Post on 05-Apr-2018
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BRONCHIOLITIS
Helmi M Lubis, Dr, Sp.A(K)
Ridwan M Daulay, Dr, SpA(K)
Wisman Dr, Sp.A
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Bronchiolitis
Bronchioles inflammation
Clinical syndromes:
fast breathing, breathing difficulties,retractions, wheezing, poor feeding, ,cough, irritability, (very young) apnoe.
Predominantly < 2 years of age
(2
6 months) Difficult to differentiate with pneumonia
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Bronchiolitis Pathology
Necrosis of the resp. epithelium Destruction of ciliated epithelial cells
Peribronchial infiltration with lymphocites & neutrophils
Sub mucosal edematous
No destruction of collagen, muscle, or elastic tissue
Pathophysiology
Edema + accumulation of mucous & cellular debris
narrowof peripheral airway partially / totally occluded overdistention / atelectasis
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Bronchiolitis Etiology Predominantly RSV (Respiratory Syncytial Virus)
Other viruses : rhinovirus, adenovirus, influenza virus,parainfluenza virus, entero virus, etc.
Severity Prematurity OR 1.84 Underlying medical condition OR 2.84
Group A RSV strain OR 3.26
Age < 3 mo OR 4.39
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Bronchiolitis Diagnosis
Etiological diagnosisMicrobiologic examination
Clinical diagnosis
Signs and symptomsAge
Resource of infection epidemic of RSV
Laboratory finding Radiological examination
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Bronchiolitis Clinical Manifestations : mild rhinorrhea,
cough, cold, low-grade fever
1-2 d fast breathing, chest retraction,
wheezing, irritable, vomitus, poor intake Physical Examinations
tachypnea, tachycardia, retraction,
prolonged expiration, wheezing,fever,pharyngitis, conjunctivitis, otitis media,dehydration
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Bronchiolitis
Radiologic examinationdiffuse hyperinflation flat diaphragm,
Intercostal space >
retrosternal space >peribronchial infiltrates / thickening
patchy atelectasis segmental collapse
pleural effusion (rare) Laboratory finding Respiratory rate : Arterial saturation
pCO2
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Bronchiolitis Laboratory finding
Microbiologic examination
WBC : 5000 24.000 cells/mm3, predominantly PMN &bands
Blood Gas Analysis Arterial saturation
pCO2
Mild respiratory alkalosis
Metabolic acidosis
Acute respiratory acidosis
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7.4 pH
24 mEq/l
HCO3-
PaCO2
40
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Differential Diagnosis
Asthma
Pneumonia Acute Bronchitis
Congestive Heart Failure
Pulmonary Edema
Obstruction in the lower respiratory tract
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Bronchiolitis Management
Mild treated at home
Moderate / severe disease hospitalization
support : oxygen
intra venous fluid drip(antibiotics)
detect & treat possible complication
prevent the spread of inf.
Controversial : bronchodilatorcorticosteroid
antiviral
antibiotic
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2 Agonist
Flores and Horwitz, 1997
Meta-analysis of RCT inhaled 2Agonist
Sample : 3 inpatient & 5 outpatient studiesTreatment : nebulized albuterol
Outcome : clinical score, satO2, LOS
Result : unavailable evidence of2Agonist efficacy
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Corticosteroid
Garrison et al, 2000Databases (Medline, Embase, Cochrane)
Treatment : Prednison equivalent 0,6-6,3mg/kg. Total : 3,0 18,9 mg/kg
Outcome : LOS, duration of symptoms(DOS), clinical scores
Result : LOS and DOS
clinical score
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Corticosteroid
Clinical score :
Wheezing
SatO2 Accessory muscle use RR
Conclusion :
Benefits depend on severity and initiation oftreatment
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Bronchiolitis
Natural history & complications Regeneration of bronchiolar epithelium after
3 or 4 d
Cilia after 3 or 4 d
Improved clinical findings : in 3-4 days Improved radiological features: in 9 days
Persistent respiratory obstruction : 20%
Respiratory failure : 25 % Lung collaps (rare)
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Prognosis
23% infant asthma at 3 years,
Control 1% asthma
OR : 28; 90% CI 4-1235(Garrison et al. 2000 after Sigurs et al. 1995)
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Bronchiolitis Correlation with Asthma
30 % - 50 % becomes asthmatic patients
Similarity in : - pathogenic mechanisms
- pathologic disorders
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