BRONCHIOLITIS.pptx

Bronchiolitis

1. BRONCHIOLITIS Prepared by Kasoki Salima Nicole Resident in peadiatric 8/03/2023

2. Plan Definition Etiology Risk factors Mode of transmission Pathophysiology Clinical features Diagnosis Management Differentials Complications Preventions References

3. Definition Acute inflammation of the lower respiratory tract leading to mucosal swelling and mucus deposits within bronchioles Occurs primarily in infants and young children (peak incidence 3 to 6 months); their tiny airways get easily blocked by inflammatory exudate

4. Etiology Usually caused by viruses, mainly Respiratory Syncytial Virus (RSV) Other viruses: - Rhinovirus -Para influenza virus type 3 -Human Metapneumovirus -Adenovirus - Influenza - Coronavirus -Human bocavirus 1

5. Mode of transmission Mode of spread: direct droplet spread Winter epidemics in Europe and America (November – April)

6. Risk factors Non breastfed babies (maternal antibodies) Overcrowding e.g. day-care centres Age <6 months Exposure to cigarette smoke Prematures

7. Pathophysiology   Bronchiolitis occurs when viruses infect the terminal bronchiolar epithelial cells, causing direct damage and inflammation in the small bronchi and bronchioles. Pathologic changes begin 18 to 24 hours after infection and include increased mucus secretion, bronchiolar cell necrosis , and sloughing Lead to ciliary disruption, peribronchiolar lymphocytic infiltration and submucosal oedema

8. Cont pathophysiology Edema, excessive mucus, and sloughed epithelial cells lead to formation of inflammatory debri produces critical narrowing and obstruction of small airways Decreased ventilation of portions of the lung ↓ Ventilation/perfusion mismatch ↓ Hypoxia.

9. Cont pathophysiology During the expiratory phase, further dynamic narrowing of the airways produces disproportionate airflow decrease and air trapping ↓ Increased work of breathing due to increased end-expiratory lung volume and decreased lung compliance Recovery of pulmonary epithelial cells occurs after 3 – 4 days Inflammatory debris is cleared by macrophages Cilia take about 2 weeks to regenerate

10. Clinical features 1. HISTORY Begin with upper respiratory tract symptoms Coryza with rhinorrhea nasal congestion and/or discharge( thick nasal secretions) dry cough low grade fever ≤38.3ºC (usually transient) progressive breathlessness Feeding difficulty

11. Cont clinical features 2. PHYSICAL -Respiratory distress(tachypnea, nasal flaring, grunting, retractions) -Cyanosis -Irritability -High pitched wheezes expiratory more than in inspiratory -Fine inspiratory crackles -Hyperinflated chest(increase AP diameter) -Tachycardia -Palpable liver and spleen (from hyperinflation of the lungs and consequent depression of the diaphragm)

12. Bronchiolitis severity score The bronchiolitis severity score(BSS) is an assessment scale used to evaluate the severity of illness in infants Severe bronchiolitis indicated by persistently increased respiratory effort (tachypnea; nasal flaring; intercostal, subcostal, or suprasternal retractions; accessory muscle use; grunting), hypoxemia, apnea, or acute respiratory failure . Infants and young children with severe disease require hospitalization for frequent observation as well as respiratory and/or fluid support

13. SCORES 1 2 3 RR when patient quiet Normal New born ≤60 Infant≤40 Toddler 20-30 Mid dyspnoea 60-80 40—60 30-40 Moderate 81-99 60-80 40-60 Severe More than 100 80 60 Oxygen saturation 93% 90% 90-93% 88% 86-89% 86% I≤ 85% General appearance Caml, no distres, interactive Mild irritable, easily consoled Difficult to console, moderate irritable Extremelly irritable and cannot be consoled Accesory muscle use No retraction Mild retraction( abdominal) 1 OF 4 Moderate (intera coastal ,subcostal with increase work of breath 2 OF 4 Severe retraction with sub, inter,tracheal retraction, nasal flaring,see saw breathing 3 or more wheezing clear End expiratory wheezing with crackles Diffuse expiratory wheezing Diffuse inspiratory and exp wheewing with absent breath sound

14. Diagnosis Clinical presentation Pulse- oximetry Chest x-ray is not routinely indicated (esp. when in doubt ) 4. CBC: the white blood cell and differential counts are usually normal and are not predictive of bacterial superinfection or moderately raised (10,000 - 15,000/ μL ), usually 50 - 75% lymphocytes 5. RSV antigen test from nasal swab ( polymerase chain reaction, or rapid immunofluorescence) is not routinely recommended in the diagnosis of bronchiolitis.

