Acute Bronchiolitis and Viral pneumonia.pptx

Fever, common cold and cough in pediatric age groups are common. Acute bronchiolitis is a diagnostic term used to describe the clinical picture produced by several different lower respiratory tract infections in infants and very young children (younger than 1yr ,some clinicians extend it to the age of 2 yr). Pneumonia defined as inflammation of lung parenchyma.
It is the leading infectious cause of death globally among children younger than 5 yr.
The introduction of antibiotics and vaccine against measles , pertussis ,haemophilus influenzae type b and PCV vaccine reduces the pneumonia related mortality over past 15 yr.

1. ACUTE BRONCHIOLITIS AND VIRAL PNEUMONIA SPEAKER -Dr Chayanika Mishra Pediatric Resident , Kolkata

2. ACUTE BRONCHIOLITIS: Introduction Risk factors Etiology Patho physiology Clinical manifestation Diagnosis Management Complication

3. INTRODUCTION: Diagnostic term used to describe the clinical picture produced by several different lower respiratory tract infections in infants and very young children (younger than 1yr ,some clinicians extend it to the age of 2 yr.)

4. RISK FACTORS: HOST RELATED RISK FACTORS: Prematurity, especially < 32 weeks of gestation Low birth weight Age < 6-12 weeks Chronic lung disease including BPD Hemodynamically significant CHD ( Moderate to severe PH, cyanotic heart disease, or CHD that requires medication to control heart failure) Immunodeficiency Neuromuscular disorders ENVIRONMENTAL RISK FACTORS: Having older siblings Passive smoke Household crowding Child care attendance Lower socioeconomic status

5. ETIOLOGY: RSV most common virus isolated in about 75% (30-70 % in Indian studies) Rhinovirus Parainfluenza Adenovirus Human metapneumo virus Bocavirus Mycoplasma is more frequently implicated in older children with bronchiolitis

6. PATHOPHYSIOLOGY:

7. Severity of bronchiolitis: Mild Moderate Severe Feeding ability Normal ability to feed A ppear short of breath during feeding May be reluctant or unable to feed Respiratory distress Little or no respiratory distress Moderate distress with some chest wall retractions and nasal flaring Severe distress with marked chest wall retractions, nasal flaring and grunting ; Can have frequent and prolonged apnea Saturation Saturation >92% Saturation < 92%, correctable with oxygen Saturation < 92%,may or may not be correctable with oxygen

8. Differential diagnosis: Pneumonia : Fever >39°C with persistent focal crackles ; Episodic viral wheeze : Persistent wheeze without crackles, or recurrent episodes with or without a family history of atopy

9. Management: Treatment is focused on symptomatic relief and maintaining hydration and oxygenation. Fever should be controlled with paracetamol. Nose block should be cleared with saline nasal drops and gentle suctioning. Child should be made to lie in a propped up or head end elevated positioning . Orogastric tube feeding may be indicated in admitted patients. Intravenous (IV) fluids in children with impending respiratory failure or who do not tolerate orogastric/nasogastric (OG/NG) fluids. Suctioning of the upper airway in children with apnea, respiratory secretions, and feeding difficulties due to upper airway secretions. Supplemental oxygen in children with SpO2 below 90% (>6 weeks) or below 92% ( < 6 weeks or with underlying health issues). Drugs with questionable value might reduce need for admission or length of hospital stay , but broad consensus is lacking. • Nebulized hypertonic saline : In children hospitalized for >3 days • Nebulized adrenaline : 0.1–0.3 mL/kg/dose of 1:1,000 as a potential rescue medication; however inconsistent and short-lived improvement • Beta-agonists : Optional single trial; may be continued if there is clinical response (a trial of bronchodilator therapy may be initiated, but should be discontinued if there is no objective improvement.

10. No role of: • Chest physiotherapy • Antibiotics • Antivirals • Montelukast • Ipratropium bromide • Systemic or inhaled steroids • Steam inhalation • RSV polyclonal immunoglobulin/palivizumab (no roll in acute management but useful in prophylaxis) • Inhaled furosemide/inhaled interferon alfa-2a/inhaled recombinant human deoxyribonuclease (DNase) ; Interventions which are possibly effective for most severe cases : 1. CPAP 2. Surfactant 3. Heliox 4. Aerosolized ribavirin

11. Prevention: Breastfeeding : Three-fold greater risk in non-breastfed infant ; Hand hygiene ; Avoid passive smoking ; Immune prophylaxis : Palivizumab : Monoclonal antibody, monthly injections during seasonal epidemics. Indication: Infants < 12 months with prematurity < 29 weeks; CLD of prematurity; hemodynamically significant heart disease. Palivizumab is administered intramuscularly at a dose of 15 mg/kg monthly (every 30 days) during the RSV season. A maximum of five doses is generally sufficient prophylaxis during one season. Nirsevimab : On trial; single dose for 5 months Motavizumab, a second-generation mAb , and Numax -YTE , a third-generation mAb — under trial

12. Complications: Acute respiratory distress syndrome (ARDS) ; Myocarditis ; Congestive heart failure ; Arrhythmias ; Bronchiolitis obliterans ; Secondary bacterial infection ; Predisposition to childhood asthma

13. VIRAL PNEUMONIA : Introduction Risk factors Etiology Pathogenesis Clinical manifestations Diagnosis Treatment Prognosis Complications

14. INTRODUCTION : Pneumonia defined as inflammation of lung parenchyma. It is the leading infectious cause of death globally among children younger than 5 yr. The introduction of antibiotics and vaccine against measles , pertussis , haemophilus influenzae type b and PCV vaccine reduces the pneumonia related mortality over past 15 yr.

