Bronchiolitis

This presentation gives an in-depth insight of all the recent advances and evidence based treatment of the Bronchiolitis, which is one of the most common cause of hospitalisation in children less than 5 years of age

1. Bronchiolitis Dr. Kaustubh Mohite

2. CASE 1 6 months old, Tara Complains of: Intermittent cough Runny nose Otherwise, the child is active, playful. Feeding normal. 3 days

3. Older sister has similar complains of runny nose and cough after attending a birthday party 5 days back. She is a full-term born child with no adverse perinatal events. No previous hospital admissions in the past 6 months. Immunized as per age.

4. On examination: Child is active, playful. Babbling Having intermittent wet cough. Nasal congestion + RS: Mild tachypnea (40 - 45 cycles / min) SpO2: 96% on room air No retractions, nasal flaring Air entry bilaterally equal Bilateral expiratory wheeze present

5. Case 2 2 ½ -month-old, Vivek Complains of: Cough for 5 days Fever for 1 day Parents feel that the activity has decreased since morning Child is accepting breastfeeds well.

6. Full term child with no significant perinatal events. No past admissions No similar complains in family members Immunized as per age.

7. On examination: Intermittent bouts of cough Interested in surrounding Nasal congestion + SpO2: 96% in room air RS: Mild tachypnea (45-50 cycles / min) No nasal flaring, chest retractions. Air entry bilaterally equal Bilateral expiratory wheeze present

8. Case 3 1 year old, Sameer Complains of : Cough and coryza for 1 week Fever for 3 days Labored breathing since morning Was taken to a local hospital on day 1 of fever where he was started on some oral antibiotic. Child is irritable and is not accepting feeds since last 24 hours. As the symptoms worsened, he was referred to you for further management.

9. Child was born late pre-term (36 weeks) with 3 days of NICU stay. Was admitted twice in the past for similar complains in the past. Received vaccination till 3 ½ months of age in government hospital. No similar complains in any other family member.

10. On Examination: Child was irritable. Febrile Tachycardia, Tachypnea present Mild dehydration SpO2: 86 - 88% in room air. No visible cyanosis RS: Tachypnea (60-65 cycles / min) Nasal flaring present Significant subcostal, intercostal retractions present Severe bilateral biphasic wheeze heard Diffuse fine crepitations present.

11. Case 4 8 months old, Sana. Complains of: Cough for 1 week Fever for 4 days Breathing difficulty 2 days back Was taken to a local hospital where the child was admitted. Was started on Oxygen by nasal prongs, Nebulization therapy, IV fluids and IV Antibiotics. In the following 24 hours, there was no improvement in any symptoms and the respiratory distress worsened.

12. Sana is a pre-term (30 wk ) born child (BW – 1.5 kg) with a stormy NICU course. Was mechanically ventilated for 5 days followed by CPAP support for 10 days and nasal Oxygen for 2 weeks. Had received Caffeine for apnea of prematurity. Was discharged on breastfeeds with supplementary feeds. Present weight – 3.6 kg Not received any vaccines No family history.

13. On examination: Child was lethargic, drowsy Moderate to severe dehydration present No active limb movements. Head bobbing present. Central cyanosis present Extremities cold, CRT – 5 sec SpO2: 68-70% in room air, 90% with NRM (100% FiO2) RS: Periodic, inefficient breathing. Intermittent apnea. Severe nasal flaring present. Significant Subcostal, intercostal, suprasternal retractions present. Decreased air entry bilaterally with crepitations

