Bronchiolitis by Ng
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Bronchiolitis is an inflammation of the small airways (bronchioles) commonly caused by viral infection, especially respiratory syncytial virus (RSV) in infants under 1 year old. It causes wheezing and difficulty breathing. Clinical features include cough, wheezing, respiratory distress, and feeding difficulties. Chest x-ray may show hyperinflation of the lungs. Diagnosis is usually made clinically based on symptoms and age of the child. Treatment focuses on supportive care and monitoring for signs of worsening respiratory distress.
Bronchiolitis by Ng
- 2. Definition • Bronchiolitis is a first time wheezing with a viral respiratory infection. • It is a common respiratory illness in children less than 24 months with its peak incidence between 3 to 6 months of age.
- 3. The common causal organisms of bronchiolitis • Respiratory syncytial virus (RSV) is responsible for >50% of cases . • Other agents include parainfluenza adenovirus, Mycoplasma, and, occasionally, other viruses. • Human metapneumovirus is an important primary cause of viral respiratory infection or it can occur as a co-infection with RSV
- 4. Epidemiology • A common respiratory illness especially in infants aged 1 to 6 months old • Cyclical periodicity with annual peaks occurs in November,December and January .
- 5. Pathophysiology 1)RSV infection incites a complex immune response. Eosinophils degranulate and release eosinophil cationic protein, which is cytotoxic to airway epithelium. 2)Immunoglobulin E (IgE) antibody release may also be related to wheezing. 3)Other mediators invoked in the pathogenesis of airway inflammation include chemokines such as interleukin 8 (IL-8), macrophage inflammatory protein (MIP) 1α. .
- 9. • RSV-infected infants who wheeze express higher levels of interferon-γ in the airway as well as leukotrienes. RSV co-infection with metapneumovirus can be more severe than monoinfection
- 10. Acute bronchiolitis is characterized by bronchiolar obstruction with edema, mucus, and cellular debris. Resistance in the small air passages is increased during both inspiration and exhalation, but because the radius of an airway is smaller during expiration, the resultant respiratory obstruction leads to early air trapping and overinflation. If obstruction becomes complete, there will be resorption of trapped distal air, and the child will develop atelectasis
- 11. Clinical features • Coryzal symptoms precede a sharp,dry cough,increasing breathlessness • Wheezing is often:High pitched,expiratory>inspiratory • Feeding difficulty associated with increasing dyspnoea • Recurrent apnoea
- 12. •Subcostal and intercostal recession •Hyperinflation of the chest:sternum prominent,liver displaced downwards •Fine end-inspiratory crackles •Tachycardia •Cyanosis or pallor
- 13. Investigations A chest ray is not routinely required,but recommended for children with: 1)severe respiratory distress 2)unusual clinical features 3)an underlying cardiac or chronic respiratory disorder 4)Admission to intensive care Page 13
- 14. Chest radiography reveals hyperinflation,segmental,lobar collapse/consolidation The white blood cell and differential counts are usually normal. Viral testing (usually rapid immunofluorescence, polymerase chain reaction, or viral culture) Page 14
- 15. chest X-ray shows hyperinflation of the lungs with flattening of the diaphragm, horizontal ribs and increased hilar bronchial markings. Note: chest X- ray is rarely helpful in bronchiolitis. 15 Page 15
- 16. The diagnosis is clinical, particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak. Page 16
- 17. A majority of chidren with viral bronchiolitis has mild illness and about 1% of these children require hospital admission Guideline for hospital admission : Home Management Hospital Management Age<than 3 months No Yes Toxic looking No Yes Chest recession Mild Moderate/severe Central cynosis No Yes Wheeze Yes Yes Crepitations on auscultation Yes Yes Feeding Well Difficult Apnoe No Yes Oxygen saturation >95% <93% High risk group No Yes
- 18. Management outline 1)General measures: •careful assessment of the respiratory status and oxygenation is critical •Arterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93% -administer supplemental humidified oxygen if necessary •Monitor for signs of impending respiratory failure -inability to maintain satisfactory Spo2 on inspired oxygen>40% or a rising pCO2 •Very young infants are at risk of apnoea require greater vigilance
- 19. 2)Nutrition and Fluid therapy Feeding.Infants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydrated.Small frequent feeds as tolerated can be allowed in children with moderate respiratory distress.Naso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomach. Intravenous fluids for children with severe respiratory distress,cyanosis,apnoea.Fluid therapy should be restricted to maintenance requirement of 100ml/kg/day for infants. 3)Pharmacotherapy: •Inhaled β-2 agonists:A trial of nebulised β-2 agonists,given in oxygen,may be considered in infants with viral bronchiolitis.Vigilant and regular assessment of the child should be carried out if such a traetment is provided •Inhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit.
- 20. 4.Antibiotic Recommended for all infants with: • recurrent apnoea and circulatory impairment, • - possibility of septicaemia • - acute clinical deterioration� • - high white cell count • - progressive infiltrative changes on chest radiograph
- 21. Prevention Passive immunization with humanised RSV specific monoclonal antibodies (Palivizumab) prophylaxis is given during the expected annual RSV outbreak season and is effective in reducing the incidence of hospitalization and severe respiratory disease in infants in the hisk risk categories.
- 22. Recommended catagories of infants for passive immunization 1.Chronic lung disease Children or infants<24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV season.Medical treatment includes supplementary oxygen,corticosteroids,brochodilators and diuretic. 2.Premature infants less thyan 32 weeks getation without chronic lung disease •Infants less than 28 weeks gestation up to 12 months of age at the start of the RSV season •Infants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season
- 23. Reference 1.Nelson Textbook Of Pediatrics 18th Edition 2.Pediatric Protocol 2nd Edition
- 24. CASE : A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP. He developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies. He has two older siblings who also have colds. He was born at 34 weeks’ gestation but had no significant neonatal problems and went home at 2 weeks of age. Both parents smoke but not in the house.His mother had asthma as a child. Examination: Max is miserable but alert. His airway is clear. He is febrile (37.8C) and has copious clear nasal secretions and a dry wheezy cough. His respiratory rate is 56 breaths/min with tracheal tug and intercostal and subcostal recession. On auscultation, there are widespread fine crackles and expiratory wheeze. The remainder of the examination is unremarkable. • What is the most likely diagnosis? • What is the commonest causative organism? • What are the indications for referral to hospital? • What is the management in hospital?
- 25. Thank you for your attention ^v^