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Bronkhiolitis

Bronchiolitis
Pengertian:
>> infeksi akut saluran pernapasan bawah
infeksi dan inflamasi pada bronkiolus, pada
umumnya disebabkan karena virus.
Ditandai batuk, pilek, wheezing, takipneu, retraksi,
dan air trapping atau hiperaerasi pada chest xray.
Sering terjadi pada usia < 2tahun

APRC, 2011

Pathology
Desquamated epithelial cells
PMN & lymphocytes
Cellular infiltration
edema
Minimal alveolar infiltration

Within
airway
Around
airway

Airway Obstruction

Wohl and Chernick, 2003


Logic : Adrenergic & Adrenergic
agonist (Epinephrine)
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Epidemiologi

Manifestasi klinis
Gejala awal infeksi saluran pernapasan
atas ringan berupa pilek, batuk, bersin,
kadang demam subfebril dan nafsu makan
berkurang .

Gejala tersebut terjadi selama 1-3 hari,


pada kasus ringan dapat menghilang.

Bila berlanjut kemudian muncul tanda


distres respirasi takipnea, retraksi
subkostal, wheezing, ronki, hipoksia
spo2< 92%.
Pada bayi muda pernapasan tak teratur,
tanda distres lebih jelas.

Diagnosis
Risiko bronkiolitis lebih berat pada bayi
yang lebih muda, penyakit jantung bawaan,
displasia bronkopulmoner, prematur,
kelainan neurologis, dan sindrom.

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Tata laksana

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Adrenaline
Abul-Ainine, Luyt, 2002
RCT 38 infants with nebulized single 3 ml levoadrenaline vs Placebo with 6 L/mnt O 2
Outcome :
RR,HR,Sp O2
Respiratory Distress Assessment Instrument
(RDAI)
Activity level.
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Adrenaline
Result :
Supportive therapy prior to treatment
Significant reduction in RR (4,3/mnt)
Significant reduction in HR (4,6 X/mnt)
No changes in SpO2 & RDAI

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Adrenaline
Mechanism :
Bronchodilatation by 2 simpathomimetic
Reversal of edema through vasoconstriction
by 1 action
Physiological antihistamine effect for
mucosal decongestion
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2 Agonist (cont)
3 inpatient studies :
St 1 : Fenoterol 0,4 ml/kg
Statistically significant improved
clinical scores, shorter hospital stay
St 2 & 3 : Albuterol 0,15 mg/kg or 2,5 mg
No difference in clinical scores &
LOS
Significant reduction in SaO2
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2 Agonist (cont)
5 outpatient studies :
Nebulized albuterol 0,15 mg/kg, 2x, 30 mnt interval
or 4x, 60 mnt interval.

Result :
St 1 : Statistically significant reduction of RR
Improve accessory muscle score
SaO2, HR
St 2 : Significant improvement in wheezing score,
total clinical score, SaO2 after 2nd dose
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Corticosteroid
Garrison et al, 2000

Databases (Medline, Embase, Cochrane)


Treatment : Systemic steroid : Prednisone,
prednisolone, methylprednisone, hydrocortisone,
dexamethasone oral, IM, IV equivalent to prednisone
0,6-6,3 mg/kg. Total : 3,0 18,9 mg/kg
Outcome : LOS, duration of symptoms (DOS),
clinical scores, SaO2 (after 24 & 72 h)
Result : Statistically significant improvement :
LOS and DOS
clinical score
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Oral Dexamethasone
Schuh, 2002
Single dose 1 mg/kg dexameth vs placebo
+ nebulized albuterol 2,5 mg/dose in 3 ml NaCl
+ O2 6-7 l/mnt
Discharged from ED after 4 h,daily DX 0,6
mg/kg/dose 5 days + nebulized alb 1,5 mg,
4x/day
Result : Improved respiratory distress at 4 h,
reduced hospitalization
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Oral Dexamethasone (cont)


Wyer, 2002
Methodologically strong, first study of
glucocorticoid efficacy for non-hospitalized
(ED visit), first time moderate wheezer
Outcome : clinical significance in decreased
hospitalization
No adverse effects despite DX high dose
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Corticosteroid
Clinical score :
Wheezing
SatO2
Accessory muscle use
RR
Conclusion :
Benefits depend on severity and initiation of
treatment
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Antibiotics
RCT double-blind
Clarithromycin 15 mg/kgBW daily for 3
weeks in 21 infants < 7 months of age VS
plasebo
Result:
Reduce short term effect: LOS, duration of O2
and B2 agonis treatment.
Decrease of IL-4, IL-8 and eotaxin levels
Tahan
F et al. Eur Respir J 2007;
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29: 91-7

Commentary
Korppi M
small sample size
B2 agonist is rarely effective
Possibly mixed infection: RSV + atypical bacteria

Kneyber MCJ and Kimpen JLL


Methodological flaws unreliable results (small
sample size, AB for 3 weeks while LOS control only 88
hours)
Abuse of AB increased resistance
Eur27 Respir J 2007; 29(6): 1283-5

Fluids
RCT in 65 infants
Result: Nebulized 3% hypertonic saline is
effective in decreasing symptoms compared
to 0.9% saline, both + 5 mg Terbutaline

Sarrel ME et al. Chest 2002; 122: 201520


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Current Management
Barber & Hammer, 2003 Switzerland
99% bronchodilator (salbutamol) + 30% ipr
br
40% steroid : OPD, 57% steroid : IPD
18% cromoglycates
56% antibiotics
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