Bronchiolitis

Definition

bull Bronchiolitis is a first time wheezing with a viral respiratory infection

bull It is a common respiratory illness in children less than 24 months with its peak incidence between 3 to 6 months of age

bull Respiratory syncytial virus (RSV) is responsible for gt50 of cases

bull Other agents include parainfluenza adenovirus Mycoplasma and occasionally other viruses

bull Human metapneumovirus is an important primary cause of viral respiratory infection or it can occur as a co-infection with RSV

The common causal organisms of bronchiolitis

Epidemiology

bull A common respiratory illness especially in infants aged 1 to 6 months old

bull Cyclical periodicity with annual peaks occurs

in NovemberDecember and January

1)RSV infection incites a complex immune response Eosinophils degranulate and release eosinophil cationic protein which is cytotoxic to airway epithelium

2)Immunoglobulin E (IgE) antibody release may also be related to wheezing

3)Other mediators invoked in the pathogenesis of airway inflammation include chemokines such as interleukin 8 (IL-8) macrophage inflammatory protein (MIP) 1α

Pathophysiology

bull RSV-infected infants who wheeze express higher levels of interferon-γ in the airway as well as leukotrienes RSV co-infection with metapneumovirus can be more severe than monoinfection

Acute bronchiolitis is characterized by bronchiolar

obstruction with edema mucus and cellular debris

Resistance in the small air passages is increased

during both inspiration and exhalation but because

the radius of an airway is smaller during expiration

the resultant respiratory obstruction leads to early air

trapping and overinflation

If obstruction becomes complete there will be

resorption of trapped distal air and the child will

develop atelectasis

Clinical features

bull Coryzal symptoms precede a sharpdry coughincreasing breathlessness

bull Wheezing is oftenHigh pitchedexpiratorygtinspiratory

bull Feeding difficulty associated with increasing dyspnoea

bull Recurrent apnoea

bullSubcostal and intercostal recession

bullHyperinflation of the cheststernum prominentliver displaced downwards

bullFine end-inspiratory crackles

bullTachycardia

bullCyanosis or pallor

Page 13

Investigations

A chest ray is not routinely requiredbut

recommended for children with

1)severe respiratory distress

2)unusual clinical features

3)an underlying cardiac or chronic respiratory

disorder

4)Admission to intensive care

Page 14

Chest radiography reveals hyperinflationsegmentallobar collapseconsolidation

The white blood cell and differential counts are usually normal Viral testing (usually rapid immunofluorescence polymerase chain reaction or viral culture)

Page 15

15

chest X-ray shows hyperinflation of the lungs with flattening of the diaphragm horizontal ribs and increased hilar bronchial markings Note chest X-ray is rarely helpful in bronchiolitis

Page 16

The diagnosis is clinical particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

Definition

bull Bronchiolitis is a first time wheezing with a viral respiratory infection

bull It is a common respiratory illness in children less than 24 months with its peak incidence between 3 to 6 months of age

bull Respiratory syncytial virus (RSV) is responsible for gt50 of cases

bull Other agents include parainfluenza adenovirus Mycoplasma and occasionally other viruses

bull Human metapneumovirus is an important primary cause of viral respiratory infection or it can occur as a co-infection with RSV

The common causal organisms of bronchiolitis

Epidemiology

bull A common respiratory illness especially in infants aged 1 to 6 months old

bull Cyclical periodicity with annual peaks occurs

in NovemberDecember and January

1)RSV infection incites a complex immune response Eosinophils degranulate and release eosinophil cationic protein which is cytotoxic to airway epithelium

2)Immunoglobulin E (IgE) antibody release may also be related to wheezing

3)Other mediators invoked in the pathogenesis of airway inflammation include chemokines such as interleukin 8 (IL-8) macrophage inflammatory protein (MIP) 1α

Pathophysiology

bull RSV-infected infants who wheeze express higher levels of interferon-γ in the airway as well as leukotrienes RSV co-infection with metapneumovirus can be more severe than monoinfection

