This document provides information on bronchiolitis, including its definition, epidemiology, etiology, risk factors, clinical presentation, diagnostic criteria, treatment and management, disease course, and prevention. Some key points include: - Bronchiolitis is defined as an acute inflammation of the small airways caused primarily by viral infections like RSV. It commonly affects infants under 1 year old. - Clinical presentation includes cough, wheezing, respiratory distress, and hypoxemia. Diagnosis is usually clinical without need for testing in uncomplicated cases. - Treatment is generally supportive with supplemental oxygen and fluids. Nebulized bronchodilators may help in some cases. Antibiotics are not effective as

1. DR MAHTAB
MBBS,DCH,DNB
JAMIA HAMDARD, NEW DELHI
BRONCHIOLITIS(RECENT ADVANCES)

2. BRONCHIOLITIS IS ACUTE
INFLAMMATION,EDEMA AND NECROSIS
OF EPITHELIAL CELLS LINING SMALL
AIRWAYS,INCREASED MUCOUS
PRODUCTION AND BRONCHOSPASM.
AN IMP CAUSE OF MORBIDITY IN
INFANT AND CHILDREN
INTRODUCTION AND DEFINITION

3. A PEAK INCIDENCE BETWEEN TWO - SIX
MONTH OF AGE .
EPIDEMICS DURING WINTER MONTHES
OUTBREAKS, OCCUR FROM SEPTEMBER
TO MARCH.
EPIDEMIOLOGY

4. ETIOLOGY
PREDOMINENTLY VIRAL DISEASE
RSV RESPIRATORY SYNTIAL VIRUS >50%
OTHER VIRUS PARAINFLUENZA,ADENO
VIRUS,INFLUENZA,RHINOVIRUS,BOCA
VIRUS,CORONA VIRUS,ENTEROVIRUS
.NO EVIDENCE OF BACTERIAL CAUSE OF BROCHIOLITIS

5. RISK FACTOR/CLINICAL PRESENTATION
BOYS>
NOT BREAST FEED
LIVE IN CROWDED CONDITION
YOUNG MOTHER ,MOTHER SMOKE
DURING PREGNENCY
ANATOMICAL AND IMMUNOLOGICAL
FACTOR PLAY IMPORTANT ROLE IN
SEVERITY OF DISEASE

6. CLINICAL MANIFESTATION
HISTORY ONSET,DURATION,ASSOCIATED FACTOR
BIRTH HISTORY; WEEKS OF GESTATION,NICU
ADMISSON,H/O INTUBATION AND O2 REQUIREMENT
MATERNAL History - INFECTION OF HERPES,HIV AND
PRENATAL SMOKE EXPOSURE
F/H OF CYSTIC FIBROSIS,IMMUNODEFICIENCY,ASTHMA IN
1ST DEGREE RELATIVES,
SOCIAL H/O ; SMOKER HISTORY IN HOME,DAY CARE
EXPOSURE,PETS AND TB EXPOSURE,DUST AND MOLD AND
COCKROACH

7. Typically present with viral upper
respiratory prodrome ; rhinorrhea, cough,
low grade fever onset of these symptom is
acute within 1-2 days of these prodromal
symptom these cough worsen child
develop rapid respiration ,chest retraction
and wheezing .infant may show irritability
poor feeding and vomiting in majority of
cases disease remain mild and recovery
start in 3-5 days.

8. PHYSICAL EXAMINATION
VITALS ;RR,SPO2
EXAMINATION WHEEZE DOMINANT,MIGHT
Have FINE CRACKLES ON AUSCULTATION,
PROLONGATION OF EXPIRATORY PHASE OF
BREATHING,EXPIRATORY WHISTLING
SOUND EXPIRATORY TIME MAY BE PROLONG
TACHYPNEA DOESNOT ALWAYS CORRELATE
DEGREE OF HYPOXIA OR HYPERCARBIA SO
PULSEOXIMETRY AND DETERMINATION OF
CO2 IS ESSENTIAL

9. SIGN OF RESPIRATORY DISTRESS
;TACHYPNOEA,INCREASED
RESPIRATORY EFFORT,NASAL
FLARING,TRACHEAL TUGGING,SCR
OR ICR OR EXCESSIVE USE OF
ACCESSORY MUSCLE
COMPLETE OBSTRUCTION MAY
LED TO BARELY AUDIBLE BREATH
SOUND
HYPERINFLATION MAY LED TO
PALPATION OF SPLEEN AND LIVER

