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pediatric presentation

mohamed kalash

on 13 January 2013

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Transcript of bronchiolitis

Prince Salman Hospital
Department of Pediatric bronchiolitis by : Mohamed kalash

under supervision of
Dr. I.Alhazmi introduction Bronchiolitis is an acute inflammatory injury of the bronchioles
that is usually caused by a viral infection. Although it may occur in
persons of any age, the larger airways of older children and adults
better accommodate mucosal edema.

Bronchiolitis usually affects children younger than 2 years, with a peak ininfants
aged 3-6 months. Acute bronchiolitis is the most common cause of lower respiratory tract infection in the first year of life. It is generally a self-limiting condition and is most commonly associated with (RSV) . pathophysiology - Complex immunologic mechanisms play a role in the pathogenesis of bronchiolitis.
Type 1 allergic reactions mediated by immunoglobulin E (IgE) may account for some clinically significant bronchiolitis. Infants who are breastfed with colostrum rich in immunoglobulin A (IgA) appear to be relatively protected from bronchiolitis. - Necrosis of the respiratory epithelium is one of the earliest lesions in bronchiolitis and occurs within 24 hours of acquisition of infection . Proliferation of goblet cells results in excessive mucus production, whereas epithelial regeneration with nonciliated cells impairs elimination of secretions. Lymphocytic infiltration may result in submucosal edema. - Cytokines and chemokines, released by infected respiratory epithelial cells, amplify the immune response by increasing cellular recruitment into infected airways. Interferon and interleukin (IL)–4, IL-8, and IL-9 are found in high concentrations in respiratory secretions of infected patients. - The inflammation, edema, and debris result in obstruction of bronchioles, leading to hyperinflation, increased airway resistance, atelectasis, and ventilation-perfusion mismatching. Bronchoconstriction has not been described. etiology Most cases of bronchiolitis result from a viral pathogen . Bronchiolitis is highly contagious . RSV causes 20-40% of all cases
Human metapneumovirus (hMPV) account for 10-20%
Parainfluenza virus causes 10-30%
Adenovirus accounts for 5-10%
Influenza virus accounts for 10-20%
Mycoplasma pneumoniae infection accounts for 5-15% risk factors Risk factors for the development of bronchiolitis include the following : - Low birth weight, particularly premature infants .
- Gestational age .
- Lower socioeconomic group .
- Chronic lung disease .
- Crowded living conditions, daycare, or both .
- Parental smoking .
- Age less than 3 months .
- Airway anomalies .
- Severe congenital or acquired neurologic disease .
- Congenital heart disease (CHD) with pulmonary hypertension .
- Congenital or acquired immune deficiency diseases . 90% of the patients are aged between 1 and 9 months old. Bronchiolitis is the most common cause of hospitalization up to the first year of life. It is epidemic in winters.

Bronchiolitis is a significant cause of respiratory disease worldwide.
According to the World Health Organization bulletin,[56] an
estimated 150 million new cases occur annually; (7-13%) of these
cases are severe enough to require hospital admission.
Worldwide, 95% of all cases occur in developing countries. giagnosis The history and the physical examination form the primary basis for the
diagnosis of bronchiolitis . Bronchiolitis usually develops following one to three days of common cold symptoms, including the following:

Nasal congestion and discharge .
A mild cough .
Fever ( temperature > 38ºC ) .
Decreased appetite .
Apnea (a pause in breathing for more than 15 or 20 seconds) can be the first sign of bronchiolitis in an infant. more commonly in prematurely and infants who are younger than 2 months. symptoms : Examination often reveals the following :

- Tachypnea .
- Tachycardia .
- Fever (38-39°C) .
- Retractions .
- Fine rales (47%) .
- Diffuse, fine wheezing .
- Otitis media . As the infection progresses and the lower airways are affected, other symptoms may develop, including the following:
Breathing rapidly (60 to 80 times per minute) or with mild to severe difficulty .
Wheezing, which usually lasts about seven days .
Persistent coughing, which may last for 14 or more days .
Difficulty feeding related to nasal congestion and rapid breathing , which can result in dehydration : dry mouth and skin , drowsiness , producing little or no urine . physical examination : giagnosis According to a survey of hospital-based pediatricians, the most common tests are :