14. So, let’s review all these 4 cases together…..

15. Tara Vivek Sameer Sana Cold, Cough Cough, coryza, Fever, ? Decreased activity Cough, Coryza, Fever, Breathing Difficulty Cough, Coryza Fever, Worsening Respiratory failure Activity, feeding normal Feeding normal, Slightly decreased activity Poor feeding, Irritable No Feeding, lethargic, drowsy Mild tachypnea for age Moderate tachypnea for age Severe tachypnea for age Respiratory failure No nasal flaring, chest retractions No nasal flaring, chest retractions Nasal flaring and chest retractions present Severe chest retractions, head bobbing + Air entry equal, Mild expiratory wheeze Air entry equal, significant expiratory wheeze Biphasic wheeze, crepitations heard Reduced air entry, significant crepitations present SpO2: 96 – 98% in RA SpO2: 95 – 96% in RA SpO2: 86 – 88% in RA SpO2: 68 – 70% in RA, cyanosis + Mild Moderate Severe Very Severe

16. 2013 Woods-Downes criteria for staging severity of Bronchiolitis Score 1-3: mild bronchiolitis Score 4-7: moderate bronchiolitis Score 8-14: severe bronchiolitis

17. What is Bronchiolitis ? Inflammation of airways mainly involving small airways (Bronchioles). Seen classically in < 2 years of age. Characterized by Upper respiratory tract symptoms (rhinorrhea) followed by lower respiratory tract symptoms (wheeze, crepitations). Mostly of viral etiology. Leading cause of under 2-year hospital admission.

18. Viruses infect terminal bronchial epithelial cells Direct damage and inflammation in the small bronchi and bronchioles Edema, excessive mucus, and sloughed epithelial cells lead to obstruction of small airways Partial obstruction – hyperinflation Complete obstruction – collapse / atelectasis

19. Bronchiole + itis (Inflammation)

20. At cellular level:

21. RSV Rhinovirus Para-influenza virus (esp. type 3) Influenza virus Adenovirus Human Metapneumovirus Bocavirus Corona virus

22. Viral etiology in children aged less than 2 years with clinical suspicion of bronchiolitis. Mohite K et al, NH, Bangalore   1-6 months n(coinfection) 7-12months n(coinfection) 13-18 months n(coinfection) 19-24 months n(coinfection) Total RSV 6(3) 10(3) 3(2) 19 Rhinovirus 4(3) 7(3) 1(1) 1(1) 13 Parainfluenza 2(1) 4(2) 2 2(1) 10 Influenza virus 1 6 2 9 Metapneumovirus 1 1 2 Influenza virus 1 6 2 9 Bocavirus 3(3) 1 4 Coronavirus 1(1) 1 Enterovirus 2(2) 1(1) 1(1) 4 50 clinically diagnosed cases of bronchiolitis. 92% cases were positive for viral multiplex PCR. RSV – 41.3% Rhinovirus – 26% Para-influenza virus – 20% Multi-viral infection - 28.2% 2021

23. Risk Factors: Host factors: Prematurity (< 36 weeks) Low birth weight Chronic lung disease (BPD) Anatomic defect Immunodeficiency Environmental factors: Passive smoking Crowded households Daycare High altitude (> 2500 m) Similar complains in sibling

24. Clinical Manifestations:

25. Typical timeline of symptoms:

26. Complications:

27. Total 684 infants with bronchiolitis. RSV was found to be the commonest virus

28. Diagnosis: Diagnosed clinically. Upper respiratory prodrome ------- increased respiratory efforts (< 2 years) Chest X-ray and blood investigations are not necessary to make the diagnosis. It may be necessary in; Secondary / co-morbid bacterial infections Complications Children with underlying comorbidity.

29. CXR (4/23) USG chest (18/23) 23 children < 2 years Most common X-ray feature: enlarged hilus, peri-bronchial cuffing. Most common USG finding: alveolar-interstitial syndrome pattern

30. Virology

31. Differential Diagnosis:

32. Indications for Hospitalization Toxic appearance Poor feeding Lethargy Dehydration Moderate to severe respiratory distress Apnea Hypoxemia +/- hypercapnia Parents who are unable to care at home.

