BRONCHIOLITIS

WHAT IS BRONCHIOLITIS?

 Bronchiolitis, defined as inflammation of the bronchioles,

usually is caused by an acute viral infection. Viral
bronchiolitis is the most common lower respiratory tract
infection in infants and children who are 2 years of age and
younger. The most commonly identified infectious agent is
the respiratory syncytial virus (RSV). Other identified
pathogens include adenovirus, human metapneumovirus,
influenza virus, and parainfluenza virus.
 The pathophysiology of bronchiolitis begins with an acute
infection of the epithelial cells lining the small airways within
the lungs. Such infection results in edema, increased mucus
production, and eventual necrosis and regeneration of these
cells.
 SIGNS AND SYMPTOMS

 Common cold symptoms, including:

 Rhinorrhea
 Congestion
 Fever
 Cough (the cough may become more severe as the condition
progresses)
 Changes in breathing patterns (the child may be breathing
fast or hard; you may hear wheezing, or a high-pitched sound)
 Decreased appetite
 Irritability
 Vomiting and/or diarrhea
 Cyanosis
BRONCHIOLITIS SEVERITY CLASSIFICATION
 RISK FACTORS

 Prematurity  Immune deficiency

 Environmental factors  Chronic lung disease
 Neurological disease  Age under 3 months
 Cardiac disease  Formula feeding
 Airways anomalies  RSV infection
 INDICATIONS FOR HOSPITALIZATION

 Poor feeding
 Lethargy
 Dehydration
 Moderate to severe respiratory distress, manifested by one or
more of the following signs:
 nasal flaring;
 intercostal, subcostal and suprasternal retractions;
 respiratory rate>60 breaths per minute;
 dyspnea or cyanosis
 Apnea
 Hypoxemia
 HOW IS BRONCHIOLITIS DIAGNOSED?

 Bronchiolitis is usually diagnosed solely on the history and

physical examination of the child.
 Many tests may be ordered to rule out other diseases, such as
pneumonia or asthma. In addition, the following tests may be
ordered to help confirm the diagnosis:
 Chest X-rays
 Blood tests/blood gases
 Pulse oximetry
 Nasopharyngeal swab
 PATIENT DETAILS

 SURNAME: Popa  MEDICAL HISTORY: neonatal jaundice

 FIRST NAME: Paul and anemia
 Date Of Birth: 20/12/18  SURGICAL HISTORY: no
 AGE: 4 months  ALLERGIES: no
 SEX: M  MEDICATION: Paracetamol, Nurofen
 WEIGHT: 7 KILOGRAMS  CHIEF COMPLAINT: fever and cough for
 LENGTH: 60 CENTIMETERS 2 days and lost of appetite
 PARENTS:
 MOTHER: Popa Lavinia
 OCCUPATION: Teacher
 FATHER: Popa Ionel
 OCCUPATION: Firefighter
 SIBLINGS: Popa Ioana (no
medical problems)
 INTRODUCTION

 D: Good morning, Mrs. Popa! I’m doctor Smith.

 P: Good morning, doctor!
 D: Please take a sit. Your family doctor says your little baby
has not been feeling well lately. Firstly, please tell me his
name and age so I can fill up his chart.
 P: His name is Paul Popa and he’s 4 months old.
 D: Can you approximate the weight and length?
 P: Not exactly… Last month he had 6 kilograms and 61
centimeters.
 D: No problem, then. We will measure him in a few minutes.
 MAIN COMPLAINT

 D: Now, Mrs. Popa, what brought you to see me today?

 P: My son’s condition is gradually worsening. He is coughing a
lot, having high fever and he lost his appetite.
 D: When did it start?
 P: Well, 3 days ago, after we came back from my sister’s
party, we heard him sneezing few times and had a runny nose
but we thought it was nothing serious. Now he can barely
breathe and he hasn’t eaten anything since yesterday at 2
p.m.
 D: You said you were at a party. Did Paul come in contact with
sick persons?
 P: I don’t think so. Our nephews are healthy.
 FAMILY HISTORY

 D: Do you have other children?