- rapid viral antigen testing of nasopharyngeal secretions for respiratory syncytial virus (RSV).
- arterial blood gas (ABG) analysis (in severely ill patients, especially those requiring mechanical ventilation).
- white blood cell (WBC) count with differential.
- C-reactive protein (CRP) level.
- chest radiography. investigation : Other common tests are :
- pulse oximetry .
- blood culture .
- urine analysis and culture .
- cerebrospinal fluid (CSF) analysis and culture .
- Urine specific gravity may provide useful information regarding fluid balance and possible dehydration .
- Serum chemistries are not affected directly by the infection but may aid in gauging severity of dehydration. Positive specimen for antigen detection of (RSV) in camel lung tissues using fluorescent antibody technique (FAT). Ethidium bromide stained gel electrophoresis for PCR amplification for the detection of respiratory syncytial virus genome An x ray of a child with RSV showing the typical bilateral perihilar fullness of bronchiolitis. Differential Diagnosis Bronchiolitis and asthma have similar symptoms and signs, and some concern exists that patients with asthma could be misdiagnosed with bronchiolitis. The pathology of bronchiolitis involves edema of the airway wall rather than bronchoconstriction (as in asthma). - Asthma and other causes of wheezing in childhood
- Bronchitis - Cystic fibrosis
- Congenital heart disease - Congestive heart failure (CHF)
- Pulmonary oedema - Pneumonia
- Foreign body inhalation - Aspiration
- Oesophageal reflux - Pneumothorax
- Kartagener's syndrome -Tracheomalacia/bronchomalacia Differentiating
Signs/Symptoms Differentiating Tests bronchiolitis vs pneumonia Patients with pneumonia often have a higher fever than patients with acute bronchiolitis, may appear more ill , Both bronchiolitis and pneumonia cause rapid breathing, wheezing and possible bluish skin due to lack of oxygen . CXR will detect an infiltrate from pneumonia that will not be present in acute bronchiolitis. bronchiolitis Asthma - child is usually older than 2. - the child is usually under 2. - the temperature is normal. - accompanied by a fever. - Asthma usually runs in families - it does not run in families. - will respond to medicines,
such as the Epi-pen or an
antihistamine. - will not improve when given
these medications. vs complication With bronchiolitis, as with any disease, various complications are possible, including those caused by therapy. In most cases, the disease is mild and self-limited. However, in infants who are immunosuppressed and those with preexisting heart or lung disease, RSV bronchiolitis can result in any of the following - Acute respiratory distress syndrome (ARDS)
- Bronchiolitis obliterans
- Congestive heart failure
- Secondary infection
- Myocarditis
- Arrhythmias
- Chronic lung disease management MILD MODERATE SEVERE Behaviour Respiratory
Rate Accessory
Muscle Use Feeding Oxygen Apnoeic
episodes Assessment of Severity normal normal normal None or
minimal No oxygen requirement (Sa02 > 93%) none Some/intermittent irritability Increased Resp rate
Tracheal Tug
Nasal Flaring Moderate chest wall retraction May have difficulty with feeding or reduced feeding Mild hypoxemia corrected by oxygen
(Sa02 90 - 93%) May have brief apnoeas Increasing irritability and/or lethargy Marked increase or decrease
Tracheal Tug
Nasal Flaring Marked chest wall retraction Reluctant or unable to feed Hypoxemia, may not be corrected by oxygen
(Sa02 < 90%) May have increasingly frequent or prolonged apnoeas Acute Management severity management mild moderate severe Can be managed at home. Advise parents of the expected course of the illness,
and when to return if there are problems Give Parent Information Leaflet.
Smaller, more frequent feeds.Review by GP within 24 hr. Admit.
Administer O2 to maintain adequate saturation.Consider i.v. fluids at 75% maintenance (inappropriate ADH). One to two hourly observations dependent on condition.. Cardiorespiratory monitor
Inform ICU- may require CPAP or ventilation. management Treatment : 1) Oxygen to maintain saturations in the target range 92-96%, preferably via a humidified circuit:

a. Nasal cannula up to 2 l.p.m. flow

b. Head box for higher requirements

Once in the convalescent phase oxygen supplementation needs to be actively weaned every four hours to maintain the target saturation range.

2) Respiratory support with CPAP or very rarely ventilation is managed on PICU.
The Vapotherm® (a device capable of delivering high flow of up to 8 l.p.m. of humidified oxygen) is
hopefully to undergo a safety and feasibility study but is available for rescue therapy if thought
appropriate by the consultant in charge of the child’s care. 3) Nutrition and hydration

a. Smaller and more frequent feeds either by breast or bottle-feed, calculated to a 2nd to 3rd
hourly amount, which should be specified in the notes.

b. Nasogastric / Orogastric feeds are an effective and safe method if used appropriately. It is
indicated in those who are unable to take sufficient oral intake to maintain or correct
hydration status. A referral to the dietician should be made.

c. Intravenous fluids indicated if child is vomiting or has severe respiratory distress, which may
be worsened by enteral feeds.

i. 0.45% saline (as minimum concentration) and 5% dextrose with 10mmol KCl \ 500mls
ii. 75% ‘maintenance’ requirements.
iii. Check UEs within 24hours of commencing, in particular to monitor for hyponatraemic
fluid overload.

4) Physiotherapy – no evidence to support the use of chest physiotherapy . 5) Drug therapy

In normal, immunocompetent patients with bronchiolitis a large number of trials have not found
drug therapy to be of significant benefit.

a. Bronchodilators including nebulised epinephrine – systematic reviews (complicated by the use of different agents and different outcomes) show only modest benefit in short term clinical
scores, which are not regarded as clinically significant; but no improvement in admission rates,
oxygen need or length of stay.
A trial of 6 actuations of a salbutamol MDI, administered via spacer may be tried on the advice
of senior medical staff but if no clinical improvement ensues in 20 minutes it should not be

b. Antibiotics – controlled trials show not indicated routinely.

c. Steroids (inhaled or oral) – systematic review, no evidence of benefit acutely or in
preventing future wheezing.

d. Ribavirin – not routinely recommended.

e. RSV immunoglobulin – not routinely recommended. Discharge criteria - Stable and improving
- SpO2 maintained >92% in air for period of 8-12 hours including a period of sleep
- Feeding adequately (more than 2/3 normal feeds)
- Family confident in their ability to manage How can you prevent your baby from
getting bronchiolitis ? The best steps you can follow to reduce the risk of baby become infected with RSV or other viruses that can cause bronchiolitis include :

- Make sure everyone washes their hands before touching your baby.

- Keep your baby away from anyone who has a cold, fever, or runny nose.

- Avoid sharing eating utensils and drinking cups with anyone who has a cold, fever, or runny nose. Complications of Therapy - Ventilator-induced barotrauma

- Nosocomial infection

- Beta-agonist–induced arrhythmias

- Nutritional and metabolic abnormalities thank you references :
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