Bronchiolitis

Dr. Mustafa Mohamed Ahmed

MBBS, MD
Overview

 Definition

 Clinical features

 Management

 COmplications
 DEFINITION
 defined as follows:
The definition for most clinical studies
 is the first episode of wheezing in a child
younger than 12 to 24 months who has physical
findings of a viral respiratory infection and has
no other explanation for the wheezing, such as
pneumonia or atopy.
 CAUSEs
 The number of viruses expanded.

 RSV account for 50% to 80% of cases.

 11 Other causes include the parainfluenza

viruses ( type 3 ) , influenza, and human
metapneumovirus (HMPV).
 infected with more than 1 virus.

 Rates of coinfection 10% - 30% , most commonly with

RSV and either HMPV or rhinovirus.

 A recent large prospective study of children younger

than 5 years of age hospitalized with RSV infection
revealed a coinfection rate of 6%.

Bronchiolitis: Recent Evidence on Diagnosis and Management

Joseph J. Zorc and Caroline Breese Hall
Pediatrics 2010;125;342-349; originally published online Jan 25, 2010;
DOI: 10.1542/peds.2009-2092
 Risk factors  
 Risk factors for severe RSV disease and/or complications include:
 Prematurity (gestational age <37 weeks)
 Low birth weight
 Age less than 6 to 12 weeks
 Chronic pulmonary disease (bronchopulmonary dysplasia, cystic
fibrosis, congenital anomaly)
 Hemodynamically significant congenital heart disease (eg,
moderate to severe pulmonary hypertension, cyanotic heart disease,
or congenital heart disease that requires medication to control heart
failure)
 Immunodeficiency
 Neurologic disease
 Congenital or anatomical defects of the airways
 CLINICAL FEATURES 
 a viral upper respiratory prodrome followed by
increased respiratory effort and wheezing

 Infants with moderate to severe, typically present for

medical attention 3-6 days after illness onset.

 Often preceded by 1-3 days h/o URT symptoms, such

as nasal congestion and/or discharge and mild cough.
 It typically presents with:
- fever (usually ≤38.3ºC)
- cough
- mild respiratory distress.

 Compared to other viruses, fever tends to be

lower with RSV and higher with adenovirus.
 
 Aspects that help in determining the severity of
illness and need for hospitalization include :
 Assessment of hydration status
 Symptoms of respiratory distress (tachypnea, nasal
flaring, retractions, grunting)
 Cyanosis, indicating profound hypoxemia
 Episodes of restlessness or lethargy (may indicate
hypoxemia and/or impending respiratory failure)
 Physical examination
 tachypnea and intercostal and subcostal retractions, often with
expiratory wheezing.

 The chest: hyperexpanded & ? hyperresonant to percussion.

 expiratory wheeze, prolonged expiratory phase, and both coarse

and fine crackles.

 Mild hypoxemia commonly is detected.

 Wheezing may not be audible if the airways are profoundly
narrowed.
 Other examination findings may include
- mild conjunctivitis
- pharyngitis
- otitis media.
 AAP defines severe disease as:
"signs and symptoms associated with poor feeding and
respiratory distress characterized by tachypnea, nasal
flaring, and hypoxemia".

(AAP) : American Academy of Pediatrics

 Factors that have been associated with increased illness
severity include:

 Toxic or ill appearance

 Oxygen saturation <95 % while breathing room air
 Age younger than 3 months
 Respiratory rate ≥70 breaths per minute **
 Atelectasis on chest radiograph
 Evaluation
 Laboratory tests and radiographs are not routinely indicated.

 CBC and chest radiograph are indicated in patients with an

unusual clinical course or severe disease
 Radiographs
 Chest radiographs are not necessary in the routine
evaluation of bronchiolitis.

 unlikely to alter treatment and may lead to

inappropriate use of antibiotics.
Indications of Radiographs

 Ininfants and young children with

moderate or severe respiratory distress
 if there are focal findings on examination
- cardiac murmur
 toexclude alternate diagnoses in children
who fail to improve at the expected rate.
 Diagnosis
 It is diagnosed clinically.

 The diagnosis may be supported by radiographic or

laboratory studies, but these tests are not necessary for
diagnosis
 There is debate about whether testing for specific viral
agents alters Mx or outcome

 However, the identification of a viral etiologic agent has

been associated with a decreased utilization of antibiotic
treatment
 DD
 Bronchiolitis must be distinguished from a variety
of acute and chronic conditions.
 These include:
- viral-triggered asthma or wheezing
- pneumonia
- chronic lung disease
- foreign body aspiration
- gastroesophageal reflux disease
- and/or dysphagia leading to aspiration
- congenital heart disease
- heart failure
- vascular rings.
 Treatment

 self-limited disease.