33. Non-Severe Bronchiolitis: Managed on OPD basis. Mainstay of treatment: Supportive care Anticipatory guidance Supportive care: Maintenance of adequate hydration Relief of nasal congestion / obstruction Monitoring of disease progression

34. NO pharmacologic effects in non-severe bronchiolitis due to……. Lack evidence of benefit Increases cost of care May have adverse effects

35. Anticipatory guidance for parents:

36. Moderate - Severe Bronchiolitis

37. Bronchodilators: Routine use of inhaled bronchodilators in first episode of bronchiolitis is NOT RECOMMENDED However, a one-time trial of inhaled bronchodilators (salbutamol or epinephrine) may be warranted for infants and children with severe bronchiolitis. 

38. 2021 Multicentric retrospective study Infants < 12 months with bronchiolitis from 49 hospitals from 2010 – 2018 Total 4,46,696 children visiting ER with bronchiolitis were included Primary outcomes: Rate of hospital admission ICU admission ER return visit post discharge.

39. Early bronchodilator use was not associated with a reduction in any outcomes

40. 2020 Use of salbutamol had no effect on bronchiolitis in children <24 months of age. Moreover, the treatment can also lead to side effects Salbutamol should not be recommended for treatment of bronchiolitis in infants.

41. Total of 21 studies were included in this meta-analysis Primary Outcome was effect of bronchodilators in Oxygen Saturation of the patients admitted with bronchiolitis. Secondary outcomes included effect of bronchodilators in: Improvement of clinical scores Admission to the hospital Duration of hospitalization Time to resolution of illness Pulmonary function tests

42. Bronchodilator recipients did not show any improvement in any of the parameters as compared to placebo.

43. Children with severe disease or respiratory failure generally were excluded from trials evaluating inhaled bronchodilators in children with bronchiolitis.  A subset of young children with the clinical syndrome of bronchiolitis may have virus-induced wheezing or asthma and may benefit from inhaled bronchodilator therapy.

44. Multicentric, prospective study of 2207 children hospitalized with bronchiolitis. PCR studies were done to find the virus and clinical condition was corelated. Children with Rhinovirus-associated bronchiolitis were more likely than those with respiratory syncytial virus (RSV)-associated bronchiolitis to be >12 months of age and to have a history of wheezing and eczema . Benefited from bronchodilator therapy due to pre-existing allergic manifestations.

45. No proven benefit of both oral and inhaled bronchodilator

46. Nebulized Hypertonic Saline: Even though there is no strong evidence against the use of nebulized hypertonic saline in bronchiolitis, some studies have concluded that it may reduce the rate of hospitalization. Mixed thought regarding its efficacy.

47. Inhaled HS causes decrease in airway edema in Bronchiolitis. Increases the osmotic levels at the luminal surface of the airways causing absorption of water and reduces the possibility of airway edema. Uses the principle of vaporization: Moisturize the airway surface. Increase mucosa cilia function Accelerate elimination of obstructive sputum.

48. 2018 Meta-analysis of 18 studies . 2102 children included from these studies. Conclusion: HS inhalations offered only limited clinical benefits , though the differences between HS and control groups were statistically significant. The heterogeneity between the studies was substantial.

49. 2017 Meta-analysis included 17 trials with 3105 children . Hospitalized infants treated with nebulized HS had a statistically significant shorter mean length of hospital stay as well as lower post-inhalation clinical scores. Nebulized HS with 3%, 7% and 14% NS showed reduced risk of hospitalization as compared to nebulization with 0.9% NS.

50. 2016 Among infants admitted to the hospital with bronchiolitis, treatment with nebulized 3% HS compared with NS had no difference in LOS or 7-day readmission rates.

51. Glucocorticoids: (Systemic / Inhaled) Glucocorticoids theoretically reduce airway obstruction by decreasing bronchiolar swelling. Uncertain benefits in bronchiolitis First episode of bronchiolitis - inflammation from asthma, and these patients can benefit from systemic glucocorticoids. For children with a first episode of bronchiolitis, systemic glucocorticoids are not recommended .