Acute bronchiolitis is characterized by bronchiolar

obstruction with edema mucus and cellular debris

Resistance in the small air passages is increased

during both inspiration and exhalation but because

the radius of an airway is smaller during expiration

the resultant respiratory obstruction leads to early air

trapping and overinflation

If obstruction becomes complete there will be

resorption of trapped distal air and the child will

develop atelectasis

Clinical features

bull Coryzal symptoms precede a sharpdry coughincreasing breathlessness

bull Wheezing is oftenHigh pitchedexpiratorygtinspiratory

bull Feeding difficulty associated with increasing dyspnoea

bull Recurrent apnoea

bullSubcostal and intercostal recession

bullHyperinflation of the cheststernum prominentliver displaced downwards

bullFine end-inspiratory crackles

bullTachycardia

bullCyanosis or pallor

Page 13

Investigations

A chest ray is not routinely requiredbut

recommended for children with

1)severe respiratory distress

2)unusual clinical features

3)an underlying cardiac or chronic respiratory

disorder

4)Admission to intensive care

Page 14

Chest radiography reveals hyperinflationsegmentallobar collapseconsolidation

The white blood cell and differential counts are usually normal Viral testing (usually rapid immunofluorescence polymerase chain reaction or viral culture)

Page 15

15

chest X-ray shows hyperinflation of the lungs with flattening of the diaphragm horizontal ribs and increased hilar bronchial markings Note chest X-ray is rarely helpful in bronchiolitis

Page 16

The diagnosis is clinical particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

bull Respiratory syncytial virus (RSV) is responsible for gt50 of cases

bull Other agents include parainfluenza adenovirus Mycoplasma and occasionally other viruses

bull Human metapneumovirus is an important primary cause of viral respiratory infection or it can occur as a co-infection with RSV

The common causal organisms of bronchiolitis

Epidemiology

bull A common respiratory illness especially in infants aged 1 to 6 months old

bull Cyclical periodicity with annual peaks occurs

in NovemberDecember and January

1)RSV infection incites a complex immune response Eosinophils degranulate and release eosinophil cationic protein which is cytotoxic to airway epithelium

2)Immunoglobulin E (IgE) antibody release may also be related to wheezing

3)Other mediators invoked in the pathogenesis of airway inflammation include chemokines such as interleukin 8 (IL-8) macrophage inflammatory protein (MIP) 1α

Pathophysiology

bull RSV-infected infants who wheeze express higher levels of interferon-γ in the airway as well as leukotrienes RSV co-infection with metapneumovirus can be more severe than monoinfection

Acute bronchiolitis is characterized by bronchiolar

obstruction with edema mucus and cellular debris

Resistance in the small air passages is increased

during both inspiration and exhalation but because

the radius of an airway is smaller during expiration

the resultant respiratory obstruction leads to early air

trapping and overinflation

If obstruction becomes complete there will be

resorption of trapped distal air and the child will

develop atelectasis

Clinical features

bull Coryzal symptoms precede a sharpdry coughincreasing breathlessness

bull Wheezing is oftenHigh pitchedexpiratorygtinspiratory

bull Feeding difficulty associated with increasing dyspnoea

bull Recurrent apnoea

bullSubcostal and intercostal recession

bullHyperinflation of the cheststernum prominentliver displaced downwards

bullFine end-inspiratory crackles

bullTachycardia

bullCyanosis or pallor

Page 13

Investigations

A chest ray is not routinely requiredbut

recommended for children with

1)severe respiratory distress

2)unusual clinical features

3)an underlying cardiac or chronic respiratory

disorder

4)Admission to intensive care

Page 14

Chest radiography reveals hyperinflationsegmentallobar collapseconsolidation

The white blood cell and differential counts are usually normal Viral testing (usually rapid immunofluorescence polymerase chain reaction or viral culture)

Page 15

15

chest X-ray shows hyperinflation of the lungs with flattening of the diaphragm horizontal ribs and increased hilar bronchial markings Note chest X-ray is rarely helpful in bronchiolitis

Page 16

The diagnosis is clinical particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

Epidemiology

bull A common respiratory illness especially in infants aged 1 to 6 months old

bull Cyclical periodicity with annual peaks occurs

in NovemberDecember and January

1)RSV infection incites a complex immune response Eosinophils degranulate and release eosinophil cationic protein which is cytotoxic to airway epithelium

