This document provides information on acute bronchiolitis and wheezing in children under 5 years old. It defines bronchiolitis as an acute viral infection of the small airways. The most common cause is respiratory syncytial virus (RSV). Diagnosis is based on symptoms like cough and wheezing. Risk factors for severe bronchiolitis include apnea, respiratory distress, and cyanosis. Treatment focuses on supportive care and oxygen supplementation. Wheezing in young children can be categorized based on pattern and duration. Factors like prenatal vitamin D, maternal obesity, and acetaminophen use may influence wheezing development. Evaluation of recurrent wheezing may include fractional exhaled nitric oxide,

1. ACUTE BRONCHIOLITIS AND UNDER 5 WHEEZER
MODERATOR
DR.PRANJALI SAXENA
PRESENTED BY DR.RAJAT AGRAWAL

2. DEFINITION
ETIOLOGY
Bronchiolitis is an acute inflammatory
condition of the bronchioles that is a result of
virus- induced injury.
Respiratory syncytial virus (RSV) is the most common viral
agent isolated in about 75% (30–70% in Indian studies).
Other viruses:. Mycoplasma is more frequently implicated in
older children with bronchiolitis

3. P
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INTERNATIONAL JOURNAL OF PEDIATRICSAND NEONATOLOGY

5. DIAGNOSIS
1.Persistent cough, following a prodrome of coryza lasting 1–3 days,
with tachypnea with or without chest recessions and wheeze
and/or crackles occurring in a child <2 years of age (usually
below 1 year of age, with a peak between 3 and 6 months).
2.Associated fever, usually below 39°C, in around 30% cases and poor feeding, vomiting
usually after 3–5 days of illness.
3. Apnea may be the only presenting feature, particularly below 6 weeks of age.
4. The chest may appear hyperexpanded and may be hyper-resonant to
percussion. Wheezes and fine crackles may be heard
throughout the lungs.

6. INDICATION FOR HOSPITILISATION
Persistent tachypnea >60 breaths/minute or respiratory distress in form of
grunting, recessions
Inadequate oral intake, inability to feed, dehydration, and inadequate fluid intake
(50–75% of usual volume)
Oxygen saturation (SpO2) <92% in room air
Child appears seriously unwell to the healthcare provider
Skill and confidence of the caregiver to look after the child at home and distance
from the hospital

7. Signs of severe bronchiolitis
1.APNEA ,OBSERVED/REPORTED
2.MARKED RESPIRATORY DISTRESS
3.CENTRAL CYANOSIS

8. Risk factor for severe bronchiolitis

9. INVESTIGATION

10. SEVERITY OF BRONCHIOLITIS

11. MANAGEMENT

12. CRITERIA FOR DISCHARGE

13. PREVENTION

14. COMPLICATION
1. Acute respiratory distress syndrome (ARDS)
2. Myocarditis
3. Congestive heart failure
4. Arrhythmias
5. Bronchiolitis obliterans
6. Secondary bacterial infection
7. Predisposition to childhood asthma

15. SUMMARY OF VIRAL BROCHIOLITIS

16. UNDER 5 WHEEZER
High pitched, musical, whistling sound,
monophonic, or polyphonic, that occurs when
intrathoracic medium and small airways are
narrowed and vibrate due to increased resistance
to the movement of air.
Wheezing occurs in large proportion of children
under 5 years of age. It is commonly associated
with viral respiratory tract infections.

17. Wheeze can be divided according to its pattern and duration:
1.Wheeze subtypes according to pattern (symptomatic
classification):
a.Episodic wheeze: Wheezing within a discrete period that is often
associated with clinical evidence of a viral cold. There is wheezing
between episodes .
b.Multitrigger wheeze: Wheezing presenting with and apart from
an acute viral episode .

18. A.Never or infrequent: Children who never wheeze or have
presented with wheezing once in their life.
B.Transient early wheeze: This is a type of wheeze that starts
early in the first year of life and then continues through the
second year before beginning to subside after the third year. Most
of these patients are not atopic and exhibit no evidence of
eosinophilia or other markers of inflammation, which are
observed in approximately 16% of affected patients ..
.
Wheeze according
to duration

19. C.Intermediate wheeze: This is very rare in the first 18 months (This
condition presents as wheezing with onset between 18 and 42
months that subsequently persists into later childhood and is
strongly associated with atopy, allergic sensitization,
hyperresponsiveness, and lower PFT scores
.
d.Late-onset wheeze: This presents as infrequent wheezing from 6
to 42 months od age that becomes more frequent at 42 months of
age and then persists to an age of 6 years (approximately 1.7–6%)..
e.Persistent wheeze: This is wheeze with onset at 6 months of age
or later that occurred in approximately 3.1% of patients.

20. This subgroup presents with symptoms similar to asthma, and
affected patients are further divided into two main subgroups:
•
Nonatopic persistent wheezing phenotype: This accounts for
approximately 40% of patients with persistent wheeze and
usually presents as episodic wheezing triggered mainly by viral
illness;
•IgE-associated atopic and/or persistent wheezing phenotype: Accounting for
60% of persistent wheezing cases, this type of wheezing usually
begins in the second year of life and persists into late childhood
.

21. . A new era in wheezy chest
1. Vitamin D status and recurrent wheeze in children
Data have confirmed that low maternal late-pregnancy serum 25-
hydroxyvitamin D levels are associated with the development of wheeze and
atopy during childhood .
2. Maternal obesity and recurrent wheeze
In the nonurban, white population, maternal prepregnancy obesity was
associated with a 22% increase in bronchodilator dispensing in offspring in
early life.
3. Maternal iron and wheeze
It has been suggested that reduced maternal iron status during pregnancy is
adversely associated with childhood wheeze, lung function, and atopic
sensitization.

22. 4. Folic acid during pregnancy
A recent study performed in Australia reported that folic
acid supplementation during late pregnancy was
associated with an increased risk of asthma at 3.5 years
old and with persistent asthma until 5 years old.
5. Prenatal administration of acetaminophen
Acetaminophen is a widely used analgesic drug that is
not known to have any teratogenic effects. Thus, it is the
most commonly used analgesic in pregnant women (34–
69%), in whom it is preferred over other nonsteroidal
anti-inflammatory.

23. FIRST TIME WHEEZING

25. MODIFIED ASTHMA PREDICTIVE INDEX

26. D/D IN WHEEZER BELOW 5 YEARS OF GAE –
ASTHMA MIMICS

27. INVESTIGATION IN RECURERENT WHEEZER
If the history is suggestive of typical viral-induced wheezing or that of asthma no investigations are
necessary. However, in ambiguous cases with suspicion of some alternative condition certain investigations may
be required
Fraction of nitric oxide (FeNO) in exhaled air may be used to
identify those with eosinophilic inflammation to predict
response to corticosteroids.
Spirometry usually cannot be performed reliably by children
under the age of 5 years other techniques such as forced
oscillation technique (FOT) and impulse oscillometry (IOS) are
now available at a few centers which can be used in doubtful
cases.

28. These may be useful to document allergen
sensitization in those who report allergic symptoms
on exposure to a particular allergen
ALLERGY TEST
X RAYS CHEST
Eosinophilia may be detected. However, its absence
does not rule out possibility of asthma.
COMPLETE
HEMOGRAMS

29. TREATMENT OF RECURRENT WHEEZER

30. MANAGEMENT OF ACUTE EXARBATION OF
ASTHMA

31. •THANKS