BRONCHIOLITIS AND

PNEUMONIA IN PEDIATRICS

BY: INTERN STUDENT NIYOMUGABO JEANNETTE

SUPERVISOR: DR UMUHOZA CHRISTIAN,

CONSULTANT PEDIATRICIAN
CASE Chief complain: Shortness of Breath
History of Presenting Illness: The symptoms started 1 week
PRESENTAT prior to admission with persistent non-productive cough
progressively increasing followed with Runny nose and nasal
ION congestion. 2 days prior to our admission she also started to have
difficulty in breathing that was so severe as the baby could not be
able to breastfeed well and started to vomit while coughing; there
was no relieving factors instead the baby kept being worsened. The
mother consulted private clinic but the symptoms persisted, that’s
when they decided to consult here for further management
ROS: no fever, no weight loss, no history of choking, no night
sweats, no diarrhea
PMH: no known chronic disease, at private clinic he was given vifex
syrup, Gramocef, Defal and sekrol, no surgical hx, immunization
uptodate, birth hx: born by svd, with 3.3 kg, no neonatal admission,
cried immediately
Nutrition: Breastfeed until 3.5 months, started infant formula
alternating with breast milk due to unavailability of mother and one
day prior to admission he was given banana and porridge,
otherwise he is growing well, gaining weight and no developmental
delay
Family Hx: she is the first born, lives with both parents, mother is
a teacher and father is the tax collector
 PE:GS: in Severe Respiratory Distress,
CASE…… JACCOLD+: Dry Bucal Mucossa
VS: HR: 148, T: 37.5, SPO2: 80% on RA
RS: in severe respiratory distress with nasal
flaring, head nodding, chest indrawing,
intercoastal and subcostal recession, no
cyanosis, Diffuse wheezes and Rhonchi on both
lungs.
Other systems are unremakarble
A:5-month Y.o female patient presented with
SOB and persistent non-productive cough
associated with vomiting on history of runny
nose and nasal congestion for few days whose
PE revealed bilateral Wheezes and Rhonchi and
features of severe respiratory distress
DDX:?
Investigation: ?
CONTENT

Bronchiolitis

Pneumonia

Role of POCUS in the diagnosis

of bronchiolitis and pneumonia
in pediatrics
BRONCHIOLITIS
 INTRODUCTION
Bronchiolitis refers to inflammation and obstruction of smallest
airways in the distal lower respiratory tract called bronchioles
It is almost exclusively caused by viral infection in children
younger than 2 years
Respiratory syncytial virus (RSV) is by far the most common
identified virus, detected in up to 80% of patients, followed by
human rhinovirus
 It occurs with seasonal variations
It’s a self-limited infection in majority of children though it may
progress INTO a severe form varying from mild symptoms that can
be managed at home to acute respiratory failure requiring intense
ventilation.
ANATOMY RECALL
About 30,000 terminal
bronchioles & 10,000 alveoli.
Children have small caliber
airways compared to adults ie
narrowed diameter.
They have low ability to clear
secretions.
EPIDEMIOLOGY Bronchiolitis is a significant cause of respiratory
OF disease worldwide in Children less than 2 years.
According to the World Health Organization
BRONCHIOLITIS bulletin, an estimated 150 million new cases
occur annually; 11-20 million (7-13%) of these
cases are severe
Worldwide, 95% ofenough to require
all cases occur inhospital
developing
admission.
countries.

It is the leading cause of hospitalization in

infants and young children

It is a seasonal disorder (mostly in winter/rainy

seasons)
 RISK FACTORS
Age is the most important predictor of disease severity, with
greatest risk between 1 and 3 months.
Preterm infants, especially those less than 29 weeks of
gestation.
Chronic lung disease of prematurity.
Congenital heart disease
 Lower birthweight
Tobacco smoke exposure
Immunodefficiency
ETIOLOGY Most common

• RSV

Followed by

• Rhinovirus

Less common

• Parainfluenza virus
• Influenza virus
• Adenovirus
• Rhinovirus
• Coronavirus
• Metapneumovirus
 PATHOPHYSIOLOGY
Virus replicates in the nasal epithelium,
and an exaggerated immune response
occurs, After an incubation period of 1
to 3 days from transmission, URT
symptoms appear.
In approximately 1/3 of infected
patients, infection then spreads to the
lower respiratory tract by shedding and
aspiration of necrotic nasopharyngeal
epithelial cells. subsequently similar
mechanisms occurs in the mucosal
epithelial cells of the bronchioles.
It is characterized by acute
inflammation, edema, necrosis,
increased mucus production and
bronchospasm. leading to LRT
 CLINICAL PRESENTATION
Initially 1-3days: URTI symptoms – coryzal symptoms
like rhinorrhea, nasal congestion, sneezing, cough, low-
grade fever < = 38.3

Followed by: tachypnea, increased WOB, wheezing,

crackles, and rhonchi which result from inflammation of
the small airways, respiratory distress, dehdration

Often associated with poor feeding

DIAGNOSIS Dx is clinical: Good history and PE

A hint: most patients will say that their child

was previously healthy and now present with a
first episode of wheezing following a period of
UTI symptoms.

