dr.

SAK Indriyani, SpA, MKes

Department of Child Health
RSU Mataram

DEFINITION
Bronchiolitis
bronchiolus inflammatory disease that
commonly caused by viral infection,
characterized by wheeze

ETIOLOGY
RSV*
Parainfluenza virus
Adenovirus
Rhinovirus
Influenza virus
M. pneumonia

EPIDEMIOLOGY
Age < 2 years old (2-6 months*).
69%(75%) < 1 year old

95% < 2 years old

2,2 cases per 100 child/year
1% from admission in child aged 1 years
old
Male > female (1,5:1; 1,25:1).
Almost all years (peak in winter, rainy
season)

..........epidemiology

Transmission >> by direct contact with

nasal discharge
SAFE if distance > 6 feet
RSV can survive until 6 hours in
contaminant area nosocomial
IMPORTAT : wash your hand after
contact !!
Virus can shed until 10 days

epidemiologi

>> in non breastfeeding infant

Minimal or no ventilation room, dense

population

transmission >>>

PATHOPHYSIOLOGY
Virus
Colonization & replication in
bronchiolus terminalis mucosa
Cilliary epithelium necrotic
Cells proliferation (lymphocyte,
plasma cell, macrophage) in
peribronchial area

patofisiologi

Submucosa edema & congestion

Bronchiolus plugging with mucous &

cellular debris
Abnormal mucociliary clirens

respiratory tract lumen <<<

patofisiologi

Functional residual capacity

Lung compliance , resistance resp.

tract
Dead space

, shunt

Breath effort
Ventilation perfusion changed
O2 ,

CO2

CLINICAL MANIFESTATION
Symptoms:
1-4 days before: runny nose, congestion
Subfebrile fever (except secondary
bacterial infection)
Peak day 5: cough, difficult to breath,
wheeze, unable to drink, apneu, cyanotic

Sign:
Nasal flare (+)
Muscle involvement
Difficult to breath, takipneu, apneu
Chest hyperinflation
Retraction, expiratory effort
Rhonchi in the end of
inspiration/beginning of
expiration
Prolonged expiration, wheeze
Palpable H/L

Degree of illness in bronchiolitis

1. Mild

RR below thresholds
and
Good air exchange
and
Minimal or no retractions
and
No sign of dehydration

2. Moderate
RR > thresholds
or
Moderate retractions
or
Prolonged expiratory phase with
decreased air exchange

3. Severe
High risk patient, or
RR > 70/minutes, or
Marked retractions, or
Minimal (poor) air exchange, or
Grunting respirations, or
O2 sat <94% at sea level or <90%
at 5000 ft, or
Signs of dehydration or systemic
toxicity

4. Very severe
Apnea or respiratory arrest, or
Cyanosis with oxygen, or
Inability to maintain
PaO2 > 50 mmHg with FiO2>80%, or
Inability to maintain
PaCO2 < 55 mmHg, or
Signs of shock

DIAGNOSIS
Clinically
Laboratory & radiologic findings
confirm & predict the outcome:
* gold standard: nasopharing swab (RSV
culture)
* Rapid RSV test: Elisa, direct
fluorescent
antibody staining
(sensitivity & specificity 90%)

 Serologic: need 7-10 days to seroconversion after

inoculation
Pulse oxymetry: severity of hypoxia & evaluate
O2
therapy response
BSA: evaluate respiratory failure
Blood: not specific

 Chest x ray:
* Hyperinflation, peribronchial
hiperdense,
interestitial infiltrate, atelectasis
* 10% normal
* No correlation between severity of
clinical
manifestation with chest x ray
result

PREDICTOR OF SEVERE
MANIFESTATION

Toxic appearance
Sa O2 < 95%
Gestation < 34 weeks
RR >70x/minute
Chest x ray: atelectasis
Age < 3 months

THERAPY
Supportive, oxygenation & adequately
hydration, complication monitoring
1. Oxygen:
* Decrease hypoxemia
* Nasal prongs, facemask
2. Bronchodilator:
Controversy

Pre eliminary study: not effective

(small sample)

Meta-analysis: clinically improvement

[RR 0,76 (IK 95% 0,60;0,95)], no

decrease in admission

Albuterol + ipratropium bromide vs

albuterol: no different
Racemic epinephrine vs saline:

clinical improvement (+), safe &

effective in age < 18 months old

Racemic epinephrine vs salbutamol,

in 30 minute: clinical improvement (+)

in racemic epinephrine, but not in
salbutamol
Racemic epinephrine vs albuterol:

Racemic epinephrine safe & clinical

improvement >> recommended as
first line

3. Glucocorticoid
* Theory: decrease inflammation
good 2-adrenergic response
* Result: controversy
* RCT: dexamethasone oral/im no
benefit ??
* RCT: dexamethasone oral 0,5
mg/kgBW
admission, followed by 0,3
mg/kgBW/day in
two days after no different

4. Antibiotic:
* Controversy