 Factors that should be considered in Mx decisions include:

- the age of the child
- the stage of infection at the time supportive care was
begun
- the disease severity
- premorbid diagnoses
- the cause and site of airway obstruction
 Indications for hospitalization 
 In general, criteria for hospitalization include:
 Toxic appearance, poor feeding, lethargy, and dehydration
 Moderate to severe respiratory distress, manifested by :
- nasal flaring
- intercostal retraction
- respiratory rate >70 **
- and/or cyanosis.
 Apnea
Respiratory support 
  Oxygen to maintain the sat above 90 to 92%.

 The AAP practice guideline recommends oxygen sat <90 % as

the threshold to start supplemental oxygen.
Fluid administration 

 Parenteral fluid administration may be necessary

to ensure adequate hydration and avoid the risk
of aspiration.
 BUT, not in all ***
 Fluidand electrolyte status should be carefully
monitored.
PHARMACOLOGIC
THERAPY
 Bronchodilators
 The clinical practice guideline of AAP
recommends that bronchodilators should not
be used routinely in the management of
bronchiolitis.
 trial of inhaled bronchodilators.

 Each patient should be assessed before and up to one hour

after treatment.

 Salbutamol is first choice

 Dose:  0.15 mg/kg (minimum 2.5 mg; maximum 5 mg)

diluted in 2.5 to 3 mL saline and administered over 5 to 15
minutes; or 4 to 6 puffs via a MDI with spacer and
facemask.
 If no benefit is observed in one hour, administer a single
dose of nebulized epinephrine:
 Epinephrine 
- Dose: 0.5 ml/kg ,, Max 5 ml
- Racmic (0.05 mL/kg of 2.25 % epinephrine diluted in 3
mL normal saline).
 No response within one hour of epinephrine treatment,
do not continue the use of these agents.
 If there is a response to either one , can be every 4-6 hrs
and discontinued when the S&S of respiratory distress
improve.
 Oral bronchodilators 
 not recommended.
 The efficacy of oral salbutamol was evaluated in a
randomized trial of 129 infants with bronchiolitis who were
discharged to home from the emergency department.
 1 wk salbutamol or placebo.
 The median time to resolution of illness was similar in the
two groups.

Patel, H, Gouin, S, Platt, RW.

Randomized, double-blind, placebo-controlled trial of oral albuterol
in infants with mild-to-moderate acute viral bronchiolitis.
J Pediatr 2003; 142:509.
 Glucocorticoids

 should not be used routinely.

 may be beneficial for patients with:
- chronic lung disease (BBD)
- those with previous episodes of wheezing
(ie,
who may be at risk for asthma).
 Such patients may benefit from a short course of prednisolone:

 Prednisolone  (1 to 2 mg/kg per day in one dose or divided into

two doses per day for three to seven days).

 Alternative dexamethasone (0.4 mg/kg per day in one dose for 3

to 5 days).

 Additional data are required before systemic glucocorticoid

therapy can be recommended in patients with less severe disease
not requiring hospitalization
 Inhaled glucocorticoids 
 have not been shown to be beneficial.
 found no significant differences in symptom duration,
readmission rates, or other endpoints between the two
treatment groups.

Cade, A, Brownlee, KG, Conway, SP, et al.

Randomised placebo controlled trial of nebulised corticosteroids
in acute respiratory syncytial viral bronchiolitis.
Arch Dis Child 2000; 82:126.
 Ribavirin
 is not recommended routinely.
 may still play a role in immunocompromised patients and
those with severe bronchiolitis due to RSV.
 remains controversial.
 Antibiotics
 only when there is evidence of a coexisting
bacterial infection (eg, positive urine culture,
acute otitis media, consolidation on chest
radiograph)

 Such infections should be treated in same

manner as in absence of bronchiolitis.
 Bronchiolitis: Recent Evidence on Diagnosis and Management
Joseph J. Zorc and Caroline Breese Hall
Pediatrics 2010;125;342-349; originally published online Jan 25, 2010;
DOI: 10.1542/peds.2009-2092
 Complications

 The most frequent complications are:

 acuterespiratory abnormalities, of which

apnea and respiratory failure are the most
serious

 Secondary bacterial infection 

 Apnea may occur in infants, particularly in those born
prematurely and those younger than two months of age (eg,
those with postmenstrual age <48 weeks).

 Presenting with apnea is a risk factor for respiratory failure and

the need for mechanical ventilation.