BRONCHIOLITIS

IAP UG Teaching slides 2015-16 1

 INTRODUCTION

MostcommonseriousLRTIneedinghospital
admission

Pediatricburdenofillnessworldwide

Generallyselflimitingcondition

IAP UG Teaching slides 2015-16 2

 DEFINITION

ClinicalSyndrome

Acuteonsetofresp.symptoms<2yrsage

InitialsymptomsUpperRespiratoryTractviralinfections

Fever,coryza,progressesin46daysto
LowerRespiratoryTractinvolvementCoughandwheezing

IAP UG Teaching slides 2015-16 3

 EPIDEMIOLOGY

incidenceduetoMoreprematureinfants&childrenwith
chronicillnesses

Morecommoninchildren<12months

>50%affectedchildren2to7mos.ofage

Infants<6monthsareathighestriskof
clinicallysignificantdisease

2%to3%ofchildrenrequirehospitaladmission

Commonlyinlateautumnandearlyspring
IAP UG Teaching slides 2015-16 4
 INCREASINGHOSPITALIZATIONPREDISPOSING
FACTORS

Infantsindaycare

Exposuretopassivesmoke

Crowdinginthehousehold

Environmentalandgeneticfactorsdocontributeto
severityofdisease

IAP UG Teaching slides 2015-16 5

 BRONCHIOLITISETIOLOGY

Viral
MostcommonRespiratorysyncytialvirus
OthersInfluenza,parainfluenza
adenovirus,coronavirus,
rhinovirus
M.pneumoniathoughisolatednotrecognizedas
etiologicalagent

IAP UG Teaching slides 2015-16 6

 PATHOPHYSIOLOGY

Sloughedepithelialcells Airwayobstruction
neutrophils&lymphocytes

Complete/partial Atelectasis/over
pluggingofsomeairways distention

Ventilationandperfusion Hypoxemia
imbalance

Oncepluggingofairwayhasoccurred,treatmentisonly
respiratorysupport,O2andtime
IAP UG Teaching slides 2015-16 7
 CLINICALFEATURES

Quitevariable
Nasalobstructionwithorwithoutrhinorrhea
CoughFirstirritatingtightcough
Poorfeedingaftertheinitialonsetofsymptoms
Apneaunto20%in<12monthswithRSV
Feverhigherthan39oC[adenovirusorinfluenza]

IAP UG Teaching slides 2015-16 8

 RESPIRATORYDISTRESS
39Respiratorydistress
oC[adenovirusorinfluenza]
Mild,moderateorsevere
ClinicalfeaturesNasalflaring,tachypnea,expanded
chest,audiblewheeze
Auscultationralesorrhonchi&poorairentry,
prolongedexpiratoryphase
OtherfeaturesConjunctivitis,rhinitis&otitis
media
MildtomoderatehypoxiaPulseoximetryor
arterialbloodgases
IAP UG Teaching slides 2015-16 9
 CLINICALCLASSIFICATION

39oC[adenovirusorinfluenza]
Mild,moderate,orsevere
Basedon:

Abilitytofeed

Respiratoryeffort

Oxygensaturationobservedatadmission
IAP UG Teaching slides 2015-16 10
 INVESTIGATIONS

Completebloodcount
39oC[adenovirusorinfluenza]
CXR
Nasopharyngealaspirate(NPA)
RSVandviralculture
ElectrolytesespeciallyifneedingIVfluids
Bloodcultureiftemperature>38.5C
Bloodgases
Usuallynolabtestsneededinmildbronchiolitis
IAP UG Teaching slides 2015-16 11
 CHESTXRAY

39CXRshows
oC[adenovirusor

Hyperinflation,patchy
influenza]
infiltratestypically
migratory[post
obstructiveatelectasis
&perbronchialcuffing]

IAP UG Teaching slides 2015-16 12

 DIAGNOSIS

Aclinicaldiagnosis
InfantwithshortprodromalofupperRTI
Clinicalfindingaudiblewheezing
wheezingwithcrackles
respiratorydistresswith
chestrecession

