BqL 2010

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UPDATES INBRONCHIOLITIS

HUMAID AL HINAI

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OVERVIEW

DEFINITION

CLINICAL FEATURES

MANAGEMENT

COMPLICATIONS

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DEFINITION

defined as follows:

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.

The definition for most clinical studies

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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 humanmetapneumovirus (HMPV).

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HMPV account for 3% to 19% of cases.

clinical courses of RSV and HMPV similar

most children are infected during annual

widespread wintertime Epidemics.

Human metapneumovirus (HMPV)

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infected with more than 1 virus.

Rates of coinfection 10% - 30% , most commonlywith RSV and either HMPV or rhinovirus.

A recent large prospective study of children

younger than 5 years of age hospitalized with RSVinfection 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

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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, moderateto severe pulmonary hypertension, cyanotic heart disease, or

congenital heart disease that requires medication to control heartfailure)

Immunodeficiency

Neurologic disease

Congenital or anatomical defects of the airways

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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.

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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.

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aspects that help in determining the severity of illness and need for hospitalization include :

Assessment of hydration status

Symptoms of respiratory distress (tachypnea, nasalflaring, retractions, grunting)

Cyanosis, indicating profound hypoxemia Episodes of restlessness or lethargy (may indicate

hypoxemia and/or impending respiratory failure)

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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.

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Wheezing may not be audible if the airways are profoundlynarrowed.

Other examination findings may include

- mild conjunctivitis

- pharyngitis

- otitis media.

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AAP defines severe disease as:

"signs and symptoms associated with poor feedingand respiratory distress characterized by tachypnea,nasal flaring, and hypoxemia".

(AAP) : American Academy of Pediatrics

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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

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EVALUATION

Laboratory tests and radiographs are not routinely indicated.

CBC and chest radiograph are indicated in patients with anunusual clinical course or severe disease

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RADIOGRAPHS

Chest radiographs are not necessary in the

routine evaluation of bronchiolitis.

unlikely to alter treatment and may lead to

inappropriate use of antibiotics.

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INDICATIONS OF RADIOGRAPHS

In infants and young children with moderate or severe respiratory distress

if there are focal findings on examination

- cardiac murmur

to exclude alternate diagnoses in children whofail to improve at the expected rate.

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Studies evaluating whether radiographic findings are predictive of disease severity have had conflicting results.

One study randomly assigned 522 infants (2 to 59 months) withacute LRTI to receive or not receive a chest radiograph.

Children in the radiograph group were more likely to be diagnosedwith pneumonia or upper respiratory infection, whereas children inthe no-radiograph group were more likely to be diagnosed with

bronchiolitis.

In addition, more likely to be treated with antibiotics. The mediantime to recovery was seven days in both groups.

Swingler, GH, Hussey, GD, Zwarenstein, M.Randomised controlled trial of clinical outcome after chest radiograph in

ambulatory acute lower-respiratory infection in children.Lancet 1998; 351:404 .

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DIAGNOSIS

It is diagnosed clinically.

The diagnosis may be supported by radiographic or laboratory studies, but these tests are not necessary for

diagnosis

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There is debate about whether testing for specific viral

agents altersMx or outcome

The AAP ------- rarely alter management decisions or outcomes for the majority

However, the identification of a viral etiologic agent has

been associated with a decreased utilization of antibiotictreatment

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DD

Bronchiolitis must be distinguished from avariety 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.

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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

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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

Hypoxemia (O2 sat <95% RA) with or without hypercapnia(PCO2: >45 mmHg).

The parents are unable to care for the child at home

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RESPIRATORY SUPPORT Oxygen to maintain the sat above 90 to 92%.

Data are lacking to support the use of a specific cutoff value.

The AAP practice guideline recommends oxygen sat <90 % as

the threshold to start supplemental oxygen.

However, variability in the accuracy of oximeters, and the

presence of fever, acidosis, and hemoglobinopathy favor the use

of a higher cutoff value.

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In addition, there is evidence suggest that chronicor intermittent hypoxia (oxygen saturation 90 to94 %) may have long-term cognitive and behavioral effects.

