Dr Meenal Kapoor
Indraprastha Apollo Hospital
New Delhi

www.dnbpediatrics.com
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Acute inflammation, edema and necrosis of
epithelial cells lining small airways, increased
mucus production, and bro...
www.dnbpediatrics.com


Viral infection
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Respiratory syncytial virus (RSV)- MC (50-80%)
Rhinovirus – 2nd mc
Parainfluenza viruses...
Viral inoculation
viral replication in the epithelial cells of the
airway
Cell lysis
Necrotic cells slough off and release...



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Most common lower respiratory tract
infection in infants
Age - < 2 years, peak incidence btw 2-6 months
Winter m...
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Acute onset
Prodrome - rhinorrhea, cough, low grade fever
SYMPTOMS ◦ Rapid respiration
◦ Irritability, poor...
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
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Self-limited disease
Symptoms may persist for several weeks
In previously healthy infants - the average length o...
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Host Related Risk Factors
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◦
◦
◦

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Environmental Risk Factors
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Prematurity, LBW
Age < 6 to 12 weeks
Chronic p...
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Diagnosis - clinical
Based on history and physical examination
Laboratory tests and CXR – not required, do
not a...
 Hyperinflation

 Peribronchial

thickening

 Patchy

atelectasis (from airway
narrowing and mucus plugging)
www.dnbped...
www.dnbpediatrics.com



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Not routinely indicated
Abnormalities in TLC and DLC do not predict serious
bacterial infection in infants and you...


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Identification of viral agents does not affect
management
In the hospital setting, determining the responsi...
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SUPPORTIVE CARE

Mainstay of treatment

(A) FLUIDS :–
 Increased risk of dehydration because of their increased
need...
(B) NASAL DECONGESTION
 Saline nose drops and cleaning of nostrils by gentle
suction
(C) RESPIRATORY SUPPORT
 Supplement...
BRONCHODILATORS
 Routine use of bronchodilators in the
management of bronchiolitis is debatable
 Consider a trial of bro...
HYPERTONIC SALINE
 Aerosolized hypertonic saline - therapeutic
modality for acute bronchiolitis.
 Acts by
◦ Decreasing e...


SYSTEMIC CORTICOSTEROIDS
◦ No significant differences found in hospital admission rate, length of
stay, clinical score ...
1.
2.

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3.

4.

CPAP
Surfactant - In severe bronchiolitis there may
be secondary surfactant insufficiency
suggesting pos...
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-

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Aerosolized Ribavirin
synthetic nucleoside analogue
acts by inhibiting viral protein synthesis
delivered as a s...
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Oral bronchodilators
Montelukast
Inhaled/Systemic corticosteroids
Chest physiotherapy
Antibiotics
Steam ...
General measures
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Barrier nursing measures to prevent
nosocomial infections

Specific measures - Immunoprophylaxis
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...
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Contain RSV IgG
Prepared from pooled plasma
I/V route
Before RSV season
Disadvantages –
◦ need for I/V access;
...
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

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Produced by recombinant DNA technology
Targets the fusion protein of RSV, inhibiting
its entry into the cell an...
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I/M
Dose - 15 mg/kg monthly during the RSV season
Maximum of 5 doses is generally sufficient
prophylaxis duri...
Infants Eligible for a
Maximum of 5 Doses

Infants Eligible for a
Maximum of 3 Doses

•Infants younger than 24
months of a...



Motavizumab ( 2nd generation mAb)
Numax-YTE ( 3rd generation)
Under clinical trials

