Bronchiolitis.pptx

Approach to children with Bronchiolitis.

1. Bronchiolitis Jwan Ali AlSofi

2. Objectives:- Discuss the epidemiology, etiology and clinical manifestations of acute bronchiolitis. Discuss the differential diagnosis . Discuss the diagnostic evaluation for recurrent wheezing. Discuss the treatment of acute bronchiolitis .

3. Definition:- Bronchiolitis is a disease of small bronchioles with increased mucus production and occasional bronchospasm , sometimes leading to airway obstruction. It is an acute viral lower respiratory tract infection. Bronchiolitis is most commonly seen in infants and young children . Most severe cases occurring among infants . Respiratory syncytial virus (RSV) is a primary cause of bronchiolitis . Bronchiolitis is potentially life-threatening .

4. Respiratory syncytial virus (RSV) – is a primary cause of bronchiolitis Human metapneumovirus. P arainfluenza viruses. P nfluenza viruses. Adenoviruses. Rhinoviruses. Coronaviruses. Mycoplasma pneumoniae. Etiology:-

5. Viral bronchiolitis is extremely contagious and is spread by contact with infected respiratory secretions . Hand carriage of contaminated secretions is the most frequent mode of transmission . Transmission:-

6. Children who are at increased risk of severe, potentially fatal disease, include:- premature infants children with chronic lung disease of prematurity, hemodynamically significant congenital heart disease, neuromuscular weakness, immunodeficiency 9

7. Epidemiology:- Bronchiolitis is the most common serious respiratory infection of infancy. Bronchiolitis is a leading cause of hospitalization of infants. Bronchiolitis occurs almost exclusively during the first 2 years of life. P eak age at 2 to 6 months . In the US, annual peaks are usually in the late winter months from December through March .

8. Bronchiolitis classically presents as a progressive respiratory illness . Bronchiolitis caused by RSV has an incubation period of 4 to 6 days . its early phase started by cough and rhinorrhea . It progresses over 3 to 7 days to : N oisy , and raspy breathing. A udible wheezing. Low -grade fever. Irritability – may reflect the increased work of breathing Decreased oral intake . Young infants infected with RSV may have apnea as the first sign of infection. Clinical Manifestations:-

9. Physical signs include : Nasal flaring. Suprasternal and Intercostal retractions. Air trapping with hyperexpansion of the lungs. percussion of the chest usually reveals only hyperresonance Prolongation of the expiratory phase of breathing Diffuse Wheezing and crackles throughout the breathing cycle. Poorly audible breath sounds suggest severe disease with nearly complete bronchiolar obstruction. With more severe disease, grunting and cyanosis may be present. Clinical Manifestations:-

10. The natural history of bronchiolitis:-

11. Happy wheezer :- Bronchiolitis , when noted in an otherwise healthy child beyond age 3 months, is often called the “ disease of the happy wheezer ,” where the child demonstrates considerable cough and wheezing while generally appearing only mildly ill. 17

12. Laboratory and Imaging:- Routine laboratory tests are not required to confirm the diagnosis . Pulse oximetry is adequate for monitoring oxygen saturation. Frequent , regular assessments and cardiorespiratory monitoring of infants are necessary because respiratory failure may develop. Antigen tests / PCR of nasopharyngeal secretions for RSV, parainfluenza viruses, influenza viruses, and adenoviruses are sensitive tests to confirm the infection.

13. Chest radiographs frequently show signs of lung hyperinflation , including : I ncreased lung lucency. F lattened or depressed diaphragms. Areas of increased density may represent:- viral pneumonia localized atelectasis . Laboratory and Imaging:-

14. Differential Diagnosis:- A sthma : A ge of presentation. P resence of fever . A bsence of personal or family history of asthma.

15. Bronchiolitis Asthma < 2 years > 2 years Fever No fever, unless a RTI is the trigger for the asthma exacerbation. Viral URI symptoms preceding presentation Sudden onset of symptoms No allergy triad Allergic history Absence of personal or family history of asthma Presence of personal or family history of asthma Response to bronchodilators – negative Response to bronchodilators – positive

16. Airway foreign body . Suggested by a focal area on radiography that remains inflated despite changes in position Cystic fibrosis. is associated with poor growth, chronic diarrhea , and a positive family history. GERD. Wheezing is likely to be chronic or recurrent, and the patient may have a history of frequent emesis. Cardiogenic asthma. Is wheezing associated with pulmonary congestion secondary to left-sided heart failure. Congenital airway obstructive lesion. Exacerbation of chronic lung disease. Viral or bacterial pneumonia . Differential Diagnosis:-

17. Treatment:- S upportive therapy : Oxygen administration, if needed. Respiratory monitoring for apnea Control of fever. Hydration. U pper airway suctioning. Bronchodilators, corticosteroids, chest physiotherapy , and hypertonic saline are seldom effective and are not generally recommended. Antibiotics should be avoided unless there is strong suspicion for concomitant bacterial infection.

18. Indications for hospitalization : Moderate to marked respiratory distress. Hypoxemia. Apnea. I nability to tolerate oral feeding. L ack of appropriate care available at home. High -risk children. Treatment:-

19. Complications and Prognosis Most hospitalized children show marked improvement in 2 to 5 days. Tachypnea and hypoxia may progress to respiratory failure requiring assisted ventilation. Most cases of bronchiolitis resolve completely. Recurrence is common but tends to be mild and should be assessed and treated similarly to the first episode.

20. The incidence of asthma seems to be higher for children hospitalized for bronchiolitis as infants. There is a 1% to 2% mortality rate, highest among infants with preexisting cardiopulmonary or immunologic impairment. Rarely, following adenovirus infection , the illness may result in permanent damage to the airways ( bronchiolitis obliterans ). Complications and Prognosis

21. Prevention:- Monthly injections of palivizumab , an RSV specific monoclonal antibody. I nitiated just before the onset of the RSV season . Indications : I nfants under 2 years old with : chronic lung disease with prematurity. Very low birth weight. H emodynamically significant cyanotic and acyanotic congenital heart disease. Immunization with influenza vaccine is recommended for all children older than 6 months and may prevent influenza-associated disease.

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