Close monitoring is required as supplementaloxygen is weaned

Infants with PCO2 >55 mmHg, hypoxemia despiteoxygen supplementation, and/or apnea may requiremechanical ventilation

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FLUID ADMINISTRATION

Parenteral fluid administration may be necessary

to ensure adequate hydration and avoid the risk of aspiration.

BUT, not in all ***

Fluid and electrolyte status should be carefullymonitored.

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CHEST PHYSIOTHERAPY

should not be used.

The use of chest physiotherapy is discouraged because it may increase the distress and irritabilityof ill infants.

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A systematic review of three randomized trials concluded thatchest physiotherapy using vibration and percussion did notimprove clinical score, reduce supplemental

oxygen requirement, or reduce length of hospital stay.

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PHARMACOLOGIC THERAPY

Bronchodilators

A lthough, ? Eficacy

difficult to sort out responders/not.

The clinical practice guideline of AAP

recommends that bronchodilators shouldnot be used routinely in the management of bronchiolitis.

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a carefully monitored trial of bronchodilator medication isan option, with continuation only if there is a documentedobjective clinical response.

Various scoring systems to document clinical responsehave been used;

one is available through the University of Cincinnati(www.cincinnatichildrens.org/svc/alpha/h/health- policy/ev-based/bronchiolitis.htm

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trial of inhaled bronchodilators.

Each patient should be assessed before and up toone 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.

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If no benefit is observed in one hour, administer a singledose 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 hrsand discontinued when the S&S of respiratory distressimprove.

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FIGURE 1

Cochrane collaboration systematic review of studies that assessed the difference in rate of improvement after 2-agonist bronchodilators or placebo

among children with bronchiolitis. (Reproduced with permission from Gadomski AM, Bhasale AL.Co

chrane Database Syst Rev .2006;(3):CD001266.)

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A 2006 Cochrane systematic review of studies

that compared bronchodilators for the

management of bronchiolitis in outpatientssuggested a potential benefit with epinephrine

administration.

However, several more recent studies did not

support the routine use of epinephrine.

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Oral bronchodilators

not recommended.

The efficacy of oral salbutamol was evaluated in arandomized trial of 129 infants with bronchiolitis who weredischarged to home from the emergency department.

1 wk salbutamol or placebo.

The median time to resolution of illness was similar in thetwo 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 .

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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).

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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

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Inhaled glucocorticoids

have not been shown to be beneficial.

A randomized trial of nebulized budesonide versus placebo in 161 infants hospitalized with respiratorysyncytial virus (RSV) bronchiolitis

found no significant differences in symptom duration,readmission rates, or other endpoints between the twotreatment 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 .

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TREATMENT Bronchodilators plus glucocorticoids

A large, multicenter trial evaluated the effectiveness of

combination therapy in preventing hospitalization in 800 infants

presenting to ED with bronchiolitis

The infants were randomly assigned to one of four treatment

groups: - nebulized epinephrine and oral placebo;

- oral dexamethasone and inhaled placebo;- nebulized epinephrine and oral dexamethasone;

- nebulized and oral placebo.

N Engl J Med. 2009 May 14;360(20):2079-89.

Epinephrine and dexamethasone in children with bronchiolitis.Pediatric Emergency Research Canada (PERC)

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TREATMENT

Outcomes in the dexamethasone and

epinephrine monotherapy groups did not differ

significantly from those in the placebo group.

Com. was associated with a decreased rate of

hospitalization one week after enrollment (17 versus 24

to 26 percent in the other groups), but the result was notsignificant when adjusted for multiple comparisons

(relative risk, 0.65, adjusted 95% CI 0.41-1.03).

N Engl J Med. 2009 May 14;360(20):2079-89.

Epinephrine and dexamethasone in children with bronchiolitis.Pediatric Emergency Research Canada (PERC)

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Ribavirin

is not recommended routinely.

may still play a role in immunocompromised patients andthose with severe bronchiolitis due to RSV.

remains controversial.

Consideration of use should be done early in the illness andon a case-by-case basis.