10. DISEASE COURSE AND PREDICTION OF SEVERITY
BRONCHIOLITIS USUALLY IS A SELF –LIMITED DISEASE.
ALTHOUGH SYMPTOMS MAY PERSIST FOR SEVERAL WEEKS, THE MAJORITY OF
CHILDREN WHO DO NOT REQUIRE HOSPITAL ADMISSION MAY CONTINUE TO
HAVE LOW GRADE SYMPTOMS UP TO 4 WEEKS .
IN PREVIOUSLY HEALTHY INFANTS, THE AVERAGE LENGTH OF HOSPITALIZATION IS
THREE TO FOUR DAYS.
THE COURSE MAY BE PROLONGED IN YOUNGER INFANTS AND THOSE WITH CO-
MORBID CONDITION .

11. PREDICTOR OF SEVERE BRONCHIOLITIS
A. HOST RELATED RISK FACTOR -
PREMATURITY, IOW BIRTH WEIGHT, AGE LESS THAN 6 TO 12
WEEKS, CHRONIC PULMONARY DISEASE ,CONGENITAL
HEART DISEASE, IMMUNODEFICIENCY
B. ENVIRONMENTAL RISK FACTOR - HAVING OLDER
SIBLINGS ,PASSIVE SMOKE ,HOUSEHOLD CROWDING, CHILD
CARE ATTENDANCE,
C. CLINICAL PREDICTORS - TOXIC OR ILL APPEARANCE,
OXYGEN SATURATION <95 PERCENT BY PULSE OXIMETRY
WHILE BREATHING ROOM AIR, RESPIRATORY RATRE 70
BREATHS PER MINUTE, MODERATE /SEVER CHEST
RETRACTION, ATELECTASIS ON CHEST RADIOGRAPH.

12. DIAGNOSTIC CRITERIA
DIAGNOSIS IS CLINICAL
DIANOSIS IS CLINICAL DIAGNOSIS,PARTICULARLY IN PREVIOUSLY HEALTHY INFANT
PRESENTING WITH FIRST TIME WHEEZING EPISODE DURING COMMUNITY OUTBREAK
CXR PA,LATERAL VIEW REQUIRED IN ACUTE RESPIRATORY DISTRESS NOT IN UNCOMPLICATED
BRONCHIOLITIS .INFILTRATE ARE MORE OFTEN IN <93%SPO2 OR GRUNTING,DECREASED
BREATH SOUND ,PROLONG INSPIRATORY AND EXPIRATORY RATIO AND CRACKLES
CXR MAY REVEAL HYPERINFLATED LUNG,PATCHY ATELECTASIS,PERIBRONCHIAL
THICKENINHG
A TRIAL OF BROCHODILATOR IS DIAGNOSTIC AND AS WELL AS THERAPEUTIC REVERSE
CONDITION AS ASTHMA DOESN’T EFFECT FIXED OBSTRUCTION,WORSE CONDITION BY
TRACHEAL OR BRONCHIAL MALACIA
CBC ; WBC AND DIFFERENTIAL USUAL NORMAL
VIRAL TESTING ;PCR,RAPID IMMUNOFLUORESCENCE OR VIRAL CULTURE IS HELPFUL IF
DIAGNOSIS IS UNCERTAIN OR F0R EPIDEMIOLOGICAL PURPOSE,NOT REQUIRED IN
UNCOMPLICATED BRONCHIOLITIS
MEASUREMENT OF LDH CONCENTRATION IN NASAL WASH FLUID HAS BEEN PROPOSED AS AN
OBJECTIVE INDICATOR OF BRONCHIOLITIS SEVERITY

