BRONCHIOLITIS

MS ANAM
RESPIROLOGI DIV. CHILD HEALTH DEPT.
DIPONEGORO UNIVERSITY/KARIADI HOSPITAL
 INTRODUCTION
• Common cause of illness in young children
• Common cause of hospitalization in young
children
• Associated with chronic respiratory symptoms
in adulthood
• May be associated with significant morbidity
or mortality
 Description
• Acute infectious inflammation of the
bronchioles resulting in wheezing and airways
obstruction in children less than 2 years old
• bronchiolitis most common at age < 18-24
months, peak age 2-6 months
• antibodies to RSV present in 25%-50% by age
12 months, 95% by age 5 years, 100% adults
• males more likely to develop severe infections
 Etiology
Respiratory Syncytial Virus (RSV) is most
common cause of bronchiolitis
Other:
o parainfluenza virus
o adenovirus
o influenza virus
o human metapneumovirus
 RSV

Paramyxoviridae, Pneumovirus, Respiratory Syncytial Virus (multiple

serotypes A > B), originally called chimpanzee coryza virus
 Incidence
estimated 33.8 million new RSV-associated acute lower
respiratory infections occurred globally in children < 5
years old in 2005

o based on data from 36 studies (including 10

unpublished studies)
o ≥ 3.4 million of new episodes required
hospitalization
o estimated 66,000-199,000 children < 5 years old
died from RSV-associated acute lower respiratory
infections in 2005 (99% in developing countries)
Nair H, Nokes DJ, Gessnere BD, Dherani M, Madhi SA, Singleton RJ, etal. Global burden of acute
lower respiratory infections due to respiratory syncytial virus in young children: a systematic review
and meta-analysis. Lancet 2010 May 1;375(9725):1545
• RSV may cause 18.1 emergency department
(ED) visits per 1,000 children ≤ 7 years old per
year in United States
• hospitalizations due to RSV-associated
bronchiolitis increased from 2002 to 2007
Pathogenesis
• spread requires close contact
with infected individual or
surfaces contaminated by
secretions
– from only humans and
chimpanzees
– can survive on crib rail about
6 hours
– transmitted via respiratory
droplets, hands, fomites
• short (4-5 days) incubation, viral
shedding 1-3 weeks
• cell needs protease, budding
 denuding of airway epithelium, airway edema and
excessive mucus production
 resistance of peripheral airways more significant in
infants, so infants have more severe disease
 respiratory syncytial virus can survive on dry
inanimate surfaces for up to 6 hours, based on 1
citation in systematic review
 Risk Factors
POSIBLE RISK FACTORS RSV  HOSPITALIZATION

 recurrent wheezing (relative risk [RR] 5.9)

 infrequent wheezing (RR 2.98)
 maternal asthma (RR 1.72)
 paternal asthma (RR 1.23)
 maternal atopic dermatitis (RR 1.11)
Pediatrics 2006 Nov;118(5):e1360

 underlying medical conditions (primarily prematurity)

household crowding Pediatrics 2002 Feb;109(2):210
Risk factors for bronchiolitis-associated deaths
Study in USA

low birth weight

increasing birth order
low 5-minute Apgar score
young maternal age
unmarried mother
tobacco use during pregnancy

Pediatr Infect Dis J 2003 Jun;22(6):483

 COMPLICATION
• Otitis Media  62 % (within 10 days)
Pediatrics 1998 Apr;101(4):617

• Future respiratory illness

o RSV bronchiolitis associated with increased risk for wheezing for up to
5 years
o RSV lower respiratory tract illnesses associated with increased risk of
wheeze through early childhood but not later
o infants hospitalized for bronchiolitis may be at higher risk of asthma
diagnosis at age 20 years
o infants hospitalized for bronchiolitis may be at higher risk for recurrent
wheezing or asthma at age 7 years
 Severe RSV infection associated with multiple
extrapulmonary manifestations

– heart failure
– hypotension
– elevated cardiac troponin levels
– cardiac arrhythmias (ventricular and supraventricular
tachycardia)
– central apnea
– seizures, focal and generalized
– focal neurologic abnormalities
– hyponatremia
– syndrome of inappropriate antidiuretic hormone (SIADH)
– UTI  5,4%

Crit Care 2006;10(4):R107 full-text

 Clinical Manifestation
• History
o early rhinorrhea, cough, low-grade fever
o later tachypnea, wheezing, retractions, fussiness, poor
feeding, lethargy, apnea
• Physical Examination
o tachypnea, retractions, fever, tachycardia
o fever may suggest more severe infection, longer hospital
stay and worse lung disease
o Skin: sianosis concurrent conjunctivitis, otitis media or
pharyngitis, auscultation wheezing, prolonged expiratory
phase
 DIAGNOSIS
• Based on history and physical exam, and should
not routinely order laboratory and radiologic
studies for diagnosis
• Typical bronchiolitis presents as seasonal
respiratory illness in children < 2 years old with
– fever
– tachypnea
– wheezing
– increased respiratory effort (grunting, nasal flaring,
and intercostal and/or subcostal retractions)
 Rule Out
• Pneumonia
• Rhinovirus common
in hospitalized
infants with
respiratory tract
disease, second most
common agent after
RSV
 LABORATORY AND RADIOLOGIC STUDIES
(Not Routinely Recommended For Diagnosis)