Investigations

• FBC, CRP (less contributive)

• Blood work and imaging are mainly necessary to rule out
other causes

Chest X-ray

• Not mandatory
• Findings: hyper-inflated lungs, patchy atelectasis,
flattened diaphragm
• Not necessary for those with mild disease
• May be necessary in cases of moderate-severe respiratory
distress
SEVERITY ASSESSMENT

Severe
Moderately Bronchiolitis:
Mild Bronchiolitis: Severe Persistent
Little or no Bronchiolitis: tachypnea,
respiratory distress, Tachypnea, considerable
normal mental moderately respiratory distress,
status, normal increased WOB, no agitation, apnea
activity level apnea, normal level (mostly in preterm
of alertness and <2months of
age)
INDICATION Children under 3 months
FOR Children with pre-existing conditions
ADMISSION such as prematurity
Ongoing respiratory support
required
Need for supplemental hydration
Moderate-severe signs of
Respiratory distress
Consider if:
Risk factors for severe bronchiolitis
are present
Supportive care at home is not
feasible
 Management is supportive
MANAGEMENT Regular Nasal sunction
Respiratory support If SPO2 <90 % on RA
Hydration (assess level of dehydration)
Ensure adequate feeding orally or through
NGT
Manage pain and any fevers.
In case of severe bronchiolitis, nebulize
with hypertonic saline
In case of respiratory failure, use non-
invasive Naso CPAP or mechanical
ventilation(rare cases)
Family education, Nasal suction, and
expected course of disease
COMPLICATIONS

Dehydration (
fever,
Respiratory tachypnea, Aspiration
Apnea
failure tachycardia pneumonia
and low
intake)
Secondary
Recurrent Future
bacterial
wheezes Asthma
infections
 DIFFERENTIAL DIAGNOSIS

Wheeze
 Polyphonic Asymmetric crackles: bacterial
Reactive airway disease or viral pneumonia
Congestive heart failure Cough
secondary to congenital Pneumonia
heart disease Bordetella Pertussis infection
 Monophonic:
Foreign body aspiration

No URTI symptoms
Congenital heart disease
Foreign body aspiration
Chronic pulmonary diseases
 By nature, bronchiolitis is a
PROGNOSIS self-limited disease with a
relatively good prognosis.
With timely diagnosis and
adequate supportive
Mortality risk is relatively low
treatment.
and declining in otherwise
healthy children.

The most common sequela

attributed to bronchiolitis is
the development of reactive
airway disease or asthma
later in childhood.
KEY POINTS
 CASE SUMMARY
CC: SOB and Fever
HPI: the symptoms started 10 days prior to admission when he developed
productive cough associated with chest pain followed by low grade fever, and 2 days
later, he started to develop difficulty in breathing associated with moderated
abdominal pain and unsubsiding fevers, that’s when they consulted the traditional
healers and was given medication that induced vomiting right after the visit but the
abdominal pain got improved however, despite the fevers, coughing and SOB that
become so severe, there was no hemoptysis. They consulted HC and was referred at
DH where they did chest CT and revealed empyema and was transferred here for
further management
PMH: was hospitalized at DH on ceftriaxone and cloxacillin, they have also drained
500 cc of Pus, no know chronic Disease, immunization is uptodate and there was
good weight gain except these days of sickness, had no TB contact
ROS: Weight loss of unknown kgs, No night sweats, no palpitations, no dyspnea, no
diarrhea,
Family HX: He lives with both parents, and no known chronic disease in the family
CASE…….. PE: vs: HR:110, RR:25, SPO2: 96%
GS: was ambulating and not wasted,
JACCOLD: -
RS: in mild respiratory distress with nasal
flaring, has decreased breath sounds on the
right lung, good air entry on left lung field
and there was no crackles, no wheezes on
both lung fields
No features of malnutrition
Other systems are unremarkable
Assessment: 14 years old male patient with
10 days hx of productive cough, chest pain,
fever and SOB whose PE revealed decreased
breath sounds on the right lung and features
of mild respiratory distress
DX
PNEUMONIA
Pneumonia refers to inflammation of lung
parenchyma (bronchioles and alveoli) /
interstitium mostly due to infections.

