recent advances on bronchiolitis in children

2. Case
6 month old boy presented with runny nose , for 3 days and
breathing difficulty from last 2 days O/E temp 99f, R/R 60,
spo2 92% at room air there are ronchi and fine rales on chest
bilatery He is full vaccinated
Took treatment from local GP but symtoms worsen , he
advised chest xray and reffered the patient to you at 5th
day of illness with label of pneumonia .

4. Acute bronchiolitis
Dr. SHAHID RASHID
SENIOR REGISTRAR PAEDIATRICS
KMSMC & ALLIED HOSPITALS

5. Learning objectives
At the end of presentation,the audience will be able to :
• Enumerate its causes and risk factors
• Identify its clinical presentation
• When and what investigations to go for
• Learn how to provide in patient and outpatient care.
• Evidence based new recommendation for management of
bronchiolitis

6. Definition
Bronchiolitis is broadly defined as a clinical syndrome of
respiratory distress that occurs in children <2 years of age and is
characterized by upper respiratory symptoms (eg, rhinorrhea)
followed by lower respiratory infection with inflammation,
which results in wheezing and/or crackles (rales).
◦ -reference taken from nelson textbook of paeditrics 21st edition

7. RSV
>50%
Human
metapneumovir
us
Adeno
influnza
rhino
covid
19
mycoplasma ,
purtussis
Eitiology

8. RSV
• <12 months,
• lower respiratory tract disease,
• winter season,
• known circulation of RSV
• fever tends to be lower with respiratory syncytial virus (RSV) and
higher with adenovirus , Influenza virus ,

9. Clinical Clues to Differentiate Etiology

10. Bronchiolitis vs Pneumonia
• Consider a diagnosis of pneumonia if the baby or child has:
• high fever (over 39°C) and/or
• persistently focal crackles.

11. Bronchiolitis vs Asthama/ viral-induced wheeze
• persistent wheeze without crackles or
• recurrent episodic wheeze or
• a personal or family history of atopy.
Take into account that these conditions are unusual in children under
1 year of age

12. Natural History Bronchiolitis
• Typical illness with bronchiolitis begins with upper respiratory tract
symptoms, followed by lower respiratory tract signs and symptoms
on days 2 to 3, which peak on days 3 to 5 and then gradually
resolve.

13. Pathophysiology
-photo coutesy nelson textbook of
paediatrics 21st edition

14. Study Review on resolution of cough
• In a systematic review of four studies including 590 children with
bronchiolitis who were seen in outpatient settings and not treated with
bronchodilators
• the mean time to resolution of cough ranged from 8 to 15 days.
• 50 percent of patients within 13 days
• 90 percent within 21 days.
Department of Family Medicine, Box 354696, University of Washington, Seattle, WA
98195-4696, USA.
PubMed, DARE, and CINAHL (all to July 2012)

15. Risk factors
• Males>females
• Those exposed to second hand smoke
• Ones not breastfed
• Crowded conditions
• Infants of the mother who smoked during pregnancy
• Older family members
• -reference taken from nelson textbook of paeditrics 21st edition

16. Risk factors of bronchiolitis severity
• Age <6months(<3months)small Airways can’t accommodate mucosa edema
• Premature <37weeks
• Low birth weight
• Cardiopulmonary disease(CHD,CLD)
• Tachypnea
• Immuocompormised children
• Neurological disease
• Malnutrition
• -reference taken from uptodate

17. Clinical manifestation
Diagnosis depends on history and physical examination
• Tachycardia
• R/R40 to 80
• Mild conjunctivitis
• Otitis media
• Wheezing and respiratory rales
• Hypoxemia
• Cyanosis
• Apnea(in premature,younger than 2 moths)
• Increased work of breathing
• Scalene retraction
• Abdominal muscles
◦ reference taken from NHS PAEDITRIC GUIDELNES

18. Diagnostic evaluation:
• Diagnosis is mostly clinical.No invetigations are routinely
recommended.
Pulse oximetry
• CXR . Not recommended Do if
• 1.localizing signs
• 2. Cardiac murmur is detected
• 3. Unsure of diagnosis  pneumonia ,foreign body aspiration,
heart failure, vascular ring, aspiration pneumonia
• Urea and electrolytes if IV fluids are indicated
• Blood gas if saturations are, <92% in FiO2 0.5
• Blood cultures if temperature > 39C
• Cbc maybe normal(wbc and differential counts)

19. SEVERITY ASSESSMENT
• we consider severe bronchiolitis if any of the following present :
• ●Persistently increased respiratory effort (tachypnea; nasal flaring;
intercostal, subcostal, or suprasternal retractions; accessory muscle use;
grunting) as assessed during repeated examinations separated by at least
15 minutes
• ●Hypoxemia (SpO2 <95 percent)
• ●Apnea
• ●Acute respiratory failure
• We consider nonsevere bronchiolitis to be indicated by
the absence of all of the above

20. Management of bronchiolitis
Non Severe
• Out patient management
Severe
• In patient management

21. Management of Non Severe Bronchiolitis

22. The Goal of Treatment
• Relieve symptoms and provide supportive care
• Ensure hydration
• Suctioning: relives nasal congestion distress, improves work of breathing
and ability to feed
• maintenance of adequate hydration by encouraging more fluid
• Councel the mother about disease as well as Red flag signs and when to
return .
• Follow-up according to day of illness, usually within one to two days, may
occur by phone or at the office
• We generally don’t use pharmacologic interventions.

