K4- Bronchiolitis (IKA)

7/31/2019 K4- Bronchiolitis (IKA)

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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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K4- Bronchiolitis (IKA)

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