It is lower respiratory tract infection

usually caused by bacterial, viral or
fungal.
In pneumonia, the alveoli become filled
with exudates and inflammatory cells
leading to poor lung function with
features of cough, fever, and SOB.
 Pneumonia is the leading cause of
EPIDEMIOLOGY death globally among children
younger than age 5 yr, accounting
for an estimated 1.2 million (18%
total) deaths annually.

The incidence of pneumonia is

more than 10-fold higher(0.29
episodes vs 0.03 episodes), and
the number of childhood-related
deaths from pneumonia ≈2,000
fold higher, in developing than in
developed countries.
ETIOLOGY
RISK FACTORS
•Asthma
•Not exclusively breastfed •BPD
•LBW •Cystic fibrosis
•Low socio-economic •GERD
status •Immunodeficiency
•CHD •Sickle cell disease
RISK FACTORS OF PNEUMONIA
ASSOCIATED WITH CHILDREN UNDER
5YRS – KIBAGABAGA DH
Uwamahoro, M. (2019). Epidemiology of
Pneumonia in Children in Rwanda.
University of Rwanda.
• Participants 137

• <1yr 59.1% ; 1-5yrs=40.9%

• M=55.5%, F=45.5%

-Children living in rural areas were at higher risk

57.7% than those in urban areas 43.3%

-Not receiving vaccination

-SGA

-Parent education level

-Having a family member who smokes indoors

 PATHOGENESIS
Pneumonia occurs because of an impairment of host defenses, invasion by a virulent organism,
and/or invasion by an overwhelming inoculum.
In the typical scenario, pneumonia follows an upper respiratory tract illness that permits
invasion of the lower respiratory tract by bacteria, viruses, or other pathogens that trigger the
immune response and produce inflammation.
The lower respiratory tract air spaces fill with white blood cells, fluid, and cellular debris. This
process :

Reduces lung compliance,

 Increases resistance
Obstructs smaller airways
Collapse of distal air spaces
Air trapping
Altered ventilation-perfusion relationships.

Severe infection is associated with necrosis of bronchial or bronchiolar epithelium and/or

pulmonary parenchyma.
CLINICAL •Fever

PRESENTATION •Cough (productive)

•SOB
•Tachypnea
•Respiratory distress
(intercostal/subcostal recession,
nasal flaring etc)
•Cyanosis and respiratory fatigue (in
severe cases especially for infant)
•Crackles and wheezing on
auscultation, decreased breath
sounds
•Bronchial breathing
SEVERITY CLASSIFICATION
 History and P/E
DIAGNOSIS Investigations:
FBC Chest x-
ray
Urinalysis
Blood culture
U&E
Blood smear
HIV Test
Chest x-ray showing
pneumonia

This chest X-ray clearly shows

an area of lung inflammation
indicating pneumonia is
present.
RADIOLOGICAL
FINDINGS
Lobar Pneumonia with
parapneumonic effusion
RADIOLOGICAL FINDINGS
R-upper lobe consolidation
RADIOLOGICAL
FINDINGS

PCP Pneumonia
 Treatment of suspected bacterial
MANAGEMENT pneumonia is based on the
presumptive cause and the age and
clinical appearance of the child.
For mildly ill children who do not
require hospitalization, amoxicillin is
recommended.

With the emergence of penicillin-

resistant pneumococci, high doses of
amoxicillin (80-90 mg/kg/24 hr) should
be prescribed.
For school-age children and in children
in whom infection with M. pneumonia
or C. pneumoniae is suggested, a
macrolide antibiotic such as
azithromycin is an appropriate choice.
COMPLICATION
S OF Complications of pneumonia are usually the result
of direct spread of bacterial infection within the
PNEUMONIA thoracic cavity.
 pleural effusion,
empyema
pericarditis.
S. aureus, S. pneumoniae, and S. pyogenes
are likely to cause :
parapneumonic effusions
empyema

Nonetheless many effusions that complicate

bacterial pneumonia are sterile.
PROGN Typically, patients with bacterial pneumonia show response to
therapy, with improvement in clinical symptoms (fever, cough,
OSIS tachypnea, chest pain), within 48-96 hr of initiation of antibiotics.