23. Criteria for admission
• Apnoea
• Underlying cardiac defects, especially large L to R shunt
• SaO2, < 92% in air
• Pre-existing lung diseases such as Chronic Lung Disease/Ex-Preterm/Cystic
Fibrosis
• Poor feeding
• Age <6 weeks
• Significant dehydration
• Re-attends A&E in <48 hrs
• Unsure of Diagnosis
◦ reference taken from NHS PAEDITRIC GUIDELNES

26. Management of Severe Bronchiolitis
Supportive care
• Respiratory support
• Supplemental oxygen
• Nasal suctioning
• Fluid Management
• Glucocorticoids
• Hypertonic saline Nebulization
• Adrenaline Nebulization
• Antiviral
• Bronchodilators
• Bronchodilators plus
glucocorticoids
• Palivizumab
• Heliox
• Leukotriene inhibitors
• Anti biotics

27. Respiratory support
Suctioning
.Supplemental oxygen to maintain oxygen 90-92 % via nasal cannula,
face mask, or head box
.HFNC
.CPAP
.Intubation

28. Nasal suctioning
• In a retrospective cohort study of 740 infants (2 to 12 months)
hospitalized with bronchiolitis, those who had three or four lapses of
mechanical suctioning of more than four hours had longer hospital
stay than those who had no lapses in suctioning

29. 'Interventions that are not
routinely recommended'

30. Bronchodilators
• Meta-analyses of randomized trials and systematic reviews suggest
that bronchodilators may provide modest short-term clinical
improvement but do not affect overall outcome, may have adverse
effects, and increase the cost of care.
• we suggest albuterol 0.15 mg/kg (minimum 2.5 mg; maximum 5 mg)
diluted in 2.5 to 3 mL normal (0.9 percent) saline and administered
over 5 to 15 minutes .
• In randomized trials, oral bronchodilators have neither shortened
clinical illness nor improved clinical parameters, but were associated
with adverse effects (eg, increased heart rate)
• PubMed

31. Glucocorticoid
• In a 2013 meta-analysis evaluating the use of systemic glucocorticoids (oral,
intramuscular, or intravenous) for acute bronchiolitis in children (0 to 24
months of age), no significant differences were found in hospital admission
rate, length of stay, clinical score after 12 hours, or hospital readmission rate
• In an observational study of 2479 children <2 years who had been hospitalized
for bronchiolitis and had a subsequent hospitalization for asthma,
administration of glucocorticoids during their hospitalization for bronchiolitis
was not associated with improved outcomes
• In randomized trials and meta-analysis, inhaled glucocorticoids
(budesonide, fluticasone, dexamethasone) have not been beneficial in
reducing symptom duration or readmission rates
• We do not recommend glucocorticoids in the management of a first episode of
bronchiolitis.
PubMed
TI
Pharmacologic treatment of bronchiolitis in infants and children: a systematic review.
AU
King VJ, Viswanathan M, Bordley WC, Jackman AM, Sutton SF, Lohr KN, Carey TS
SO
Arch Pediatr Adolesc Med. 2004;158(2):127

32. Bronchodilators plus glucocorticoids
• – We do not suggest combination therapy with bronchodilators plus
glucocorticoids for infants and children with a first episode of
bronchiolitis.
• Although a randomized trial suggested that administration of
nebulized epinephrine and oral dexamethasone in the emergency
department decreased the rate of hospitalization within one week of
the emergency department visit, the result was not significant when
adjusted for multiple comparisons

33. Conclusions: Clinical scores and oxygen saturation levels improved more rapidly in
the bronchodilator groups than in the placebo group up to 24 h, but these drugs
did not have a sufficient effect to change the natural course of the disease.

