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Bronchiolitis
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9. Bronchiole: A tiny continuation of the bronchi & connects to
the alveoli. Resp. bronchioles the final branches
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13. A clinical scenario
ā¢ Age: 5mo, formula fed, with UR catarrh (rhinitis, -/+
cough, LGF x3d). Then suddenly developed fast br.,
tachycardia, chest indrawing, wheezing. Still
playful, ~normal feeding
What is the Dx?
15. At the end of this session you will learn
ā¢ Bronchiolitis is a very common viral (RSV) ARI
ā¢ Commonest LRTI & pneumonia in infants (3-9mo)
ā¢ Mostly mild: LGF & cold; self-limited
ā¢ Prognosis is excellent
ā¢ Needs only supportive Rx: mostly no ABT
ā¢ It is uncommon in breastfed babies
ā¢ Can cause hyperactive airways
ABT: antibiotic therapy LRT: lower resp. tract
16. INTRODUCTION
Bronchiolitis: inflammation of bronchioles with excessive
mucus & bronchospasm
ā¢ Common c/of hospitalization
ā¢ May be associated with significant MM
ā¢ Can cause Hyperactive/Reactive Airway:
ā Bronchospasm from allergy/infection
ā Mostly temporary
ā Not BA; but asthma-like syn.
ā May later become BA (child is old enough for bronchial
challenge test)
17. MICROBIOLOGY
ā¢ Typically viral: RSV: 80%
ā Influenza, parainfluenza A B C
ā Rhinovirus
ā Metapneumovirus
ā Coronavirus (SARS. MERS)
ā Bocavirus
ā¢ Occasionally M pneumoniae
18. RSV
Ubiquitous
ā¢ Seasonal
ā Temperate Southern H: May-Sep, peak May-July
ā ,, Northern H: Nov.- April, peak Jan-Feb
ā Tropical: rainy season
ā¢ 90% by 2y age have exposure
METAPNEUMOVIRUS
ā¢ Paramyxovirus; may co-infect with other viruses
ā¢ May cause pneumonia
PARAINFLUENZA: Usually type 3
20. INFLUENZA VIRUS
ā¢ Very similar to RSV or parainfluenza v. in CF
ā¢ Similar in distribution to RSV
BOCAVIRUS: May cause pertussis-like illness
RHINOVIRUS
ā¢ >160 serotypes! Mainly ācommon coldā
ā¢ Affects LRT in children with chr. LD
ā¢ Often co-infects with other viruses
CORONAVIRUS
ā¢ 2nd commonest c/of common cold
ā¢ Non-SARS types cause bronchiolitis
ā¢ SARS, MERS
21. EPIDEMIOLOGY
ā¢ Typically 3-9 mo
ā 60% <6 mo; 80% <1y. Not beyond 5y
ā¢ 60% of all LRTI in infants. 3% admission
Incidence: 31/1,000 infants
RSV in admitted pts.
ā¢ 40% of all LRTI in 1st y of life
ā¢ 20% of all LRTI in ļ£ 5 y ..
23. FACTORS FOR SEVERE B.
ā¢ Preterm, LBW, age: <6w
ā¢ Cystic fibrosis
ā¢ BA, Chr. LD or anatomical defects of airways
ā¢ Cardiac disease, kidney disease
ā¢ Immunodeficiency
ā¢ ENVIRONMENTAL: active/passive smoking, overcrowding,
child care centre, high altitude
24. CLASSICAL PRESENTATION
ā¢ Starts as URT catarrh: rhinitis, -/+ cough, LGF: 1-3d then:
ā fast br., tachycardia, chest indrawing, wheezing
ā¢ Mostly mild
ā¢ Full recovery: 2-8w
ā¢ No recurrence in RSV. If any, look for HD, BA, CF, etc.
25. PHYSICAL SIGNS
ā¢ Tachypnea: cut-offs
ā <60d 60 bpm (Preterm 70)
ā 2mo-12mo 50 ,,
ā 1y- 5y 40 ,,
ā¢ Vesicular br. with prolonged expiration, diffuse wheezes
and crackles
ā¢ ~Dehydration
ā¢ ~conjunctivitis or AOM
ā¢ ~cyanosis or apnea in young infants
26. S/of SEVERE DISEASE
Indication of admission: average stay: 3 d
ā¢ Age <3 mo.
