Bronchiolitis as a diagnosis if the child has a coryzal prodrome that lasts between 1-3 days and is followed by: • A persistent cough AND • Tachypnea or chest recession for both , AND • Wheeze or crackles on auscultation for both National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 https://www.linkedin.com/pulse/who-do-you-think-pete-baker Diagnosis 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 9
  10. 10. Colourbox Do not perform a routine chest x ray Generally the diagnosis of bronchiolitis is Clinical and investigations are not considered helpful Chest x ray can’t discriminate between bronchiolitis and other lower respiratory tract infections Stephens D, Lalani A, Schuh S. Predictors of major intervention in infant with bronchiolitis. Pediatr Pulmonol2009;44(4):358-63 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 10
  11. 11. • The treatment for bronchiolitis is Supportive • No effective drug treatment Bronchiolitis is a viral and the rate of secondary bacterial infection is very rare Significant disadvantages associated with use of antibiotics: • Adverse reactions • Bacterial resistance • Cost implications Luo Z, Fu Z, Liu E ,et al. Nebulized hypertonic saline treatment in hospitalized children with moderate to severe viral bronchiolitis. Clin Microbiol Infect2011;17(12):1829-33 National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 11
  12. 12. Ineffective treatments All of the followings should not be used to treat children with bronchiolitis: • Antibiotics • Hypertonic saline • Nebulized adrenaline • Salbutamol • Montelukast • Ipratropium bromide • Systemic or inhaled corticosteroids National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 12
  13. 13. When to give oxygen wiseGEEK Oxygen supplementation is needed if a child’s oxygen saturated is persistently < 92% in air No routine oxygen for all children with bronchiolitis National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 13
  14. 14. The following informations to parents caring for children with bronchiolitis at home: • ‘Red flag’ symptoms:  Worsening of breathing work:  A reduced fluid intake  Apnea or cyanosis  Exhaustion • Avoid smoking at home • Follow up National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 14
  15. 15. Bronchiolitis versus Asthma 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 15
  16. 16. Clinical Features of Bronchiolitis • Starts with upper respiratory tract symptoms:  Nasal obstruction  Cough • Progresses over 3-4 days to involve the bronchioles:  Dyspnea  Poor feeding • On auscultation: mixture of wheeze and crackles National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 16
  17. 17. Asthma • It is less commonly under 1 year of age • Recurrent respiratory symptoms:  Wheeze  Cough  Difficulty of breathing  Chest tightness • Symptoms worse after exposure to triggers and at night • Personal or family history of atopy or asthma • On auscultation: widespread wheeze • Improve lung function after adequate treatment Wu P, Hartert TV. Evidence for a causal relationship between respiratory syncytial virus infection and asthma. Expert Rev Anti Infect Ther2011;9(9):731-45 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 17
  18. 18. Post bronchiolitis syndrome • Recovery takes between 5 – 7 days • Persistent cough lasts >2 weeks occur in 50% • Infants have increase frequency of subsequent wheeze • Some children get chronic and relapsing episodic wheezing with subsequent viral infections • Association between RSV and later on development of asthma is well documented Wu P, Hartert TV. Evidence for a causal relationship between respiratory syncytial virus infection and asthma. Expert Rev Anti Infect Ther2011;9(9):731-45. 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 18
  19. 19. References • Bush A. Thomson AH..acute Bronchiolitis.BMJ2007,335(7628):1037-1041 • Deshpande SA, Northern V.The clinical and health economic burden of respiratory syncytial virus disease among children under 2 years of age in a defined geographical area. Arch Dis Child2003,88(12):1065-9 • National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 • Scottish Intercollegiate Guidelines Network. Bronchiolitis in children: A national clinical guideline .2006. http://www.sign.ae.uk/pdf/sign91.pdf • Walsh P,et al.A validated clinical model to predict the need for admission and length of stay in children with acute bronchiolitis. Eur J Emerg Med2004;11(5):265-72 • Corneli HM,et al. Bronchiolitis: clinical characteristics associated with hospitalization and length of stay. Pediatr Emerg care 2012;28(2):99-103 • Stephens D, Lalani A, Schuh S. Predictors of major intervention in infant with bronchiolitis. Pediatr Pulmonol2009;44(4):358- 63 • Luo Z, Fu Z, Liu E ,et al. Nebulized hypertonic saline treatment in hospitalized children with moderate to severe viral bronchiolitis. Clin Microbiol Infect2011;17(12):1829-33 • Wu P, Hartert TV. Evidence for a causal relationship between respiratory syncytial virus infection and asthma. Expert Rev Anti Infect Ther2011;9(9):731-45 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 19
  20. 20. Dreamstime.com 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 20

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