15. RISK FACTORS : Low birth weight SAM Vitamin A Deficiency Lack of breast feeding Overcrowding Indoor air pollution History of bronchitis Immunodeficiency

16. ETIOLOGY : INFECTIOUS: Bacterial Viral Fungal Rickettsial Mycobacterial Parasitic NONINFECTIOUS: Hypersensitive reaction Drug induced Radiation induced Aspiration_food /gastric acid/ hydrocarbons / foreign body

17. VIRAL: Common RSV Bronchiolitis Parainfluenza types 1-4 Croup Influenza A & B High fever, winter months Adenovirus Can be severe, often occurs between Jan - April Human metapneumovirus Similar to RSV Uncommon: Rhinovirus Rhinorrhea Enterovirus Neonates Herpes simplex Neonates, Immunocompromised persons CMV Infants, Immunocompromised persons (HIV) Measles Rash, coryza, conjunctivitis Varicella Unimmunised, Immunocompromised persons Hanta virus Rodents Corona viruses COVID-19, SERS, MERS

18. Age group Frequent pathogens Neonates (< 3 wks ) Gr B Streptococcus > E. Coli > other Gm – ve bacilli > S. pneumoniae > H. influenzae 3 wks – 3 months RSV > other respiratory viruses (Rhinovirus, Human Parainfluenza, Influenza, Human metapneumovirus, Adeno) > S. pneumoniae > H. influenzae. If patient is afebrile consider C. trachomatis. 4 months- 4 years RSV > other respiratory viruses (Rhinovirus, Human Parainfluenza, Influenza, Human metapneumovirus, Adeno) > S. pneumoniae > H. influenzae > M. pneumoniae ≥5 years M. Pneumoniae > S. pneumoniae > Chlamydophila. pneumoniae > H. influenzae > Influenza > Adeno > other respiratory viruses > Legionella

19. Recurrent Pneumonia: Differential Diagnosis of Recurrent Pneumonia HEREDITARY DISORDERS Cystic fibrosis Sickle cell disease DISORDERS OF IMMUNITY HIV/AIDS Bruton agammaglobulinemia Selective immunoglobulin G subclass deficiencies Common variable immunodeficiency syndrome Severe combined immunodeficiency syndrome Chronic granulomatous disease Hyperimmunoglobulin E syndromes Leukocyte adhesion defect Defined as 2 or more episodes in a single year or 3 or more episodes ever with radiological clearing between occurrences.

20. DISORDERS OF CILIA Primary ciliary dyskinesia Kartagener syndrome ANATOMIC DISORDERS Pulmonary sequestration Lobar emphysema Congenital cystic adenomatoid malformation Gastroesophageal reflux Foreign body Tracheoesophageal fistula (H type) Bronchiectasis Aspiration (oropharyngeal incoordination) Aberrant bronchus

21. Pathogenesis: Lower respiratory tract has number of defence mechanism which protect against infections-coughing ,mucociliary clearance ,macrophages ,secretory Ig A. Pneumonia results from: Disruption of a complex lower respiratory ecosystem that is site of dynamic interaction between 1. Potential pathogens , 2. Resident microbial community 3. Host immune defences.

22. Pathogenesis:

23. Secondary bacterial infection: Bacteria Mechanism of lung parenchymal involvement M. pneumoniae As is seen in viral pneumonia. S. pneumoniae Local edema that aids in the proliferation of organisms and their spread into adjacent portions of lung, often resulting in the characteristic focal lobar involvement Group A streptococcus Results in more diffuse lung involvement with interstitial pneumonia and involvement of lymphatic vessels & pleura. S. aureus confluent bronchopneumonia , characterized by extensive areas of hemorrhagic necrosis and irregular areas of cavitation, resulting in pneumatoceles, empyema, and, at times, bronchopulmonary fistulas .

24. Clinical Manifestations: Prodromal symptoms- Preceded by several days of symptom onset. Fever - Low grade compared to bacterial pneumonia. Tachypnea - Most consistent manifestation. Features of increased work of breathing- Chest retraction & nasal flaring. Children may lie on one side with the knees drawn up to the chest- splinting on the affected side to minimize pleuritic pain and improve ventilation. Abdominal pain- common in lower-lobe pneumonia. In infants , there may be a prodrome of URTI and poor feeding, leading to the abrupt onset of fever, restlessness, apprehension, and respiratory distress.

25. Physical findings: Tachypnea - Most consistent manifestation Diminished breath sounds, scattered crackles, and rhonchi are commonly heard over the affected lung field. With the development of increasing consolidation or complications of pneumonia such as pleural effusion or empyema , dullness on percussion is noted and breath sounds may be diminished. Abdominal distention may be prominent because of gastric dilation from swallowed air or ileus. The liver may seem enlarged because of downward displacement of the diaphragm secondary to hyperinflation of the lungs or superimposed congestive heart failure . It is often not possible to distinguish viral pneumonia (especially adenovirus) clinically from disease caused by Mycoplasma and other bacterial pathogens.

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