ā¢ Toxic look, dehydrated, apneic spells
ā¢ RR: >70
ā¢ O2 <90% on room air; CO2 trapping
ā¢ Nasal flare (pneumonia)
ā¢ Atelectasis
ā¢ Poor feeding
ā¢ S/o HF
ā¢ 2y infx.
Parent unable to home care
27. Apnea in bronchiolitis
ā¢ 20% of admitted RSV Bronchiolitis in < 2-3 mo, prematurity
ā¢ May be the presenting symptom
ā¢ Recurrence rate 50%
ā¢ Mortality <2%
28. Dehydration in ARI
ā¢ Fever
ā¢ Fast br.
ā¢ Poor intake
ā¢ Vomiting
ā¢ Runny nose
ā¢ Parenteral diarrhea
29. DIAGNOSIS: Clinical
ā¢ Based on: h/o & PE
ā¢ Supported by CXR
ā¢ hyperinflation, flat diaphragm, air bronchograms,
peribronchial cuffing, patchy infiltrates, atelectasis
30. Air trapping. Peribronchial cuffing due to wall thickening. Minimal
focal atelectasis. Tubular heart. Flat low-set D
33. DX: VIRAL ISOLATION
ā¢ Generally not warranted. It rarely affects Rx/outcomes
ā it may decrease AB use; may stop spread
ā may help guide antiviral Rx
ā¢ Nasal aspirate: Ag detection; EM; FAB tests; culture & PCR
OTHER TESTS
Mostly in complications
ā¢ CBC: 2y infx.
ā¢ CRP: ā¦
ā¢ ABG to evaluate respiratory failure
ā¢ CXR for pneumonia, heart disease
34. DD
ā¢ BA
ā¢ Bronchitis/pneumonia
ā¢ Chr. lung D
ā¢ FB, GERD or aspiration
ā¢ Cong. HD or HF
ā¢ Vascular rings, bronchomalacia, complete tracheal rings or
other anomalies
COURSE
Depends on co-morbidities. Usually self-limited
ā wheezing may continue >1w
ā Anorexia & disturbed sleep may persist for 2-4w
35. DD: Bronchiolitis & Bronchitis
ā¢ Anatomical: bronchioles are very small & delicate airways
that lead to alveoli ("cul de sacsā for gas exchange).
Bronchi are much larger "pipes" immediately after the
trachea
ā¢ Bronchiolitis is an infant to early childhood illness
ā¢ Bronchitis is more seen in teens & adults
ā¢ Cigarette smoke is a predisposing factor for both d.
ā¢ Both are viral inf. & do not require ABT
ā¢ Bronchitis has more productive cough
36. TREATMENT: SUPPORTIVE CARE
ā¢ Clean airway with saline, correct dehydration
ā¢ Antipyretics SOS
ā¢ Humidified O2
ā¢ Mechanical ventilation for pCO2 >55 or apnea
ā¢ Monitor:
ā apnea, hypoxia
ā hydration, respiratory
failure, HF
37. CHEST PHYSIOTHERAPY
ā¢ Not recommended: no cl. improvement, nor reduces O2
need or shorten hospital stay
ā¢ May increase distress & irritability
FLUID ADMINISTRATION
Oral & IVF in dehydration
Monitor for fluid overload as SIADH may occur
BRONCHODILATORS: Not recommended
Consider in severe wheezing
Albuterol/racemic epinephrine may work; but SE
common: tachycardia, hypoxemia, tremor,
constipation, insomnia, etc.
Anticholinergics: No benefit
38. CORTICOSTERIODS
Not recommended
ā¢ May help in chr. LD or recurrent wheezing
ā¢ Prednisone, dexamethasone
ā¢ Inhaler: not helpful
RIBAVIRIN
ā¢ Not routinely recommended
ā¢ Very costly. May be useful in severe RSV
ā¢ Must be used early
ANTIBIOTICS: No routine ABT. Used in 2y bacterial infx.