 P: Yes, I also have a 4 years old daughter.
 D: Did she or other family members suffer from any infectious diseases
like chickenpox, measles, hepatitis in the last two months?
 P: No, sir.
 D: Does anyone in your family have some genetic disorders or congenital
abnormalities?
 P: No, no one has.
 D: Are there any diseases that have been running in your family?
 P: My father has always been of poor health. My father-in-law died last
summer of a heart attack and my mother-in-law has asthma. My
husband was diagnosed with type 2 diabetes, but he keeps it under
control with medication.
 D: So you have respiratory pathologies in family. Does anybody in your
family smoke?
 P: Yes, my father and my husband, but they never smoke inside the
house or when Paul is with them.
 PRENATAL HISTORY

 D: Mrs. Popa, have you ever smoked, especially during

pregnancy?
 P: I used to smoke when I was in high school, but I quitted
after I got married.
 D: That is really good to know. Did you have any health
problems during pregnancy?
 P: In the last month I had some problems with gestational
diabetes, but my gynecologist said it is very common among
pregnant women.
 D: What medication did the doctor prescribe?
 P: On his recommendation I took some natural teas, but I do
not remember their names.
 BIRTH HISTORY
 D : Ok , M r s . P o p a , t h a n k yo u f o r t h e i n f o r m a t io n . No w , p l ea s e le t m e k n o w
s o m et h i n g a b o u t y ou r p r e gn a n c y. D i d yo u p e r f o r m a c e s a re a n s e c t io n ?
 P : No , d oc t o r . I t w a s a v a gi n a l d el i v er y . I d i d n ’ t h a ve a n y t ro u b l e d u r i n g m y
p r e gn a n c y a n d r i g h t a f t e r b ir t h I w a s t o l d t h a t P a u l i s a h ea l t h y li t t l e b o y . H i s
A p ga r s c o r e i s 1 0 .
 D : Go o d t o h e a r t h a t . W h a t w a s h i s b i r t h w e i gh t a n d l e n gt h ?
 P : W el l , h e h a d 3 . 4 k i l o gr a m s a n d 4 9 . 7 c e n t i m e t e r s .
 D : I s h e b o t t l e -f e d ?
 P : No . I ’ m st i l l b r e a st f ee d i n g h i m , b ec a u s e I c on si d e r e d t h i s a h e a l t h y o p t io n f or
m y k id .
 D : I n f a c t , i t r ea l l y i s. H ow a b o u t i m m u n i z a t i on ? D o es h e h a ve a l l t h e v a c c i n e s
done?
 P : No , h e o n l y d i d t h e on e f or H ep a t i t i s B. I d o n ’ t t h in k t h i s i s sa f e f o r m y c h i ld r e n .
 D : M r s . P o p a , w h a t yo u s h ou l d k n o w a b o u t v a c c i n e s i s t h a t t h e y a r e sa f e . Th e y
u n d e r go e xt e n si v e t e s t in g b e f o r e b ei n g l ic e n s e d , a nd v a c c in e s a f e t y c o n t i n u e s t o
b e m on i t o r ed a s l o n g a s a v a c c i n e i s i n u s e . S o y ou h a v e n ot h i n g t o w or r y a b o u t .
E v en i f s om e d i s ea s e s d o c o m p le t e ly d i s a p p e a r in R o ma n i a , t h e y a r e c o m mo n i n
o t h er p a r t s o f t h e w or l d a n d a r e j u s t a p la n e r i d e a w a y. I ’ m s u r e y o u t oo k t h is
d e c i s i on b e c a u s e yo u c o n s id e r e d i t t h e b e st o p t i on f o r yo u r c h i l d ’ s h e a l t h , b u t I
h o p e yo u w il l a l s o t h i n k a b o u t w h a t I s a i d . N ow , b e f or e a s ki n g y o u m o r e q u e s t i o n I
w o u ld l i k e t o e xa mi n e h im b et t er . P le a s e p u t h im o n t h i s t a b l e . I t w on ’ t h u r t .
RESULTS OF CLINICAL
EXAMINATION
P h y si c a l e x a m i n a t i o n sh o w e d a w e ll-
d e v e l o p e d , we l l - n o u r i sh e d i n fa nt .
T h e r e w e re n o c o n g e n i t a l
a b n o r m a lit ie s. T h e p a t i e n t h a d a
n o r m a l we ig ht ( 7 k g ) a n d l e n g t h (6 0
c m ). H e is a le r t , b u t d y sp n e i c .
Temperature: 38.4°C

B l o o d p re ss u re : 9 5 / 7 0 m m H g

H e a r t ra t e : 1 3 5 / m i n , r e g u l a r

R e s p i ra t o ry r a t e : 6 5 /m i n w i t h na sa l
f la r i n g a nd int e r c o s t a l r e t r a c t i o ns

P u l se o x im e t ry : 8 5 % o n r o o m
t e m p e ra t u re

L u n g a u s c u lt a t i o n r e v e a l e d a
p r o l o n g e d e x p i r a t o r y p h a se w i t h e nd
e x p i r a to ry wh e e z e .
T h e n o se c o nt a i n e d c l e a r m u c u s.
 MEDICAL HISTORY

 D: When did you last check his temperature?