IAP UG Teaching slides 2015-16 13

 DIFFERENTIALDIAGNOSIS

Congenitalanomaliesvascularring,congenital
heartdisease
Gastroesophagealreflux
Aspirationpneumonia
Foreignbodyaspiration

IAP UG Teaching slides 2015-16 14

 MANAGEMENTPRINCIPLES

Supportivecaremainstayoftherapy

Moderatelyillinfantsrequiresupplementary.O2

IVFinyounginfantstachypnea,partialnasalobstruction.&feeding
difficulties.

RoleofbronchodilatorsControversial.Canhaveatrialwith
nebulisedsalbutamol,Nebulisedepinephrineorhpertonicsaline

IAP UG Teaching slides 2015-16 15

 OXYGEN

Humidifiedoxygenideal

Supplementaloxygen
ifSaO2<94%,combinationofclinicallysignificantrespiratorydistress,
RR>60/min,feedingdifficulty

MaintainSaO2above95%

Usenasalprongs/facemask/hood/headbox

Hypoxemia+/distress,despitehighO2flow,requireventilatory
support.

IAP UG Teaching slides 2015-16 16

 FLUIDTHERAPY

Indications
Nasalflaring,tachypnea(>60/min),apneic
episodes,markedretractions,tiringduringfeeds
Normalmaintenancevolumes
N/2orN/4dextrosesaline
Fluidvolumesincreasedupto20%
iffrequentorpersistentfever(>38.5C)and/or
markedlyincreasedrespiratoryeffort
Monitorserumelectrolytes

IAP UG Teaching slides 2015-16 17

 ICUMANAGEMENT

Neededinthefollowingcategory:
Progressiontosevererespiratorydistress,especiallyinatrisk
group
Apneicepisodes
E.g..associatedwithdesaturation
or>15secondsduration
orfrequentrecurrentbriefepisodes
Persistentdesaturationdespiteoxygen
ABGevidenceofrespiratoryfailure
i.e.pO2<80mmHg;
pCO2>50mmHg;
pH<7

IAP UG Teaching slides 2015-16 18

 CPAP

Maybenefitinfantswithbronchiolitisby
stentingopenthesmallerairwaysduringall
phasesofrespiration

Preventsairtrapping&obstructivedisease

IAP UG Teaching slides 2015-16 19

 DISCHARGE

Minimalrespiratorydistress
SaO2>90%inroomair
Exceptinchroniclungdisease,heartdisease,or
otherriskfactors
NotreceivedsupplementalO2for10hrs.
Minimalornochestrecession
Abletotakeoralfeeds

IAP UG Teaching slides 2015-16 20

 COMPLICATIONS

Respiratorycomplicationsmostfrequent

Infectiouscomplicationssecondmostcommon

Cardiovascular,electrolyteimbalance

IAP UG Teaching slides 2015-16 21

 COMPLICATIONS

Complicationrateswerehigherin
formerprematureinfants
congenitalheartdisease
othercongenitalabnormalities

Infants3335weeksGA
highestcomplicationrates
longerhospitalstay,
Increasedcoststhanotherformerprematureinfants

IAP UG Teaching slides 2015-16 22

 SERIOUSCOMPLICATIONS

Respiratoryfailure
Apnea
Pneumothorax
Amongformerprematureinfants
congenitalabnormalities
Riskofseriousbacterialinfectionsinfirstmonthof
liferegardlessofRSV+/

IAP UG Teaching slides 2015-16 23

 PROGNOSIS

Generallyselflimitingcondition
2%to3%ofchildrenrequirehospitalization
NeedforsupplementalO2basedonSaO2on
admissionandpredictlengthofhospitalstay
Bewareofrapiddeteriorationinhighriskgroup
Deathisuncommoneveninhighriskgroup

IAP UG Teaching slides 2015-16 24

ThankYou

IAP UG Teaching slides 2015-16 25