(positive culture, AOM, Consolidation on CXR)
39. NON-STANDARD THERAPIES
ā¢ Heliox
ā helium & O2 decreases breathing work
ā only small benefit in limited patients
ā¢ RSV-IG or Palivizumab
ā no improvement in routine cases
ā¢ Surfactant
ā may decrease duration of mechanical ventilation or ICU
stay
40. DISCHARGE CRITERIA
ā¢ Normal RR
ā¢ Adequate feeding
ā¢ No supplemental O2
ā¢ Caretaker educated & confident; capable of bulb suctioning
PROGNOSIS: Excellent
ā¢ MR <1% in admitted children
ā¢ 80% deaths in infants
41. COMPLICATIONS
Highest in high-risks
ā¢ Apnea: in young infants
ā¢ Respiratory failure: 15%
ā¢ 2y bacterial inf.: 1%
ā¢ Collapse, consolidation
ā¢ Otitis media
Prognosis
ā¢ Excellent
ā¢ Death: <2% (2y bacterial pn. & interstitial pn.)
42. CXR: hyperinflation with flattened diaphragm & bilateral atelectasis in
the R apical & L basal regions in a 16d-old with severe bronchiolitis
43. PREVENTION
ā¢ Hand washing; avoid viral contact, smoking
ā¢ New vaccine under trials
ā¢ Hyperimmune Ig
ā¢ MAB: palivizumab
ā 55% less admission for preterm/chr. LD & 45% for cong.
HD. Given monthly through RSV season
ā¢ Influenza vaccine
44. BRONCHIOLITIS & B.A.
ā¢ RSV is a risk for recurrent wheeze (40%) & reduced FEV1
up to age 11y
ā¢ Association of RSV with later BA
ā may be a predisposition factor
45. Bronchiolitis obliterans (BO)
ā¢ Or obliterative/constrictive B. usually adenovirus.
Rare but fatal (irreversible): fibrosis +/or
inflammation: block
B. obliterans organizing pn. (BOOP) or cryptogenic
organizing pn. (COP)
ā¢ Non-infx.; often in Rh A, or with amiodarone
ā¢ CF & CXR show pn. But no response to ABT
48. DH: Asymmetry of L hemidiaphragm. Gas-filled organs or a NGT within the chest
confirm DX. confused in diaphragmatic paralysis or after lung reduction surgery
50. Pneumoperitoneum: mostly perforation. Erect XR: air crescent under D. Sometimes, a double-
wall, or Rigler's, sign can be seen which refers to internal & external air outlining the intestinal
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52. A tension PT: air under pressure: one-way valve. tracheal shift, hyperresonance & no
BS, distended neck veins, hypoxia. affected lung collapses; widened IC spaces
53. Pneumomediastinum. Most commonly follows injury to esophagus/adjacent alveoli. CXR: free air may
outline anatomic structures. Common findings are a thin line of radiolucency that outlines the cardiac
outline, vertically oriented streaks of air in the mediastinum, a double bronchial wall sign, or lucency
around the right pulmonary artery, the "ring around the artery" sign. Air is most easily detected
retrosternally on lateral CXR. Air is fixed in a pneumomediastinum & does not rise to the highest point
54. Airway FB, most often in children; the
commonest site is R main B due to its being
posterior, straighter, & wider. Indirect s/of
ingestion include focal overinflation with partial
obstruction or collapse in complete obstruction.
See a radiopaque object lodged in the R main
bronchus of a child
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56. Aspiration pn.: aspirated flora or gastric contents. A. pneumonitis: from chemical
insult. CXR: bilateral opacities in the middle or lower zones. Acute: infiltrates or lobar
57. Rt. middle lobe collapse with obliteration of R heart border
59. MCQs
ā¢ RSV is the commonest c/of bronchiolitis
ā¢ ABT is usually required in B
ā¢ Most B are later associated with BA
ā¢ In EBF babies B is rare
ā¢ Anticholingergic nebulization is beneficial in B
ā¢ B is usually a killer D
ā¢ SARS/MERS is caused by RSV
ā¢ Antiviral Rx is beneficial in all B cases