15. Cont diagnosis Xtic finding on Chest X-ray support Dx include: Increased lung vol with flat diaphragms. Mild cardiomegaly. Prominent vascular marking in a sunburst pattern originating at the hilium. Fluid seen in interlobar fissures & pleural effusions may be present.

16. Indications for hospitalization 1. Sick appearance, poor feeding, lethargy, or dehydration 2. Moderate to severe respiratory distress with one or more of the following signs: nasal flaring; intercostal, subcostal, or suprasternal retractions; respiratory rate >70 breaths per minute; dyspnea; or cyanosis 3. Apnea; Hypoxemia with or without hypercapnia (arterial or capillary carbon dioxide tension >45 mmHg) 5. Parents who are unable to care for them at home

17. Management nonsevere bronchiolitis  Infants and children usually can be managed in the outpatient setting 1. Supportive care includes maintenance of adequate hydration, relief of nasal congestion/obstruction, and monitoring for disease progression. 2.Components of education and anticipatory guidance include: -Proper techniques for sunctioning the nose: saline nose drops or spray might help with congestion and runny nose. -Encourage fluids : parents should breastfeed and encourage their child to drink  

18. Cont nonsevere management Antibiotics, cough medicines, decongestants, and sedatives are not recommended cause can mask symptoms of low blood oxygen and difficulty breathing. Antibiotics may be necessary if complication as bacterial infection, like an ear infection(otitis media) or pneumonia Return to medical care immediately: apnea, cyanosis, poor feeding, new fever, increased work of breathing, decreasing fluid intake Follow-up within one to two days, may occur by phone or at the office

19. Management of severe bronchiolitis 1. Respiratory support : most children require -Nasal sunctioning -Supplemental oxygen is provided to maintain SpO 2 >90 to 92%. -Infants are at risk for respiratory failure often receive a heated humidified high-flow nasal cannula (HFNC) therapy and/or continuous positive airway pressure (CPAP) before endotracheal intubation.

20. Cont severe management HFNC also called high-flow warm humidified oxygen) and CPAP are used to reduce the work of breathing, improve gas exchange, and avoid the need for endotracheal intubation in children are at risk for progression to respiratory failure Endotracheal intubation : infants who have worsening severe distress despite a trial of HFNC and/or CPAP, who have hypoxemia despite oxygen supplementation, and those with apnea may require endotracheal intubation and mechanical ventilation

21. Cont severe management 2. Fluid management : Children may have difficulty maintaining adequate hydration because of increased needs (related to fever and tachypnea) and decreased intake related to respiratory distress. Exclusive parenteral fluid administration or feeding by NGT is necessary to ensure adequate hydration and avoid the risk of aspiration in infants and children who are hospitalized with moderate to severe respiratory distress

22. INTERVENTIONS THAT ARE NOT ROUTINELY RECOMMENDED Inhaled bronchodilators Oral bronchodilators Systemic glucocorticoids Inhaled glucocorticoids Bronchodilators plus glucocorticoids Nebulized hypertonic saline Racemic epinephrine Chest physiotherapy : is discouraged because it may increase the distress and irritability of ill infants Antibiotics : always caused by viruses

23. Discharge criteria ● Respiratory rate <60 bpm for age <6 months, <50 bpm for age 6 to 11 months, and <40 breaths per minute for age ≥12 months ●Caretaker knows how to clear the infant's airway ●Patient is stable while breathing ambient air ●Patient has adequate oral intake to prevent dehydration ●Resources at home are adequate to support the use of any necessary home therapies ●Caretakers are confident they can provide care at home ●Education of the family is complete

24. Differentials Bacterial Pneumonia Asthma Foreign body aspiration Congenital heart disease Gastroesophageal reflex Aspiration pneumonitis Pertussis

25. Complication Chronic obstructive airway disease Respiratory failure Heart failure Secondary infection, such as bacterial pneumonia Bronchiolitis obliterans (usually adenovirus) Acute otitis media

26. Prevention Standard strategies to reduce the risk of bronchiolitis and accompanying morbidity include: Hand hygiene (washing with soap or with alcohol-based rubs) to minimize transmission of infectious agents Encourage breastfeeding Minimizing passive exposure to cigarette smoke Avoiding contact to individuals with respiratory tract infections

27. Take home message Bronchiolitis is an acute infectious inflammation of the bronchioles resulting in wheezing and airways obstruction in children less than 2 years old It is cause by virus especially RSV and others virus us rhinovirus Management is just supportive

28. References Nelson textbook of Paediatrics, 21 th ed. Uptodate 2018 Illustrated textbook of Paediatrics, Tom Lissauer and Graham Clayton, 4 th ed.