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BRONCHIOLITIS
Helmi M. Lubis, dr, SpA(K)
Ridwan M. Daulay, dr, SpA(K)Wisman Dalimunthe, dr, SpA
Rini Savitri Daulay, dr, M.Ked(Ped), SpA
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Definition: bronchioles inflammation
Clinical syndromes:
fast breathing, breathing difficulties,retractions, wheezing, poor feeding, cough,irritability, (very young) apnoe.
Predominantly < 2 years of age(2 8 months)
Difficult to differentiate with pneumonia
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Pathology
Necrosis of the respiratory tract epithelium
Destruction of ciliated epithelial cells
Peribronchial infiltration with lymphocites &neutrophils
Sub mucosal edematous
No destruction of collagen, muscle, or elastic
tissue
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Pathophysiology
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Edema + accumulation of mucous & cellular debrisnarrow of peripheral airway partially / totallyoccludedover distention / atelectasis
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Etiology
Predominantly RSV (Respiratory Syncytial Virus)95%
Other viruses :Human metapneumovirus
Rhinovirus
Adenovirus
Influenza virus
Parainfluenza virus
Entero virus
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Increase severity in:
Prematurity
Underlying medical condition
Group A RSV strainAge < 3 mo
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Diagnosis
Etiological diagnosis
Microbiologic examination (viral culture)
Clinical diagnosis
Signs and symptoms
Age
Resource of infectionepidemic of RSV
Laboratory finding
Radiological examination
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Clinical Manifestation
Mild rhinorrhea
Cough
Low-grade fever
1-2 days later: Fast breathing
Cyanosis
Grunting
Chest retraction
Wheezing
Irritable
Vomitus
Poor intake
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Physical Examinations
Tachypnea
Tachycardia
Retraction
Prolonged expiration Wheezing
Fever
Mild conjunctivitis Pharyngitis
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Radiologic examination
Diffuse hyperinflationPatchy infiltrates
Flat diaphragm
Intercostal space >Retrosternal space > (lateral view)
Peribronchial infiltrates / thickening
Atelectasissegmental collapse
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Respiratory rate : Arterial saturation
pCO2
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Differential Diagnosis
Asthma
Pneumonia Acute Bronchitis
Congestive Heart Failure
Pulmonary Edema
Obstruction in the lower respiratory tract
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Management
Mildtreated at home
Moderate / severe disease :
Hospitalization
Support :
Oxygen
Intra venous fluid drip (antibiotics)
Detect & treat possible complication
Prevent the spread of infection
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Controversial :
Bronchodilator
Corticosteroid
Antiviral
Antibiotic
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2Agonist
Flores and Horwitz, 1997
Meta-analysis of RCT inhaled 2Agonist
Sample : 3 inpatient & 5 outpatient studies Treatment : nebulized albuterol
Outcome : clinical score, satO2, LOS
Result : unavailable evidence of 2
Agonist efficacy
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Corticosteroid
Treatment : Prednison equivalent 1 mg/kgBW
Outcome : LOS, duration of symptoms (DOS),
clinical scores Result :
LOS and DOS
Clinical score
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Corticosteroid
Clinical score :
Wheezing
SaO2
Accessory muscle use RR
Conclusion :
Benefits depend on severity and initiation oftreatment
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Natural history & complications Regeneration of bronchiolar epithelium after 3 or 4 d
Cilia after 9 d
Improved clinical findings : in 3-4 days Improved radiological features: in 9 days
Persistent respiratory obstruction : 20%
Respiratory failure : 25 %
Lung collaps
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Prognosis
23% infantasthma at 3 years,
Control1% asthma
OR : 28; 90% CI 4-1235
(Garrison et al. 2000 after Sigurs et al. 1995)
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Correlation with Asthma
30 % - 50 % becomes asthmatic patients
Similarity in :Pathogenic mechanisms
Pathologic disorders
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