• Blood Test
– white blood count does not appear to predict bacteremia
in febrile children with RSV lower respiratory tract
infection (level 2 [mid-level] evidence)
– blood cultures rarely positive in children with RSV
infection
• Urine Culture
alone (instead of septic workup) may be adequate
for infants with RSV infection or clinical bronchiolitis,
but urine culture has low yield
 Chest X-Ray
almost always consistent with diagnosis in typical bronchiolitis
presentation, but often misinterpreted

chest x-ray may show

o hyperinflation (hallmark of bronchiolitis)

o patchy infiltrate
o atelectasis
o reticular-nodular pattern suggestive of
interstitial viral pneumonia
 Biopsy and Pathology

rarely required for clinical management

typical lung biopsy findings include
• multinucleated giant cells (on
immunofluorescence of respiratory epithelium)
• necrosis of respiratory epithelium, destruction of
ciliated epithelial cells, peribronchiolar
lymphocytic and monocytic infiltrate, submucosal
edema, bronchiolar plugging by cellular debris and
fibrin, intra alveolar edema, hyaline membranes
Follicular bronchiolitis. (A) Hyperplastic lymphoid tissue surrounding the bronchiole.
Mild bronchiolar fibrosis is also present. (B) Hyperplastic lymphoid tissue appears
to compress the lumen of one bronchiole (centre right). The adjacent bronchioles
show marked chronic inflammation. There is mild bronchiolectasis and chronic
inflammation of a bronchiole in the surrounding lung parenchyma.
 Other Diagnostic Testing
• Binax NOW RSV rapid antigen test suggests RSV infection if
positive, but does not have sufficient sensitivity to rule out
RSV infection
• rapid antigen testing may help diagnosis of RSV infection in
neonates
• diagnostic performance of rapid antigen test to detect RSV
» Sn 90.3%
» Sp 88.2%
» PPV 51.3%
» NPV 98.5%
» positive likelihood ratio 7.7
» negative likelihood ratio 0.11
 Specimen Collection Methods
• nasal swabs appear less sensitive but less
uncomfortable than nasopharyngeal aspirate
for diagnosis of RSV infection
• lower nasal swabs are accurate compared to
nasopharyngeal swabs for identifying
influenza and respiratory syncytial virus (RSV)
in children (level 1 [likely reliable] evidence)
and appear less uncomfortable (level 2 [mid-
level] evidence)
 TREATMENT
 Assess hydration and ability to take fluids orally
(SR)
 Oxygen
o Insufficient evidence to determine when to use
oxygen therapy in children with lower respiratory tract
infections
o American Academy of Pediatrics recommendations
o if oxyhemoglobin saturation (SpO2) persistently below 90%,
adequate supplemental oxygen should be used to maintain
SpO2 ≥ 90% (AAP Option D)
o oxygen may be discontinued if SpO2 ≥ 90% and infant is
feeding well and has minimal respiratory distress (AAP
Option D)
Therapies with possible benefit
o nebulized epinephrine might reduce hospital admissions
(especially in first 24 hours) in children with acute viral
bronchiolitis (level 2 [mid-level] evidence)
o nebulized hypertonic saline appears more effective than nebulized
normal saline in reducing symptoms and shortening hospital stay
(level 2 [mid-level] evidence)
o zinc may reduce lower respiratory illness duration in boys in
developing countries (level 2 [mid-level] evidence)
o surfactant might reduce duration of mechanical ventilation (level
2 [mid-level] evidence)
o montelukast may reduce postbronchiolitis symptoms at 2-4 weeks
(level 2 [mid-level] evidence), but inconsistent evidence for
reducing clinical severity, length of hospital stay or long-term
symptoms
Conflicting or insufficient evidence of benefit

 bronchodilators (other than epinephrine) do not appear

effective other than minor short-term improvements of
questionable clinical significance (level 2 [mid-level] evidence)
 steroids
o systemic steroids may not reduce hospital admissions,
length of stay or readmissions in children with acute viral
bronchiolitis (level 2 [mid-level] evidence)
o inhaled steroids do not appear to reduce rate of
postbronchiolitic wheezing or rehospitalization after acute
bronchiolitis (level 2 [mid-level] evidence)
o combined dexamethasone and epinephrine may be
associated with reduced hospital admissions in infants with
bronchiolitis (level 2 [mid-level] evidence)
Antiviral Therapies
ribavirin may reduce duration of mechanical
ventilation in high-risk patients but insufficient
evidence for other outcomes (level 2 [mid-
level] evidence)

respiratory syncytial virus IV immunoglobulin

(RSV IVIG) does not appear effective (level 2
[mid-level] evidence
antibiotics do not appear to reduce duration of
symptoms or hospital stay in children with bronchiolitis
(level 2 [mid-level] evidence)
heliox has insufficient evidence to assess clinical benefit
insufficient evidence regarding noninvasive modes of
respiratory support for infants with bronchiolitis
chest physical therapy does not reduce disease severity
or length of hospital stay in nonventilated infants with
acute bronchiolitis (level 1 [likely reliable] evidence)
AAP RECOMMENDATION
2006
 RECOMMENDATION
R
1A