34. Nebulized hypertonic saline
• In the emergency department In a 2018 meta-analysis of eight randomized trials
evaluating administration of hypertonic saline in the emergency department, hypertonic
saline reduced the rate of hospitalization among children with bronchiolitis (risk ratio
0.77, 95% CI 0.62-0.96), but there was substantial heterogeneity
• For hospitalized children – For infants and children admitted to the hospital with
bronchiolitis, we suggest not routinely treating with nebulized hypertonic saline. In a
meta-analysis of 20 randomized trials (2350 participants) in children hospitalized with
bronchiolitis, length of stay was similar in the hypertonic saline and normal saline groups.
• meta-analysis of randomized trials concluded that nebulized hypertonic saline (with or
without epinephrine) may reduce length of stay, but the evidence is limited by
imprecision, risk of bias, and heterogeneity
• The 2015 NICE bronchiolitis guideline recommends against the use of
hypertonic saline in children with bronchiolitis [26]. The 2014 AAP clinical practice
guideline on the management of bronchiolitis indicated that clinicians "may administer
hypertonic saline to infants and children hospitalized for bronchiolitis" [1].

35. Antimicrobial therapy
Antibiotics—only in babies <6 weeks old with a temperature >39C, mycoplasma ,
unsure of diagnosis (suspected pneumonia ) or in Cystic fibrosis patients
• Antibiotics should not be used routinely in the treatment of bronchiolitis, which
is almost always caused by viruses
• Bronchiolitis does not increase the risk for serious bacterial infection. However,
occasionally concomitant or secondary bacterial infections may occur.
• Antibiotic of choice , clarithromycin
• Ribavirin – We do not recommend ribavirin in the routine treatment of infants
and children with bronchiolitis. However, in immunocompromised patients with
severe bronchiolitis due to RSV, antiviral therapy may play a role
• Anti-RSV preparations – We do not recommend anti-RSV preparations for the
treatment of bronchiolitis in infants and children. In randomized trials,
intravenous immune globulin with a high neutralizing activity against RSV (RSV-
IGIV, which has been discontinued) and RSV-specific humanized monoclonal
antibody (palivizumab) failed to improve outcomes in infants

36. Leukotriene inhibitors
• a 2015 meta-analysis of five randomized trials did not find an effect
on duration of hospitalization or clinical scores in children with
bronchiolitis .
• We do not suggest montelukast or other leukotriene inhibitors for the
treatment of bronchiolitis

37. Prevention
• Meticulous hand hygiene, face mask
• Palvizumab an intramuscular monoclonal antibody to RSV f protein
For imunocompromise patients
• Influenza vaccine
◦ reference taken from Nelson 21st edition

38. Discharge criteria:
• 1. Feeding well
• 2. SPO2>92% in air
• 3. Parents confident, especially with small babies.
• Reference from NHS paeditric guidelines

39. Key safety information for looking after a baby or child at home
•how to recognize developing 'red flag' symptoms: when to return
•worsening work of breathing (for example grunting, nasal flaring, marked chest recession)
•fluid intake is 50% to 75% of normal or no wet nappy for 12 hours
•apnea or cyanosis
•exhaustion (for example, not responding normally to social cues, wakes only with prolonged
stimulation).
•that people should not smoke in the baby or child's home because it increases the risk of more
severe symptoms in bronchiolitis
•arrangements for follow-up if necessary.

40. What have we learnt?
• Acute bronchiolitis is a diagnostic term mostly causes by
viruses(RSV),presents with tachypnea wheezing crackles and
ronchi
• Diagnosis is mainly clinical,labs and cxr not routinely
recommended
• Treatment is mostly supportive (suctioning, hydration and O2
supplemental)
• Condition is self limiting.

41. QUIZ SESSION

42. A 2 years old infant with 3 days of history of cough ,coryza and wheeze
comes in ER with spo2 of 88%,afebrile and R/R of 50/min
how will you manage?
1. Outpatient nebulization ,suctioning and sp02 monitoring
2. Outpatient o2 inhalation ,suctioning.nebulization and encourage oral
feed
3. In patient hydration and 02 inhalation
4. In patient o2 inhalation and antibiotics

43. A patient 4 years old boy comes to ER with cough with
runny nose and eyes,on examination he’s tachypneic with
laboured breathing and ronchi,which diagnostic test will
you first go for
1.Cbc e esr
2.Cxr
3.Abg;s
4.Pulse oximetry

44. Which of the following statements are most
accurate about pathogenesis of bronchiolitis:
1. Viral replication occurs after an incubation period of 2 to 8 days
2. Approximately one third of infected infants will develop fever
3. Key signs of infection include congestion rhinorrea irritability and poor feeding
4. All of the above

45. A 5 year old child known case of cystic
fibrosis,presents to you with wheeze,cough and
conjunctivitis for 5 days with a fever of 101 sp02
of 90% tachypneic
how will you manage
1. Give antibiotics,o2 inhalation,spo2 monitoring, hydration and suctioning
2. Give palvizumab monthly for three consecutive months wth supportive
management
3. Give ribavirin along with o2inhalation hydration sp02 monitoring
4. Supportive management(hydration,o2 inhalation,suctioning ,antipyretics)