CASE

BB Boy Duquena, 5 weeks old, born via CS premature SGA 3 kg had rhinorrhea and cough, 3 days PTC. had difficulty of breathing, few hours PTC. With no accompanying fever. At the ER, he looked very sick, initial chest X-ray did not show consolidation. PE revealed wheezes and rhonchi. WBC-predominance of lymphocytes.

Salient Features
Boy Premature Rhinorrhea Cough Difficulty of breathing Fever No consolidation on CXR Wheezes and Rhonchi WBC: predominance of lymphocytes

Diagnosis
With the given salient features the diagnosis is Bronchiolitis caused by Respiratory Syncytial Virus. RSV comes from the family Paramyxoviridae and subfamily Pneumovirinae. It is a medium-sized, membrane-bound RNA virus that develops in the cytoplasm of infected cells and matures by budding from the cell membrane. (Nelson, )

Pathogenesis
Three events characterize bronchiolitis: virus-induced necrosis of the bronchiolar epithelium, hypersecretion of mucus and round cell infiltration, and edema of the surrounding submucosa. These events constitute the formation of mucous plugs leading to obstruction of bronchioles causing hyperinflation or collapse of the distal lung tissue.

Therapeutic Objectives

To alleviate bronchiolitis To reduce re-infection and other complications of the disease caused by RSV

SANE
1. To stop the difficulty of breathing of the patient

Drug Class

Safe ty Corticostero +++ ids + [Inhaled] Beta +++ Agonists +

Afforda ble ++ +++

Necessi Effica ty cy ++++ ++ +++

TOT AL 12

++++ 14

Class A: Corticosteroids, inhaled Inhaled corticosteroids are formulated to be used directly to the tissues of the respiratory tract. Corticosteroids have anti-inflammatory effects. They do not directly relax the smooth muscle of the respiratory tract but reduce bronchial reactivity. On airway obstruction, their effect is due to their constriction of engorged vessels in the bronchial mucosa. Due to severe adverse effects corticosteroids are used for patients who require urgent treatment. Class B: Beta Agonists They relax the smooth muscle of the respiratory tract and inhibit bronchoconstriction. They are best delivered by inhalation to achieve a local effect on airway smooth muscle with least systemic toxicity.
BETA AGONISTS

Drug Epinephrine

Safe ty ++

Afforda ble +

Necessi Effica ty cy +++ ++

TOT AL 8

Salbutamol Terbutaline

++ ++

+++ +++

+++ +++

+++ ++

11 10

Epinehprine It is a rapid-acting bronchodilator that can be injected subcutaneously or inhaled as a microaerosol. Effect of bronchodilation is achieved 15 minutes after inhalation and will last 60-90 minutes. Adverse drug effects include tachycardia and arrhythmias. Salbutamol Salbutamol or albuterol is a short-acting beta2-adrenergic receptor agonist used for the relief of brochospasm. Usually given via inhalational route for direct effect on the smooth muscle of the respiratory tract. The maximal effect can take place within 5-20 minutes of Terbutaline A beta2-receptor agonist that is known for as a fastacting bronchodilator. The inhaled form of terbutaline starts working within 15 minutes and can last up to 6 hours.

2. To reduce re-infection and other complications of the disease caused by RSV

Ribavirin Ribavirin is a synthetic nucleoside analogue that inhibits a wide range of RNA and DNA viruses. Ribavirin-5'-monophosphate blocks the conversion of inosine-5'-monophosphate to xanthosine-5'-monophosphate and interferes with the synthesis of guanine nucleotides as well as that of both RNA and DNA. Ribavirin-5'-monophosphate also inhibits capping of virus-specific messenger RNA in certain viral systems. In studies demonstrating the effectiveness of ribavirin in the treatment of respiratory syncytial virus (RSV) infection in infants, the compound was administered as a small-particle aerosol. In infants with RSV infection who were given ribavirin by continuous aerosol for 36 days, illness and lower respiratory tract signs resolved more rapidly and arterial oxygen desaturation was less pronounced than in placebo-treated groups. In