13. SUMMARY OF INTERVENTION FOR MN OF
ACUTE BRONCHIOLITIS
• Intervention with clear evidence of effectiveness-
• supportive care supplement o2 and ivfluid
• Intervention which are possibily effective-
• nebulized bronchodilators(epinephrine and salbutamol)
• Nebulised hypertonic saline
• Dexamethasone and inhaled epinephrine
• Intervention which are possibily effective in most severe cases
• Cpap,surfactant,heliox,aerosilised ribavirin
• Intervention which are possibly ineffective
• Oral bronchodilators,montelukast,a
• Inhaled/systemic corticosteroid
• Chest physiotherapy
• Antibiotics
• Steam inhalation
• RSV POLYCLONAL IgG/Palivizumab
• Inhaled furesemide/inhaled interferonalfa2a/inhaled recombinant human Dnases

14. TREATMENT
INFANT WITH WHEEZING
ADMINISTER ALBUTROL AEROSOL
AND OBSERVE RESPONSE
IN <3 YR MDI+MASK+SPACER
BROCHIOLITIS WITH RD HOSPITALISED
RISK FACTOR FOR SEVERE DISEASE IS
AGE <12WK,PT BIRTH,UNDERLYING
COMORBIDITY LIKE
CVD,PULMONARY,NEUROLOGIC,OR
IMMUNOLOGIC

15. FLUID ADMINISTRATION
INCREASED RISK OF DEHYDRATION BECAUSE
OF THEIR INCREASED NEEDS RELATED TO
FEVER ,TACHYPNEA AND REDUCED ORAL
ACCEPTANCE .
CHILDREN HAVING DEHYDRATION OR
DIFFICULTY IN FEEDING SAFELY BECAUSE OF
RESPIRATORY DISTRESS SHOULD BE GIVEN
INTERVENOUS FLUIDS.
INCREASED RISK OF FLUID RETENTION AND
SUBSEQUENT PULMONARY CONGESTION DUE
TO EXCESSIVE ANTIDIURETIC HORMONE
PRODUCTION , SO URINE OUTPUT SHOULD BE
CAREFULLY MONITORED.

16. NASAL DECONGESTION
SALINE NOSE DROPS AND CLEANING OF NOSTRILS BY
GENTLE SUCTION MAY HELP TO RELIEVE NASAL BLOCK .
B. RESPIRATORY SUPPORT
SUPPLEMENTAL OXYGEN
HUMIDIFIER OXYGEN SHOULD BE ADMINISTERED TO HYPOXEMIC INFANTS BY
ANY TECHNIQUE (NASAL CANNULA, FACE MASK ,ORHEAD BOX)
SUPPLEMENTAL OXYGEN IS INDICATED IF SPO2 FALLS PERSISTENTLY BELOW 90%
IN PREVIOUSLY HEALTHY INFANTS. DISCONTINUED IF SPO2 IS AT OR ABOVE 90%
AND THE INFANT IS FEEDING WELL AND HAS MINIMAL RESPIRATORY DISTRESS.

17. CPAP; IN SEVERE BRONCHIOLITIS
EARLY INTERVENTION IN FORM OF CPAP
HAS BEEN USED TO PREVENT
MECHANICAL VENTILATION
MECHANICAL VENTILATION;INDICATION
WORSENING OF RESPIRATORY
DISTRESS,LISTLESSNESS AND POOR
PERIPHERAL
PERFUSION,APNEA,BRADYCARDIA AND
HYPERCARBIA

18. CHEST PHYSIOTHERAPY
CLEAR EXCESSIVE RESPIRATORY
SECRETION,THUS HELP TO REDUCE AIRWAY
RESISTENCE
CHEST PHYSIOTHERAPY DISCOURAGED IN
CHILDREN BCZ IT MAY INCREASE IN DISTRESS
AND IRRITABILITY OF ILL INFANTS

19. BROCHODILATOR
USE DEBATABLE,
STUDY SHOW BROCHODILATOR OTHER THAN
EPINEPHRINE INCLUDED
SALBUTAMOL,TERBUTALINE,IPRATROPIUM
HAVING NO SIGNIFICENT IMPROVEMENT IN
OXYGENATION,HOSPITALISATION RATE AND
DURATION OF HOSPITALISATION
EPINEPHRINE WAS ASSOCIATED WITH
DECREASED LENGHTH OF STAY COMPARED TO
SALBUTAMOL
ORAL BROCHODILATOR SHOULD NOT BE USED
IN MANAGEMENT OF BROCHIOLITIS