 P: Yesterday, around 7 pm. He had 38.9 and I gave him
Paracetamol for babies with rectal administration and he felt
better. This sound coming from his chest… It really scares me!
What is it?
 D: That sound is called wheezing and more babies with
respiratory pathologies have it. This is pretty common at his
age and especially in this season. Little Paul seems to have
bronchiolitis, but in order to be sure we are going to do an X-
ray test. This will eliminate other possible pathologies.
Because of this low oxygen saturation, I want to give him a
face mask and administrate oxygen in order to make
breathing easier.
 MEDICAL HISTORY

 D: Does he have other medical conditions?

 P: No, I think he doesn’t. He had neonatal jaundice, but he
recovered quickly. After one month, at a routine control we
were said that he has anemia.
 D: So, was he hospitalized?
 P: No, our family doctor prescribed some iron supplements.
 D: Ok, then. We will also run some blood tests to ensure that
everything’s fine. Did he take another medicine?
 P: I only gave him Paracetamol for babies when he got a cold.
In 3 days he was fine.
 D: Did you observe any allergies?
 P: No, doctor.
 RADIOLOGY RESULTS

-No evidence of
congenital
abnormalities of
the pulmonary or
cardiac systems
-Visible inflammation
of the lungs
 DIAGNOSIS

 D: Now, seeing the result of the radiograph I can certainly tell you that
the diagnosis is bronchiolitis. We just eliminate the possibility of
pneumonia.
 P: I have never heard of bronchiolitis. Could you explain it to me, please?
 D: Yes, Mrs. Popa. It is an inflammation of the smallest respiratory parts,
called bronchioles, which results in difficult breathing and increased
mucus production. This is pretty common among children at his age.
 P: What could have caused it?
 D: It is caused by a virus called respiratory syncytial virus. In this period
of the year, which means the cold months, there are so many cases that
we can call it an epidemy. Paul, probably caught this virus through the
air.
 P: So it has nothing to do with his grandmother's asthma. I mean, he
couldn't have inherited asthma, right?
 D: At this point it is really hard to give an answer to your question. There
is a probability of developing asthma too, but it is low and we can not
confirm it because the symptoms appear by the age of 5.
 TREATMENT

 P: Oh, I see… Does he need to be hospitalized?

 D: Yes, because he is hypoxic and dehydrated as he refuses to
eat. He will be put under observation for few days, until his
condition is getting better. Bronchiolitis usually requires no
therapy, but in his case we have to administrate him oxygen,
intravenous fluids, cortisone and bronchodilators until his
oxygen saturation will come to normal. We also wait for the
blood test results to come to see if he still has anemia or not.
 P: Oh, ok, I understand.
 D: See you in the ward, Mrs. Popa and don’t worry. Everything
is going to be all right. Paul is a strong little boy and he is on
good hands.
 P: Thank you, doctor! Good bye!
 TREATMENT OPTIONS

 Bronchiolitis is a self-limiting disease and most children can

be managed with supportive care at home. For those patients
who require hospital admission, it is recommended supportive
care by providing supplemental O2 and hydration. Gentle
nasal suctioning may also be used to relieve nasal
obstruction.
 Supplemental oxygen therapy should be provided if
saturations fall below 90% and used to maintain saturations
at over 90%. This should be provided using nasal cannulae,
or a face mask.
 It is also recommended to administrate:
 Glucose 500ml- intravenous
 Hydrocortisone hemisuccinate - 0.56 to 8 mg/kg/day oral or IV in 3
or 4 divided doses
 Bronchodilators (ex: Albuterol)
Days of hospitalization:3
Blood tests: Normal
Treatment:
--Oxygen therapy
--Hydrocortisone hemisuccinate
25mg/8h (i.v.)
--Bromhexin 5 drops*3/day
--Aerosols- Respirum
2,5 ml*3/day
--Algin 6ml/8h
After hospital discharge:
--Bromhexin 5 drops*3/day
 BIBLIOGRAPHY

 https://jamanetwork.com/journals/jamapediatrics/article-ab
stract/510756
 https://www.sciencedirect.com/science/article/pii/S014067
3606690776
 https://www.mayoclinic.org/diseases-conditions/bronchiolitis
/symptoms-causes/syc-20351565