www.dnbpediatrics.com
www.dnbpediatrics.com
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  1. 1. Dr Meenal Kapoor Indraprastha Apollo Hospital New Delhi www.dnbpediatrics.com
  2. 2.   Acute inflammation, edema and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm (AAP 2006) First episode of wheezing in a child < 12-24 months with physical findings of a viral respiratory infection and has no other explanation for the wheezing, such as pneumonia or atopy www.dnbpediatrics.com
  3. 3. www.dnbpediatrics.com
  4. 4.  Viral infection ◦ ◦ ◦ ◦ ◦ ◦ ◦ Respiratory syncytial virus (RSV)- MC (50-80%) Rhinovirus – 2nd mc Parainfluenza viruses Influenza virus Adenovirus Coronavirus Newer respiratory viruses - human metapneumovirus (hMPV), human bocavirus (HBoV) www.dnbpediatrics.com
  5. 5. Viral inoculation viral replication in the epithelial cells of the airway Cell lysis Necrotic cells slough off and release inflammatory mediators Airway inflammation and edema Increased mucus production Narrowing and obstruction of the bronchioles Increased resistance to air flow, decreased ventilation and air trapping www.dnbpediatrics.com
  6. 6.     Most common lower respiratory tract infection in infants Age - < 2 years, peak incidence btw 2-6 months Winter months In India - September to March www.dnbpediatrics.com
  7. 7.       Acute onset Prodrome - rhinorrhea, cough, low grade fever SYMPTOMS ◦ Rapid respiration ◦ Irritability, poor feeding SIGNS – ◦ Tachycardia and tachypnea ◦ Wheeze, Crackles , grunting ◦ Retractions ◦ Cyanosis, impaired perfusion ◦ Hyper-resonant chest on percussion Pulse oximetry Other associated problems - conjunctivitis, otitis media, pharyngitis www.dnbpediatrics.com
  8. 8.     Self-limited disease Symptoms may persist for several weeks In previously healthy infants - the average length of hospitalization is 3 - 4 days Prolonged course – ◦ Younger infants ◦ Comorbid conditions (e.g., chronic lung disease) www.dnbpediatrics.com
  9. 9.  Host Related Risk Factors ◦ ◦ ◦ ◦ ◦  Environmental Risk Factors ◦  Prematurity, LBW Age < 6 to 12 weeks Chronic pulmonary disease Hemodynamically significant congenital heart disease Immunodeficiency Having older siblings, Passive smoke, Household crowding Clinical Predictors ◦ Toxic look, SpO2 <95% on room air, RR – 70/min, Moderate/Severe chest retractions, Atelectasis on CXR www.dnbpediatrics.com
  10. 10.     Diagnosis - clinical Based on history and physical examination Laboratory tests and CXR – not required, do not alter treatment decisions CXR ◦ If the diagnosis is in doubt ◦ co-morbidity like chronic lung disease or heart disease is suspected ◦ there is no improvement ◦ child severely ill www.dnbpediatrics.com
  11. 11.  Hyperinflation  Peribronchial thickening  Patchy atelectasis (from airway narrowing and mucus plugging) www.dnbpediatrics.com
  12. 12. www.dnbpediatrics.com
  13. 13.    Not routinely indicated Abnormalities in TLC and DLC do not predict serious bacterial infection in infants and young children hospitalized with lower respiratory tract infection due to RSV Measurement of lactate dehydrogenase (LDH) concentration in the nasal-wash fluid ◦ proposed as an objective indicator of bronchiolitis severity ◦ increased values (suggestive of a robust antiviral response) have been shown to be associated with decreased risk of hospitalization ◦ Needs further validation www.dnbpediatrics.com
  14. 14.      Identification of viral agents does not affect management In the hospital setting, determining the responsible virus may help to avoid unnecessary antibiotic use Available tools - Antigen detection, Immunofluorescence, PCR, and culture of respiratory secretions obtained by nasal wash or nasal aspirate. New techniques - real-time polymerase chain reaction(PCR), nested PCR, and multiplex PCR PCR – most sensitive www.dnbpediatrics.com
  15. 15.   SUPPORTIVE CARE Mainstay of treatment (A) FLUIDS :–  Increased risk of dehydration because of their increased needs (related to fever and tachypnea) and reduced oral acceptance  Intravenous fluids  Children who can tolerate enteral feedings - small frequent feedings or orogastric or nasogastric feedings  Children with bronchiolitis are also at an increased risk of fluid retention (and subsequent pulmonary congestion) www.dnbpediatrics.com
