Bronchiolitis in Children Dr SAK Indriyani SpA MKes

dr. SAK Indriyani, SpA, MKesDepartment of Child HealthRSU Mataram

DEFINITIONBronchiolitis

bronchiolus inflammatory disease that commonly caused by viral infection, characterized by wheeze

ETIOLOGYRSV*Parainfluenza virusAdenovirusRhinovirusInfluenza virusM. pneumonia

EPIDEMIOLOGYAge < 2 years old (2-6 months*).69%(75%) < 1 year old95% < 2 years old2,2 cases per 100 child/year1% from admission in child aged 1 years oldMale > female (1,5:1; 1,25:1).Almost all years (peak in winter, rainy season)

..........epidemiologyTransmission >> by direct contact with nasal dischargeSAFE if distance > 6 feetRSV can survive until 6 hours in contaminant area nosocomialIMPORTAT : wash your hand after contact !!Virus can shed until 10 days

epidemiologi

>> in non breastfeeding infant Minimal or no ventilation room, dense population

transmission >>>

PATHOPHYSIOLOGYVirus

Colonization & replication in bronchiolus terminalis mucosa

Cilliary epithelium necrotic

Cells proliferation (lymphocyte, plasma cell, macrophage) in peribronchial area

patofisiologiSubmucosa edema & congestionBronchiolus plugging with mucous & cellular debrisAbnormal mucociliary clirens

respiratory tract lumen

patofisiologiFunctional residual capacityLung compliance , resistance resp. tractDead space , shunt

Breath effort

Ventilation perfusion changed

O2 , CO2

CLINICAL MANIFESTATIONSymptoms:1-4 days before: runny nose, congestionSubfebrile fever (except secondary bacterial infection)Peak day 5: cough, difficult to breath, wheeze, unable to drink, apneu, cyanotic

Sign: Nasal flare (+) Muscle involvement Difficult to breath, takipneu, apneu Chest hyperinflation Retraction, expiratory effort Rhonchi in the end of inspiration/beginning of expiration Prolonged expiration, wheeze Palpable H/L

Degree of illness in bronchiolitis

Mild RR below thresholdsand Good air exchangeand Minimal or no retractionsand No sign of dehydration

2. Moderate

RR > thresholdsor Moderate retractionsor Prolonged expiratory phase with decreased air exchange

4. Very severe Apnea or respiratory arrest, or Cyanosis with oxygen, or Inability to maintain PaO2 > 50 mmHg with FiO2>80%, or Inability to maintain PaCO2 < 55 mmHg, or Signs of shock

DIAGNOSIS Clinically Laboratory & radiologic findings confirm & predict the outcome:* gold standard: nasopharing swab (RSV culture) * Rapid RSV test: Elisa, direct fluorescent antibody staining (sensitivity & specificity 90%)

Serologic: need 7-10 days to seroconversion after inoculation Pulse oxymetry: severity of hypoxia & evaluate O2 therapy response BSA: evaluate respiratory failure Blood: not specific

Chest x ray:* Hyperinflation, peribronchial hiperdense, interestitial infiltrate, atelectasis* 10% normal* No correlation between severity of clinical manifestation with chest x ray result

PREDICTOR OF SEVERE MANIFESTATION Toxic appearance Sa O2 < 95% Gestation < 34 weeks RR >70x/minute Chest x ray: atelectasis Age < 3 months

THERAPY Supportive, oxygenation & adequately hydration, complication monitoringOxygen:* Decrease hypoxemia* Nasal prongs, facemask2. Bronchodilator: Controversy

Pre eliminary study: not effective (small sample)

Meta-analysis: clinically improvement [RR 0,76 (IK 95% 0,60;0,95)], no decrease in admission

Albuterol + ipratropium bromide vsalbuterol: no different

Racemic epinephrine vs saline:clinical improvement (+), safe & effective in age < 18 months old

Racemic epinephrine vs salbutamol,in 30 minute: clinical improvement (+) in racemic epinephrine, but not in salbutamol

Racemic epinephrine vs albuterol:Racemic epinephrine safe & clinical improvement >> recommended as first line

3. Glucocorticoid* Theory: decrease inflammation

good 2-adrenergic response* Result: controversy* RCT: dexamethasone oral/im no benefit ??* RCT: dexamethasone oral 0,5 mg/kgBW admission, followed by 0,3 mg/kgBW/day in two days after no different

4. Antibiotic:* Controversy

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