20. STEROID
SYSTEMIC CORTICOSTEROID
ORAL ,IM OR IV,AND INHALE CORTICOSTERIOD FOR ACUTE BRONCHOLITIES IN CHILDREN.
RCT SHOWES NO SIGNIFICANT DIFFERENCE IN HOSPITAL ADMISSION ,LENGTH OF STAY CLINICAL
COURSE OF AFTER 12 HOURS OR HOSPITAL READMISSION RATE
INHALE CORTICOSTEROID
USE OF ICS DURING ACUTE BRONCHIOLITIS HAS BEEN PROPOSED TO PREVENT POST-BRONCHIOLITIC
WHEEZING. A SYSTEMATIC REVIEW OF 5 STUDIES.SHOWS
THERE IS NO EVIDENCE FOR USE OF INHALED CORTICOSTEROIDS TO PREVENT OR REDUCE POST –
BRONCHIOLITIS WHEEZING AFTER RSV BRONCHIOLITIS.

21. ANTIBIOTICS
UNNECESSARY USE OF ANTIBIOTICS IS
ASSOCIATED WITH INCREASED COST OF T/T
,ADVERSE REACTION AND DEVELOPMENT OF
BACTERIAL RESISTENCE IN COMMUNITY AND
GEOGRAPHIC REGION

22. HYPERTONIC SALINE
AEROSOLIZED HYPERTONIC SALINE HAS BEEN PROPOSED
AS THERAPEUTIC MODALITY IN ACUTE BRONCHIOLITIS.BY
DECREASING EPITHELIAL EDEMA,IMPROVE ELASTICITY AND
VISCOSITY OF MUCOUS THUS IMPROVING AIRWAYS
CLEARENCE.
POTENCIAL SE POTENCIALLY ACUTE BROCHOSPASM
A RECENT RCT HIGH VOLUME NORMAL SALINE IS AS
EFFECTIVE AS 3%NS IN MILD BROCHIOLITIS.

23. INHALED FUROSEMIDE
IT MAY IMPROVE OUTCOME BY ACTING
ON AIRWAYS SMOOTH MUSCLE,AIRWAYS
VESSEL,ELECTROLYTE AND FLUID
TRANSPORT ACROSS RESPIRATORY
MUCOSA AND REDUCING AIRWAYS
INFLAMMATION
ONE RCT SHOW NO SIGNIFICENT
CLINICAL EFFECTS

24. STEAM INHALATION
STEM INHALATION/MIST
INHALATION PROP0SED TO
IMPROVE AIRWAYS CLEARENCE OF
MUCOUS AND OUTCOME OF ACUTE
BRONCHIOLITIS
I/V/O LIMITED STUDIES REQUIRE
MORE STUDIES TO
PROVE/DISAPPROVE STEAM
INHALATION IN ACUTE
BRONCHIOLITIS

25. LEUKOTRIENE RECEPTOR ANTAGONIST
IN T/T OF BRONCHIOLITIS HAVING CONFLICTING RESULT ,MANY RCT
SHOWING NOT GETTING BENEFIT SO CURRENTLY NOT
RECOMMENDED FOR T/T
HELIOX
MAY IMPROVE ALVEOLAR VENTILLATION AS IT FLOW THROUGH
AIRWAYS WITH LESS TURBULANCE AND RESISTENCE,THIS REDUCE
WORK OF BREATHING AND IMPROVE OXYGENATION IN RESPIRATORY
ILLNESS WITH MODERATE TO SEVERE RESPIRATORY OBSTRUCTION
INCLUDING ACUTE BRONCHIOLITIS
BUT MORE STUDIES REQUIRE FOR THIS AS PREVIOUS STUDIES IT
DIDN’T EFFECT NEED OF INTUBATION AND MECHINACHAL
SUPOPORT AND HOSPITAL STAY

26. ANTI VIRAL
RIBAVARIN;SYNTHETIC NUCLEOSIDE ANALOGUE ACT BY
INHIBITING VIRAL PROTEIN SYNTHESIS,HAVING BROAD
ANTIVIRAL ACTIVITY DELIVERED AS SMALL PARTICLE
AEROSOL 18-20HR/DAY ,EXPENSIVE,TERATOGENIC EFFECT
TO CARE GIVER
FEW RCT SHOW NO IMPROVEMENT IN CLINICAL OUTCOME
MAY CONSIDERED IN HIGH RISK INFANT
(IMMUNOCOMPROMISED INFANT AND HEMODYNAMICALLY
SIGNIFICENT CARDIOPULMONARY DISEASE)
NO OTHER ANTIVIRAL IS CURRENTLY APPROVED

