BRONCHIOLITIS

DR. FLORECILLA D. NELMIDA-ECUBE

SENIOR LECTURER
 BACKGROUND
• BRONCHIOLITIS is an acute inflammatory injury of the bronchioles that is
usually caused by a viral infection ( most commonly respiratory syncytial virus )
• It is the most common cause of lower respiratory tract infection in the first year
of life
• Occurs in any age, severe symptoms mostly evident only in young infants ( larger
airways of older children and adults accommodate mucosal edema )
• Usually affects children younger than 2 years, with a peak in infants aged 3-6
months
• Generally a self –limiting condition of RSV
 PATHOPHYSIOLOGY
• Bronchioles are small airways ( <2 mm in diameter ) and lack cartilage and
submucosal glands
• The terminal bronchiole, a 16th generation airway is the final conducting airway that
terminates in the respiratory bronchioles
• The acinus ( the gas exchange unit of the lung ) consists of respiratory bronchioles,
alveolar duct and alveoli
• The bronchiolar lining consists of surfactant secreting Clara cells and neuroendocrine
cells which are the source of bioactive products such as somatostatin, endothelin and
serotonin
 PATHOPHYSIOLOGY
• Bronchiolar injury and the subsequent interplay between inflammatory and mesenchymal cells can
lead to diverse pathologic and clinical syndromes
• Effects of bronchiolar injury may begin 18-24 hours after the infection and include
Increased mucus secretion
Bronchial obstruction and constriction
Alveolar cell death, mucus debris, viral invasion
Air trapping
Atelectasis
Reduced ventilation leading to ventilation-perfusion mismatch
Labored breathing
 PATHOPHYSIOLOGY
• The inflammation, edema, and debris result in obstruction of bronchioles, leading to hyperinflation,
increased airway resistance, atelectasis and ventilation- perfusion mismatching, Bronchoconstriction
has not bee described
• Infants are affected most often because of their small airways, high closing volumes, and insufficient
collateral ventilation
• Recovery begins with regeneration of bronchiolar epithelium after 3-4 days; however, cilia do not
appear for as long as 2 weeks
• Mucus plugs are instead predominantly removed by macrophages
• Infection is spread by direct contact with respiratory secretions
• Virtually all children experience RSV infection within the first 3 years of life but a previous infection
does not convey immunity
 ETIOLOGY
• Most cases of Bronchiolitis result from a viral pathogen such as RSV, rhinovirus, human
metapneumovirus (hMPV), parainfluenza virus, adenovirus, coronavirus, influenza virus or
human bocavirus
• Spread is from person to person through direct contact with nasal secretions, airborne droplets
and fomites
• RSV is the most commonly isolated agent in 75% of children younger than 2 years who are
hospitalized for Bronchiolitis
• Viral shredding in nasal secretions continues for 6-21 days after symptoms develop
• Incubation period is 2-5 days
• Parainfluenza virus causes 10-30% of all Bronchiolitis cases
 RISK FACTORS
• Age < 3 months ( 2/3 of all infants hospitalized with RSV infection are younger than
5 month
• Low birth weight particularly premature infants
• Gestational age (infants born at < 29 weeks gestation are at particularly higher risk
for hospitalization from RSV
• Low socioeconomic group
• Crowded living conditions, childcare center attendance,
• Parental smoking
• Chronic Lung disease ( Bronchopulmonary Dysplasia )
 RISK FACTORS
• Severe congenital or Acquired neurologic disease
• Hemodynamically significant CHD eg, pulmonary hypertension
• Congenital or Acquired Immune deficiency disease
• Airway anomalies
 PROGNOSIS
• Acute lower respiratory infections in children younger than 5 years of age remains a
leading cause of childhood mortality in the world ( WHO )
• The mortality in children hospitalized due to Bronchiolitis ranges from 0.2% -7%
 PRESENTATION
• HISTORY
- Clinical manifestations are usually subtle
- infants may become increasingly fussy and have difficulty feeding during the 2-5
day incubation period
- Low grade fever and increasing coryza and congestion usually follow the incubation
period
- in older children and adults, as well as in up to 60% of infants, RSV infection is
generally confined to the upper airway and does not progress further
 PRESENTATION
• HISTORY
- Over a period of 2-5 days, RSV infection progresses from the upper to the
lower respiratory tract leading to cough, dyspnea, wheezing, and feeding
difficulties
- Infants younger than 1 month may present as hypothermic
- Severe cases progress to respiratory distress with tachypnea, nasal flaring,
retractions, irritability and possibly cyanosis
 PHYSICAL EXAMINATION
• Tachypnea
• Tachycardia
• Fever (38-39 C )
• Retractions
• Fine rales (47%)
• Diffuse, fine wheezing
• Otitis media
• The diagnosis is made on the basis of age and seasonal occurrence, tachypnea, and the
presence of coryza, and fine rales, wheezes or both upon auscultation of the lungs
PHYSICAL EXAMINATION
• HYPOXIA is the best predictor of severe illness and correlates best with the
degree of tachypnea ( > 50 breaths/min )
• The degree of wheezing and or retractions correlates poorly with hypoxia
• First time infection is usually most severe; subsequent attacks are generally
milder, particularly in older children
• APNEA occurs early in the course of the disease and maybe the presenting
symptom in infants younger than 2 months or those born prematurely; rarely
lasts longer than a few days; however, 10% patients require intubation and
mechanical ventilation
PHYSICAL EXAMINATION