Consider these possibilities if no improvement with adequate

therapy

Complications, such as empyema

bacterial resistance

Nonbacterial etiologies such as viruses or fungi

aspiration of foreign bodies or food

Preexisting diseases such as immunodeficiencies, cystic fibrosis, or

congenital pulmonary airway malformation
SYMPTOM OVERLAP
A FE W GU I DI NG CLU ES

CONDITION FEVER UNWELL RECESSIO USUAL COUGH ASCULT

N/ AGE ATION
TACHYPN RANGE
EA
BRONCHIOLI USUALLY ONLY IF YES BELOW 2 HIGH WHEEZE
TIS LOW SEVERE YEARS (6M- PITCHED MORE
GRADE 2 years) THAN
BELOW 39 CRACKLE
C S
PNEUMONIA YES (LOW YES YES ANY AGE VARIABLE CRACKLE
GRADE TO S, more
HIGH) than
CONDITION INVESTIGATIO IMAGING TREATMENT COMPLICATIO
wheeze
N NS
BRONCHIOLITIS NOT NEEDED NOT NEEDED SUPPORTIVE APNEA
RESPIRATORY
FAILURE
ATELECTASIS
PNEUMONIA FBC,BS,HIV,bloo CXR THERAPEUTIC PARAPNEUMPNI
d culture ACCORDING TO C EFFUSSIONS
CAUSE LUNG ABSESS
EMPYEMA
 POCUS IN
BRONCHIOLITIS/PNEUMONIA
IN PEDIATRICS
ROLE OF POCUS IN DX
BRONCHIOLITIS AND PNEUMONIA
IN CHILDREN
Advantage
•Immediate results and facilitates
dx
•Ease of repeating scan to guide
management or monitor
improvement
•High sensitivity and specificity
compared to CXR
•Higher dx accuracy compared to
CXR
•No radiation exposure
Normal lung POCUS of an infant
with a linear probe
•A line – artifact reflections of the
pleural line
POCUS IN PNEUMONIA-
FINDINGS
• Fluid bronchogram: only observed in • Pleural sliding alteration: reduced or absent
obstructive pneumonia. pleural sliding
• Pleural abnormalities: less echogenic pleural
• Hepatization: areas of the aerated line in consolidation area, irregularities, diffuse
lung are replaced by fluid, the lung appearance, not visualized (in neonates)
tissue becomes more visible at the
ultrasound and a tissue-like appearance • Subpleural consolidation:
pneumonia/atelectasis
is observed (with air bronchogram).
• B-lines: A type of comet-tail artifact that is
• Pleural effusion associated with reduced pulmonary air/fluid
ratio and interlobular septal thicken
• Shred sign: consolidation with
irregular borders. • Air bronchogram
• Static It can be scattered (dotted) or
• Lung point: It may be present in branched.
newborns with pneumonia (not a • Dynamic: it might show movements with
diagnostic criteria) breathing and suggests pneumonia rather
than atelectasis
 U/S findings in CAP
Pulmonary consolidation
POCUS IN PNEUMONIA Air bronchogram
Pleural effusion
Pleural abnormalities
SEASHORE SIGN IN M-MODE – LUNG
SLIDING PRESENT: HELPS RULE OUT
PNEUMOTHORAX
BARCODE SIGN IN M-MODE-LUNG SLIDING
ABSENT: SEEN IN PNEUMOTHORAX OR
ANY LUNG HYPERINFLATING CONDITION
 POCUS IN
BRONCHIOLITIS
•The presence of normal lung sliding
with or without A lines—normal
pattern (Fig.1b)
•Presence of focal multiple B lines
(black and white lung) (Fig.1c)
•Presence of confluent B lines (white
lung) (Fig.1d)
•Presence of hypoechoic/hyperechoic
area with ill-defined margins at the
subpleural region—subpleural
consolida-tion (< 1cm, > 1cm)
(Fig.1e)
• Irregularities in the pleural line—
thickening greater than 0.5mm,
evidence of small subpleural
EVALUATION OF CORRELATION
BETWEEN LUSS AND B-RSS

Krishna, D., Khera, D., Toteja, N., Sureka, B., Choudhary, B., Ganakumar, V. M., &
Singh, K. (2022). Point-of-Care Thoracic Ultrasound in Children with Bronchiolitis.
Indian Journal of Pediatrics.
TAKE HOME
MESSAGE
Bronchiolitis is a self-limiting viral disease, but
supportive tx can be lifesaving.
Pneumonia is the leading cause of under 5
mortality globally and in Rwanda.
Presentation at the ER is often very similar in
both bronchiolitis and pneumonia.
History including age groups, and symptom
progression will guide your suspicion.
Normalize to use POCUS in Bronchiolitis and
Pneumonia
The adequate diagnosis will direct you to
REASSURE
TREAT
ADMIT
 NELSON TEXTBOOK OF PEDIATRICS
REFERENCES 20th edition
Pediatric National clinical
treatment guidelines
Basic Pediatric ETAT Protocol June
2022 Edition
https://www.msdmanuals.com/prof
essional/pediatrics/respiratory-disor
ders-in-young-children/bronchiolitis
http://www.pathophys.org/bronchiol
itis/
https://www.uptodate.com/contents
/community-acquired-pneumonia-in
-children