52. Meta-analysis including 17 RCTs (2596 cases) comparing short term systemic or inhaled glucocorticoids versus placebo in children with bronchiolitis. Evidence does not support a clinically relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalization. Combined dexamethasone and epinephrine may reduce outpatient admissions.

53. Among infants with bronchiolitis treated in the emergency department, combined therapy with dexamethasone and epinephrine may significantly reduce hospital admissions.

54. That’s enough of evidence-based medicine…… But what must be done practically when you have a sick child with suspected bronchiolitis ??

55. Inpatient management:

56. Fluid Management: Patients may have difficulty in maintaining adequate nutrition due to: Increased needs (fever, tachypnea) Decreased intake Exclusive parenteral fluid administration : avoid the risk of aspiration in infants and children who are hospitalized with bronchiolitis and have moderate to severe respiratory distress. For children who can tolerate enteral feedings, strategies to maintain hydration include small frequent feedings or orogastric or nasogastric feedings

57. Respiratory Support: Nasal Suctioning: Relieve nasal obstruction Significantly decreases upper airway resistance. Use of saline nasal drops. Avoid deep suctioning Nasopharyngeal suctioning may be traumatic and may increase edema and nasal obstruction. Oropharyngeal suctioning can induce cough

58. 2014 There was significant association between increased LOS and percentage use of deep suctioning during the first 24 hours of admission . Lapses of more than 4 hours between suctioning events in the first 24 hours after admission were associated with statistically significant longer LOS .

59. 2. Supplemental Oxygen Low flow devices High flow nasal cannula CPAP Endotracheal intubation

60. Low flow devices: Maintained respiratory drive. Maintain SpO2 above 90-92 % AAP suggests SpO2 < 90% as a cut-off for initiating oxygen therapy.

61. HHHFNC: (heated, humidified, high flow)

62. Mechanism of action:

63. 2013

64. CPAP: CPAP is used to avoid endotracheal intubation. It decreases work of breathing in children with progressive hypoxemia and hypercarbia. May be given as a trial measure if HFNC fails.

65. 2017 Superiority analysis suggested a higher success rate with nCPAP as compared to HFNC. The success rate with the alternative respiratory support, intubation rate, durations of non-invasive and invasive ventilation, skin lesions, and length of PICU stay were comparable between groups

66. Endotracheal Intubation: Children with ongoing or worsening severe distress despite a trial of HFNC and/or CPAP, those who have hypoxemia despite oxygen supplementation , and those with apnea may require endotracheal intubation and mechanical ventilation. 

67. Other therapy: Chest Physiotherapy Antibiotics in case of secondary infections Ribavirin (used in immunocompromised patients with severe bronchiolitis) Anti-RSV preparations ( Pavilizumab – RSV-specific humanized monoclonal antibody) Heliox (70:30 or 80:20 mixture of helium : Oxygen) Leukotriene inhibitors (Montelukast)

68. Discharge Criteria: Minimal clinical criteria for discharge include: Resolved tachypnea : RR <60/min for age <6 months <55 /min for age 6 to 11 months <45 /min for age ≥12 months Caretaker knows how to clear the infant's airway. Patient is stable while breathing ambient air (for at least 12 hours). Adequate oral intake to prevent dehydration. Resources at home are adequate to support the use of any necessary home therapies ( eg , bronchodilator therapy if the trial was successful and this therapy is to be continued). Caretakers are confident they can provide care at home. Education of the family is complete.

69. Outcome:

70. Take home points: Bronchiolitis is a clinical diagnosis. Prompt triaging is important before initiating therapy. Evidence based management should be kept in mind, but management of these patient vary from case to case. Proper monitoring of the child should be done and compared with its baseline parameters on admission. Parental education is important at the time of discharge or during treatment of the child on OPD basis.

71. References:

72. Thank You