• Clinicians should diagnose bronchiolitis

and assess disease severity on the basis
of history and physical examination.
• Clinicians should not routinely order
laboratory and radiologic studies for
diagnosis

evidence level B; diagnostic studies with minor limitations and observational studies with
consistent findings; preponderance of benefits over harms and cost
 RECOMMENDATION
R
1B

Clinicians should assess risk factors for severe

disease such as age less than 12 weeks, a history
of prematurity, underlying cardiopulmonary
disease, or immunodeficiency when making
decisions about evaluation and management of
children with bronchiolitis

evidence level B; observational studies with consistent findings; preponderance of benefits

over harms
R RECOMMENDATION
2A

Bronchodilators should not be used

routinely in the management of
bronchiolitis

evidence level B; RCTs with limitations; preponderance of harm of use over benefit
 O RECOMMENDATION
2B

A carefully monitored trial of -adrenergic or –

adrenergic medication is an option.
Inhaled bronchodilators should be continued
only if there is a documented positive clinical
response to the trial using an objective means of
evaluation

evidence level B; RCTs with limitations and expert opinion; balance of benefit and harm
 RECOMMENDATION
R
3

Corticosteroid medications should not be used

routinely in the management of bronchiolitis

evidence level B; based on RCTs with limitations and a preponderance of risk over benefit
R
RECOMMENDATION
4

Ribavirin should not be used routinely

in children with bronchiolitis

evidence level B; RCTs with limitations and observational studies; preponderance of

harm over benefit
 RECOMMENDATION
R
5

Antibacterial medications should be used only in

children with bronchiolitis who have specific
indications of the coexistence of a bacterial
infection. When present, bacterial infection should
be treated in the same manner as in the absence of
bronchiolitis

evidence level B; RCTs and observational studies; preponderance of benefit over harm
SR
RECOMMENDATION
6A

Clinicians should assess hydration and ability

to take fluids orally

(strong recommendation: evidence level X; validating studies cannot be performed;

clear preponderance of benefit over harm).
R RECOMMENDATION
6B

Chest physiotherapy should not be used routinely in

the management of bronchiolitis

evidence level B; RCTs with limitations; preponderance of harm over benefit

 RECOMMENDATION
O
7A

Supplemental oxygen is indicated if oxyhemoglobin

saturation (SpO2) falls persistently below 90% in
previously healthy infants.
If the SpO2 does persistently fall below 90%, adequate
supplemental oxygen should be used to maintain SpO2
at or above 90%. Oxygen may be discontinued if SpO2 is
at or above 90% and the infant is feeding well and has
minimal respiratory distress

evidence level D; expert opinion and reasoning from first principles; some benefit over harm
RECOMMENDATION
O
7B

As the child’s clinical course improves, continuous

measurementof SpO2 is not routinely needed

evidence level D; expert opinion; balance of benefit and harm

 SR
RECOMMENDATION
7C

Infants with a known history of hemodynamically

significant heart or lung disease and premature infants
require close monitoring as the oxygen is being weaned

(strong recommendation: evidence level B; observational studies with consistent findings;

preponderance of benefit over harm).
R
RECOMMENDATION
8A

Clinicians may administer palivizumab prophylaxis

to selected infants and children with CLD or a
history of prematurity (less than 35 weeks’
gestation) or with congenital heart disease

evidence level A; RCT; preponderance of benefit over harm

 R RECOMMENDATION
8B

When given, prophylaxis with palivizumab should be

given in 5 monthly doses, usually beginning in
November or December, at a dose of 15 mg/kg per
dose administered intramuscularly

evidence level C; observational studies and expert opinion; preponderance of benefit over cost
 SR
RECOMMENDATION
9A

Hand decontamination is the most important step

in preventing nosocomial spread of RSV. Hands
should be decontaminated before and after direct
contact with patients, after contact with
inanimate objects in the direct vicinity of the
patient, and after removing gloves

(strong recommendation: evidence level B; observational studies with consistent

results; strong preponderance of benefit over harm)
RECOMMENDATION
R
9B

Alcohol-based rubs are preferred for hand

decontamination. An alternative is hand-
washing with antimicrobial soap

evidence level B; observational studies with consistent results; preponderance of

benefit over harm).
RECOMMENDATION
R
9C

Clinicians should educate personnel and

family members on hand sanitation

evidence level C; observational studies; preponderance of benefit over harm

 SR
RECOMMENDATION
10 A

Infants should not be exposed to passive smoking

(strong recommendation: evidence level B; observational studies with consistent results;

strong preponderance of benefit over harm).
R RECOMMENDATION
10 B

Breastfeeding is recommended to decrease a

child’s risk of having lower respiratory tract
disease (LRTD)

evidence level C; observational studies; preponderance of benefit over harm