  16. 16. (B) NASAL DECONGESTION  Saline nose drops and cleaning of nostrils by gentle suction (C) RESPIRATORY SUPPORT  Supplemental oxygen  CPAP ----------- inconclusive evidence  Mechanical ventilation - clinical deterioration (worsening respiratory distress, listlessness, and poor peripheral perfusion), apnea/ bradycardia/ hypercarbia www.dnbpediatrics.com
  17. 17. BRONCHODILATORS  Routine use of bronchodilators in the management of bronchiolitis is debatable  Consider a trial of bronchodilator with careful monitoring.  Salbutamol inhalation (personal or family history of atopy or asthma)  Epinephrine inhalation  Further doses of either medications continued only on documentation of improvement www.dnbpediatrics.com
  18. 18. HYPERTONIC SALINE  Aerosolized hypertonic saline - therapeutic modality for acute bronchiolitis.  Acts by ◦ Decreasing epithelial edema ◦ improving elasticity and viscosity of mucus ◦ improving airway clearance  Unanswered questions - optimal volume, frequency of administration and effective device www.dnbpediatrics.com
  19. 19.  SYSTEMIC CORTICOSTEROIDS ◦ No significant differences found in hospital admission rate, length of stay, clinical score after 12 hours, or hospital readmission rate ◦ Hence, it is recommended not to use glucocorticoids  CORTICOSTEROIDS + EPINEPHRINE ◦ Possible synergy ◦ Reduction in hospital admissions ◦ Still under evaluation  INHALED CORTICOSTEROIDS ◦ No evidence for use www.dnbpediatrics.com
  20. 20. 1. 2.  3. 4. CPAP Surfactant - In severe bronchiolitis there may be secondary surfactant insufficiency suggesting possible role of administration of exogenous surfactant Current evidence - potential use in acute severe bronchiolitis requiring mechanical ventilation Heliox Aerosolized Ribavirin www.dnbpediatrics.com
  21. 21.  - - - Aerosolized Ribavirin synthetic nucleoside analogue acts by inhibiting viral protein synthesis delivered as a small-particle aerosol for 18 to 20 hours per day in high risk infants (immunocompromised and/or hemodynamically significant cardiopulmonary disease) and in infants requiring mechanical ventilation www.dnbpediatrics.com
  22. 22.         Oral bronchodilators Montelukast Inhaled/Systemic corticosteroids Chest physiotherapy Antibiotics Steam inhalation RSV polyclonal immunoglobulin / Palivizumab Inhaled Furosemide/Inhaled interferon alfa2a / Inhaledrecombinant human DNase www.dnbpediatrics.com
  23. 23. General measures  Barrier nursing measures to prevent nosocomial infections Specific measures - Immunoprophylaxis   Polyclonal antibodies Monoclonal antibodies www.dnbpediatrics.com
  24. 24.      Contain RSV IgG Prepared from pooled plasma I/V route Before RSV season Disadvantages – ◦ need for I/V access; ◦ risk of transmission of blood-borne infections, ◦ possible interference with antibody response to routine immunization specifically live vaccines www.dnbpediatrics.com
  25. 25.     Produced by recombinant DNA technology Targets the fusion protein of RSV, inhibiting its entry into the cell and thereby preventing infection Reduces hospitalization rate in high risk infants but does not reduce mortality rates Expensive www.dnbpediatrics.com
  26. 26.      I/M Dose - 15 mg/kg monthly during the RSV season Maximum of 5 doses is generally sufficient prophylaxis during one season Once a child qualifies for prophylaxis, administration should continue throughout the RSV season and not stop at the point he or she reaches any certain age. Adv – ◦ Can be given with routine immunizations since it does not interfere with the immunologic response to vaccines ◦ Minimal S/E www.dnbpediatrics.com
  27. 27. Infants Eligible for a Maximum of 5 Doses Infants Eligible for a Maximum of 3 Doses •Infants younger than 24 months of age with chronic lung disease and requiring medical therapy •Infants younger than 24 months of age and requiring medical therapy for congenital heart disease •Preterm infants born at 31 weeks, 6 days of gestation or less •Certain infants with neuromuscular disease or congenital abnormalities of the airways •Preterm infants with gestational age of 32 weeks, 0 days to 34 weeks, 6 days with at least 1 risk factor and born 3 months before or during RSV season. www.dnbpediatrics.com
  28. 28.   Motavizumab ( 2nd generation mAb) Numax-YTE ( 3rd generation) Under clinical trials www.dnbpediatrics.com
  29. 29. www.dnbpediatrics.com

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