2)Immunoglobulin E (IgE) antibody release may also be related to wheezing

3)Other mediators invoked in the pathogenesis of airway inflammation include chemokines such as interleukin 8 (IL-8) macrophage inflammatory protein (MIP) 1α

Pathophysiology

bull RSV-infected infants who wheeze express higher levels of interferon-γ in the airway as well as leukotrienes RSV co-infection with metapneumovirus can be more severe than monoinfection

Acute bronchiolitis is characterized by bronchiolar

obstruction with edema mucus and cellular debris

Resistance in the small air passages is increased

during both inspiration and exhalation but because

the radius of an airway is smaller during expiration

the resultant respiratory obstruction leads to early air

trapping and overinflation

If obstruction becomes complete there will be

resorption of trapped distal air and the child will

develop atelectasis

Clinical features

bull Coryzal symptoms precede a sharpdry coughincreasing breathlessness

bull Wheezing is oftenHigh pitchedexpiratorygtinspiratory

bull Feeding difficulty associated with increasing dyspnoea

bull Recurrent apnoea

bullSubcostal and intercostal recession

bullHyperinflation of the cheststernum prominentliver displaced downwards

bullFine end-inspiratory crackles

bullTachycardia

bullCyanosis or pallor

Page 13

Investigations

A chest ray is not routinely requiredbut

recommended for children with

1)severe respiratory distress

2)unusual clinical features

3)an underlying cardiac or chronic respiratory

disorder

4)Admission to intensive care

Page 14

Chest radiography reveals hyperinflationsegmentallobar collapseconsolidation

The white blood cell and differential counts are usually normal Viral testing (usually rapid immunofluorescence polymerase chain reaction or viral culture)

Page 15

15

chest X-ray shows hyperinflation of the lungs with flattening of the diaphragm horizontal ribs and increased hilar bronchial markings Note chest X-ray is rarely helpful in bronchiolitis

Page 16

The diagnosis is clinical particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

1)RSV infection incites a complex immune response Eosinophils degranulate and release eosinophil cationic protein which is cytotoxic to airway epithelium

2)Immunoglobulin E (IgE) antibody release may also be related to wheezing

3)Other mediators invoked in the pathogenesis of airway inflammation include chemokines such as interleukin 8 (IL-8) macrophage inflammatory protein (MIP) 1α

Pathophysiology

bull RSV-infected infants who wheeze express higher levels of interferon-γ in the airway as well as leukotrienes RSV co-infection with metapneumovirus can be more severe than monoinfection

Acute bronchiolitis is characterized by bronchiolar

obstruction with edema mucus and cellular debris

Resistance in the small air passages is increased

during both inspiration and exhalation but because

the radius of an airway is smaller during expiration

the resultant respiratory obstruction leads to early air

trapping and overinflation

If obstruction becomes complete there will be

resorption of trapped distal air and the child will

develop atelectasis

Clinical features

bull Coryzal symptoms precede a sharpdry coughincreasing breathlessness

bull Wheezing is oftenHigh pitchedexpiratorygtinspiratory

bull Feeding difficulty associated with increasing dyspnoea

bull Recurrent apnoea

bullSubcostal and intercostal recession

bullHyperinflation of the cheststernum prominentliver displaced downwards

bullFine end-inspiratory crackles

bullTachycardia

bullCyanosis or pallor

Page 13

Investigations

A chest ray is not routinely requiredbut

recommended for children with

1)severe respiratory distress

2)unusual clinical features

3)an underlying cardiac or chronic respiratory

disorder

4)Admission to intensive care

Page 14

Chest radiography reveals hyperinflationsegmentallobar collapseconsolidation

The white blood cell and differential counts are usually normal Viral testing (usually rapid immunofluorescence polymerase chain reaction or viral culture)

Page 15

15

chest X-ray shows hyperinflation of the lungs with flattening of the diaphragm horizontal ribs and increased hilar bronchial markings Note chest X-ray is rarely helpful in bronchiolitis

Page 16

The diagnosis is clinical particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

bull RSV-infected infants who wheeze express higher levels of interferon-γ in the airway as well as leukotrienes RSV co-infection with metapneumovirus can be more severe than monoinfection