• Nonrespiratory manifestations of RSV infections include otitis media,

myocarditis, supraventricular and ventricular dysrhythmias and the syndrome
of inappropriate diuretic hormone (SIADH)
 COMPLICATIONS
• Various complications are possible including those caused by therapy
• In most cases, the disease is mild and self limited
• RSV bronchiolitis can result in any of the following
Acute respiratory Distress Syndrome (ARDS) Arrhythmias
Bronchiolitis Obliterans Chronic Lung Disease
Congestive Heart Failure
Secondary Infection
Myocarditis
• Possible association with asthma
 DIFFERENTIAL DIAGNOSES
• 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 ( ASTHMA )
Bronchomalacia Aspiration Pneumoinitis /Pneumonia
Cardiac disease Asthma
Congenital Lobar Emphysema Chlamydia and Mycoplasma pneumonia
Congenital Structural Airway Anomaly Croup
Gastroesophageal Reflux Disease ( GERD) Viral Pneumonia
 WORKUP
• Diagnosis is based on clinical presentation, the patient’s age, seasonal occurrence
and findings from the physical examination
• When all of the above are consistent with the expected diagnosis of bronchiolitis,
few laboratory studies are necessary
• Tests are typically used to exclude other diagnoses ( eg. Bacterial Pneumonia,
sepsis, Congestive heart failure ) or to confirm a viral etiology
• Though workups are common, several investigators argue that these should not be
routinely performed, citing concerns about costs, inappropriate use of antibiotics,
unnecessary hospitalization and the lack of proven benefit
 WORKUP
• Rapid viral antigen testing of nasopharyngeal secretions for RSV
• Arterial Blood gases ( ABG )- in severely ill patients or requiring ventilation
• FBC (WBC is usually 8000-15000/uL and maybe left shifted due to stress )
• CRP
• Chest xray
• others – pulse oximetry, blood culture, urine analysis and culture, urine specific
gravity ( provides useful information regarding fluid balance and possible
dehydration
 TREATMENT AND MANAGEMENT
• Since no definitive anti viral therapy exists for most causes of bronchiolitis, management of
this infants should be directed toward symptomatic relief and maintenance of hydration and
oxygenation
• ONLY OXYGEN appreciably improves the condition of young children with Bronchiolitis
and many other medical therapies remain controversial
• INITIAL MANAGEMENT – Patient should be made comfortable as possible
may administer nasal saline drops/ nasal & oral suctioning
( not routine needed )
carefully monitor the patient for apnea
temperature regulation for infants
 TREATMENT AND MANAGEMENT
• INITIAL MANAGEMENT – pulse oximetry
• ADMISSION CRITERIA ( length of stay averages 2-3 days with readmission rate 1-4%
Persistent resting oxygen saturation <90% in room air
Markedly elevated respiratory rate (> 70-80 breaths/min )
Dyspnea, intercostal retractions, cyanosis ( respiratory distress )
Chronic Lung disease ( already receiving O2 )
Congenital heart Disease esp if hemodynamically significant ( cyanosis /pulmonary
Hypertension )
Prematurity
 TREATMENT AND MANAGEMENT
• ADMISSION CRITERIA CONTINUATION
Age < 3 months
Inability to maintain oral hydration in patients younger than 6 months and
difficulty feeding as a result of respiratory distress
parent unable to care the child at home
• HOSPITAL – patient should be evaluated for ICU tx if
Worsening hypoxemia and hypercapnia Acidosis
worsening respiratory distress
Persistent oxygen desaturation/ severe cyanosis despite O2 support
Apnea
TREATMENT AND MANAGEMENT
• SUPPORTIVE THERAPY
Management is primarily supportive and should focus on therapies that
improve oxygenation and hydration
• PHARMACOLOGIC THERAPY
Limited role in the management of bronchiolitis
Bronchodilators – insufficient data to support routine use
Antivirals/ antibiotics – not routinely recommended ( Ribavirin )
Anti inflammatory agents – corticosteroids not recommended for routine
nebulized hypertonic saline
 TREATMENT AND MANAGEMENT
• COMPLICATIONS OF THERAPY
Ventilator induced trauma
Nosocomial infections
beta agonist induced arrhythmias
nutritional and metabolic abnormalities
• DISCHARGE CRITERIA
Ability of the carer to manage patient’s nasal congestion
improvement in respiratory distress ( RR < 60-70 and resting oxygen saturation
above 90 % in room air
 TREATMENT AND MANAGEMENT
• DISCHARGE CRITERIA CONTINUATION
Adequate oral intake
the education and confidence of the caretaker
no apnea in the preceding 24 hours ( in infants <6 months ) or the preceding 48
hours ( in infants > 6 months )
Acceptable oxygen saturation for more than a day
No underlying cardiopulmonary disease
 PREVENTION
• RSV is transmitted via direct contact with secretions of infected patients; droplets
and fomites play a less important role
• meticulous attention to handwashing between patient contacts
• Vaccine vs RSV (promising )
THANK YOU