BRONCHIOLITIS

Helmi M Lubis, Dr, Sp.A(K) Ridwan M Daulay, Dr, SpA(K) Wisman Dr, Sp.A

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

 Pathology
Necrosis of the resp. epithelium
Destruction of ciliated epithelial cells

Bronchiolitis

Peribronchial infiltration with lymphocites & neutrophils Sub mucosal edematous No destruction of collagen, muscle, or elastic tissue

Pathophysiology
Edema + accumulation of mucous & cellular debris narrow of peripheral airway partially / totally occluded over distention / atelectasis

Bronchiolitis

Etiology
Predominantly RSV (Respiratory Syncytial Virus) Other viruses : rhinovirus, adenovirus, influenza virus,

parainfluenza virus, entero virus, etc.

Severity

Prematurity Underlying medical condition Group A RSV strain Age < 3 mo

OR 1.84 OR 2.84 OR 3.26 OR 4.39

Bronchiolitis

Diagnosis
Etiological diagnosis

Microbiologic examination

Clinical diagnosis
Signs and symptoms Age Resource of infection epidemic of RSV

Laboratory finding Radiological examination

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

Bronchiolitis

Radiologic examination
diffuse hyperinflation
flat diaphragm, Intercostal space > retrosternal space >

peribronchial infiltrates / thickening patchy atelectasis segmental collapse pleural effusion (rare) Laboratory finding
Respiratory rate : Arterial saturation

pCO2

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

HCO3-

PaCO2 40

24 mEq/l

7.4

pH

Differential Diagnosis

Asthma Pneumonia

Acute Bronchitis
Congestive Heart Failure Pulmonary Edema Obstruction in the lower respiratory tract

Bronchiolitis
Management
Mild treated at home Moderate / severe disease hospitalization

oxygen intra venous fluid drip (antibiotics) detect & treat possible complication prevent the spread of inf. Controversial : bronchodilator corticosteroid antiviral antibiotic

support :

2 Agonist
Flores and Horwitz, 1997 Meta-analysis of RCT inhaled 2 Agonist Sample : 3 inpatient & 5 outpatient studies Treatment : nebulized albuterol Outcome : clinical score, satO2, LOS Result : unavailable evidence of 2 Agonist efficacy

Corticosteroid
Garrison et al, 2000 Databases (Medline, Embase, Cochrane)

Treatment : Prednison equivalent 0,6-6,3 mg/kg. Total : 3,0 18,9 mg/kg Outcome : LOS, duration of symptoms (DOS), clinical scores Result : LOS and DOS clinical score

Corticosteroid
Clinical score : Wheezing SatO2 Accessory muscle use RR Conclusion : Benefits depend on severity and initiation of treatment

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)

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)

Bronchiolitis

Correlation with Asthma

30 % - 50 % becomes asthmatic patients Similarity in :

- pathogenic mechanisms - pathologic disorders