27. SURFACTANT
SEVERE BRONCHIOLITIS MAY HAVE
SECONDARY SURFACTANT
DEFICIENCY,A META ANALYSIS
SHOW USE OF SURFACTANT
SIGNIFICIENTLY REDUCE
MECHANICAL VENTILLATION AND
ICU STAY
BUT IT NEED LARGER TRIAL AND
FURTHER STUDY

28. PREVENTION OF BRONCHIOLITIS
PREVENTION MEASURE INCLUDE GENERAL MEAURE AND SPECIAFIC
MEASURE
GENERAL MEASURE;A CAREFUL BARRIER NURSING PREVENT CROSS
INFECTION IN HOSPITAL OR ICU
IMMUNOPROPHYLAXIS;
PASSIVE IMMUNOPROPHYLAXIS BEFORE RSV SEASON REDUCE
ADMISSON RATE BY POLYCLONAL OR MONOCLONAL ANTIBODIES
POLYCLONAL ANTIBODIES;RSV IgG IS PREPARED FROM POOLED
PLASMA,GIVEN IV BEFORE SEASON DISADVANTAGE IS IV
ACCESS,BLOOD BORNE INFECTION

29. MONOCLONAL ANTIBODIES
PALIVIZUMAB IS A HUMANIZED MOUSE IGG1 MONOCLONAL ANTIBODY DIRECTED
AGAINST SITE A AND F GLYCOPROTEIN OF RSV
INDICATION FOR USE OF PALIVIZUMAB
1. CHILDREN YOUNGER THAN 24 MONTHES OF AGE WITH CHRONIC LUNG DISEASE OF
PREMATURITY WHO HAVE REQUIRED MEDICAL THERAPY FOR CLD WITHIN 6 MONTH
OF THE AGE.
2. INFANTS BORN AT 28 WEEKS OF GESTATION OF EARLIER WHO ARE YOUNGER THAN
12 MONTHS OF AGE AT THE START OF THE RSV SEASON.
3.INFANTS BORN AT 29 TO 32 WEEKS OFGESTATION WHO ARE YONGER THAN 6
MONTH OF THE AGE AT THE START OF THE RSV SEASON.
OF RSV.

30. 4.INFANTS BORN BETWEEN 32 AND 35 WEEKS OF
GESTATION , WHO Are younger than 6 months of age at
the start of rsv season and have 2 or more of the
following risk factor; child care attendance, school aged
siblings , exposure to environmental air pollutants ,
congenital abnormalities of the airways, or severe
neuromuscular disease
5. children who are24 months of the age or younger
than with hemodynamically significant cyanotic and a
cyanotic congenital heart disease. This includes infants
who are receiving medication to control congestive
heart failure , infants with moderate to severe
pulmonary hypertension , and infants with cyanotic
heart disease.

31. CONCLUSION
• COMMON RESPIRATORY TRACT INFECTION IN INFANCY
• COMMONEST ETIOLOGY IS RSV
• DIAGNOSIS IS CLINICAL
• LAB INVESTIGATION HAVING LIMITED ROLE DIAGNOSIS AND
MANAGEMENT
• CURRENT MN IS SUPPORTIVE;HYDRATION,SUPPLIMENT O2,MECHINACHAL
WHEN REQUIRED
• NO SPECIAFIC T/T FOR BRONCHIOLITIS
• IT IS APPROPRIATE TO ADMINISTER NEBULIZED EPINEPHRINE
ORSALBUTAMOL IF GET BENEFIT CONTINUE OTHERWISE STOP
• CORTICOSTEROID IS INEFFECTIVE
• IN ABSENCE OF EFFECTIVE VACCINE PALIVIZUMAB IS CONSIDERED FOR
PASSIVE IMMUNOPROPHYLAXIS IN HIGH RISK INFANT BEFORE SEASON

32. THANK YOU
THANK YOU HIMSR