addition, ribavirin has had a beneficial clinical effect in infants with RSV infection who require mechanical ventilation. Studies of infants with HRSV infection who were given aerosolized ribavirin, demonstrated a modest beneficial effect on the resolution of lower respiratory tract illness, including alleviation of blood-gas abnormalities. The American Academy of Pediatrics recommends that treatment with aerosolized ribavirin "may be considered" for infants who are severely ill or who are at high risk for complications of HRSV infection; included are premature infants and those with bronchopulmonary dysplasia, congenital heart disease, or immunosuppression. Large doses of ribavirin (8001000 mg/d PO) have been associated with reversible hematopoietic toxicity. This effect has not been observed with aerosolized ribavirin, apparently because little drug is absorbed systemically. Aerosolized administration of ribavirin is generally well tolerated but occasionally is associated with bronchospasm, rash, or conjunctival irritation. Aerosolized ribavirin has been approved for treatment of RSV infection in infants and should be administered under close supervisionparticularly in the setting of mechanical ventilation, where precipitation of the drug is possible. Health care workers exposed to the drug have experienced minor toxicity, including eye and respiratory tract irritation. Because ribavirin is mutagenic, teratogenic, and embryotoxic, its use is generally contraindicated in pregnancy. Its administration as an aerosol poses a risk to pregnant health care workers.
Palivizumab

Palivizumab is a humanized monoclonal antibody directed against an epitope in the A antigen site on the F surface protein of RSV. It is indicated for the prevention of RSV infection in high-risk infants and children such as premature infants and those with bronchopulmonary dysplasia or congenital heart disease. A placebo-controlled trial using once-monthly intramuscular injections (15 mg/kg) for 5 months beginning at the start of the RSV season demonstrated a 55% reduction in the risk of hospitalization for RSV in treated patients, as well as decreases in the need for supplemental oxygen, illness severity score, and need for intensive care. Although resistant strains have been isolated in the laboratory, no resistant clinical isolates have yet been identified. Potential adverse effects include upper respiratory tract infection, fever, rhinitis, rash, diarrhea, vomiting, cough, otitis media, and elevation in serum aminotransferase levels. Palivizumab is a humanized murine monoclonal anti-F glycoprotein immunoglobulin with neutralizing and fusion inhibitory activity against RSV.5 Palivizumab is administered intramuscularly at a dose of 15 mg/kg once every 30 days. An attempt should be made to maintain compliance with monthly administration.

Immunoprophylaxis with palivizumab is an effective, though costly, intervention. Optimal cost benefit from immunoprophylaxis is achieved during peak outbreak months when most RSV hospitalizations occur. If prophylaxis is initiated after widespread RSV circulation has begun, high-risk infants may not receive the full benefit of protection. Conversely, early initiation or continuation of monthly immunoprophylaxis during months when RSV is not circulating widely is not cost-effective and provides little benefit to recipients.

Alternative Drugs
No recommendations for complementary and alternative medicine for treatment of bronchiolitis are made because of limited data. In adults and older, healthy children, the symptoms of respiratory syncytial virus are mild and typically mimic the common cold and minor illnesses. Self-care measures are usually all that's needed to relieve any discomfort. Most people recover from RSV infection in 1 to 2 weeks.

Prescription

Ronnel Rodriguez, M.D. Altura Ext, Sta Mesa Manila 09226280558 Name: Boy Duquena 2011 Address: Tondo, Manila Date: June 28,

Salbutamol (Ventolin) 2.5 mg/2.5 mL nebule

Sig. Use 1 nebule per day No Refill Warning: Mouth and throat irritation may occur

__RBRodriguez__ License No.

References: American Academy of Pediatrician, Clinical Practice Guideline: Diagnosis and Management of Bronchiolitis. Fauci, A.S., E. Braunwald, D.L. Kasper, L, Stephen, L. Dan, L. Longo, L.J. Jameson and J. Loscalzo. 2008. Harrisons Principles of Internal Medicine: 17th edition. The McGraw-Hill Companies, Inc., USA. Katzung, B., S. Masters., A. Trevor., 200. Basic and Clinical Pharmacology: 11th Edition. The McGraw-Hill Companies, Inc., USA. Kliegman, Behrman, Jenson, Stanton., Nelson Textbook of Pediatrics: 18th Ediciton. Saunders Elsevier

MEDICAL THERAPEUTICS

RODRIGUEZ, Ronnel SALAZAR, Ma. Christina SANCHEZ, Darbene Lester

June 28, 2011