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A ntibiotics

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 samemanner as in absence of bronchiolitis.

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Heliox

is a mixture of helium (70 - 80 %) and oxygen (20 -30 %).

flow through airways with less turbulence andresistance than supplemental oxygen(nitrogen/oxygen), thus improving ventilation and

decreasing the work of breathing

has been evaluated in several small randomizedtrials with mixed results

NONSTANDARD THERAPIES

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A nti-RSV preparations

use of IV immunoglobulin with a highneutralizing activity against RSV (RSV-IGIV,

which has been discontinued) or RSV-specifichumanized monoclonal antibody ( palivizumab)has failed to improve outcomes in infants with or without risk factors, hospitalized with RSV

infection

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Surfactant

Clinical and laboratory evidence suggests that severe bronchiolitis may resultin secondary surfactant deficiency.

Several small randomized trials have evaluated the effects of surfactanttherapy in mechanically ventilated infants with bronchiolitis.

A meta-analysis of these trials concluded that surfactant therapy may shortenthe duration of mechanical ventilation and duration of ICU stay in childrenwith bronchiolitis.

However, additional data are needed before reliable estimates of themagnitude of the effects can be made.

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Hy pertonic saline

theoretically has the potential to reduce airway

edema and mucus plugging

Several trials have indicated a potential benefit of

3 % saline compared to normal (0.9 %) saline.

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In a meta-analysis of three trials (189 patients), treatment

of children hospitalized with acute bronchiolitis with

nebulized 3% saline

was associated with decreased mean length of stay

(mean difference -0.94 days (95% CI -1.48-(-0.4) days).

No adverse events related to nebulized 3% saline were

reported.

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CONCLUSIONS: Current evidence suggests nebulized 3% salinemay significantly reduce the length of hospital stay and improve theclinical severity score in infants with acute viral bronchiolitis.

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Montelukast

Its role in Rx, was evaluated in a randomized trial in 53

infants and young children (>4 weeks to 2 years; mean age3.8 months).

Treatment with montelukast did not affect the clinical course,oxygen saturation, length of stay, or cytokine levels.

Additional studies are necessary to determine what role, if any.

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CONCLUSIONS: Montelukast did not improve the clinical course in acute

bronchiolitis. No significant effect of montelukast on the T-helper 2/T-helper 1

cytokine ratio when given in the early acute phase could be demonstrated .

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Bronchiolitis: Recent Evidence on Diagnosis and Management

Joseph J. Zorc and Caroline Breese Hall

Pediatrics2010;1

25;34

2-349; originally published online

Jan

25,

2010;DOI: 10.1542/peds.2009-2092

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DISCHARGE CRITERIA

No established criteria for discharge. One clinical practiceguideline suggests the following:

RR <70 breaths/min Caretaker can clear the infant's airway using bulb suctioning

Patient is stable without supplemental oxygen

Patient has adequate oral intake to prevent dehydration

The resources at home are adequate to support the use of anynecessary home therapies (eg, inhalation therapy if the trial wassuccessful and this therapy is to be continued)

Caretaker is confident they can provide care at home

Education of the family is complete

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MX GUIDLINE

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COMPLICATIONS

The most frequent complications are:

acute respiratory abnormalities, of which apnea

and respiratory failure are the most serious

Secondary bacterial infection

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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).

In a retrospective review, 21 percent of 185 infants younger than

12 months who were hospitalized with RSV infection presented

with apnea.

Presenting with apnea is a risk factor for respiratory failure andthe need for mechanical ventilation.

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TAKE HOME MS

1. Crackles should be reassessed after Neb.

2. Saturation not during sleep.

3. Gases are not routinely done BUT in sever cases.

4. Hydration is based on assessment

5. The dose of Salbutamol & Epinephrine

Neb.6. X ray

7. Severity Score.

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REFRENCES

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

Uptodate, Bronchiolitis in infants and children: Treatment;outcome; and prevention, Last literature review for version17.3: September 30, 2009

Uptodate, Bronchiolitis in infants and children: Clinicalfeatures and diagnosis Last literature review for version

17.3: September 30, 2009

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