Acute bronchiolitis is characterized by bronchiolar

obstruction with edema mucus and cellular debris

Resistance in the small air passages is increased

during both inspiration and exhalation but because

the radius of an airway is smaller during expiration

the resultant respiratory obstruction leads to early air

trapping and overinflation

If obstruction becomes complete there will be

resorption of trapped distal air and the child will

develop atelectasis

Clinical features

bull Coryzal symptoms precede a sharpdry coughincreasing breathlessness

bull Wheezing is oftenHigh pitchedexpiratorygtinspiratory

bull Feeding difficulty associated with increasing dyspnoea

bull Recurrent apnoea

bullSubcostal and intercostal recession

bullHyperinflation of the cheststernum prominentliver displaced downwards

bullFine end-inspiratory crackles

bullTachycardia

bullCyanosis or pallor

Page 13

Investigations

A chest ray is not routinely requiredbut

recommended for children with

1)severe respiratory distress

2)unusual clinical features

3)an underlying cardiac or chronic respiratory

disorder

4)Admission to intensive care

Page 14

Chest radiography reveals hyperinflationsegmentallobar collapseconsolidation

The white blood cell and differential counts are usually normal Viral testing (usually rapid immunofluorescence polymerase chain reaction or viral culture)

Page 15

15

chest X-ray shows hyperinflation of the lungs with flattening of the diaphragm horizontal ribs and increased hilar bronchial markings Note chest X-ray is rarely helpful in bronchiolitis

Page 16

The diagnosis is clinical particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

Acute bronchiolitis is characterized by bronchiolar

obstruction with edema mucus and cellular debris

Resistance in the small air passages is increased

during both inspiration and exhalation but because

the radius of an airway is smaller during expiration

the resultant respiratory obstruction leads to early air

trapping and overinflation

If obstruction becomes complete there will be

resorption of trapped distal air and the child will

develop atelectasis

Clinical features

bull Coryzal symptoms precede a sharpdry coughincreasing breathlessness

bull Wheezing is oftenHigh pitchedexpiratorygtinspiratory

bull Feeding difficulty associated with increasing dyspnoea

bull Recurrent apnoea

bullSubcostal and intercostal recession

bullHyperinflation of the cheststernum prominentliver displaced downwards

bullFine end-inspiratory crackles

bullTachycardia

bullCyanosis or pallor

Page 13

Investigations

A chest ray is not routinely requiredbut

recommended for children with

1)severe respiratory distress

2)unusual clinical features

3)an underlying cardiac or chronic respiratory

disorder

4)Admission to intensive care

Page 14

Chest radiography reveals hyperinflationsegmentallobar collapseconsolidation

The white blood cell and differential counts are usually normal Viral testing (usually rapid immunofluorescence polymerase chain reaction or viral culture)

Page 15

15

chest X-ray shows hyperinflation of the lungs with flattening of the diaphragm horizontal ribs and increased hilar bronchial markings Note chest X-ray is rarely helpful in bronchiolitis

Page 16

The diagnosis is clinical particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

Clinical features

bull Coryzal symptoms precede a sharpdry coughincreasing breathlessness

bull Wheezing is oftenHigh pitchedexpiratorygtinspiratory

bull Feeding difficulty associated with increasing dyspnoea

bull Recurrent apnoea

bullSubcostal and intercostal recession

bullHyperinflation of the cheststernum prominentliver displaced downwards

bullFine end-inspiratory crackles

bullTachycardia

bullCyanosis or pallor

Page 13

Investigations

A chest ray is not routinely requiredbut

recommended for children with

1)severe respiratory distress

2)unusual clinical features

3)an underlying cardiac or chronic respiratory

disorder

4)Admission to intensive care

Page 14

Chest radiography reveals hyperinflationsegmentallobar collapseconsolidation

The white blood cell and differential counts are usually normal Viral testing (usually rapid immunofluorescence polymerase chain reaction or viral culture)

Page 15

15

chest X-ray shows hyperinflation of the lungs with flattening of the diaphragm horizontal ribs and increased hilar bronchial markings Note chest X-ray is rarely helpful in bronchiolitis

Page 16

The diagnosis is clinical particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

bullSubcostal and intercostal recession

bullHyperinflation of the cheststernum prominentliver displaced downwards

bullFine end-inspiratory crackles

bullTachycardia

bullCyanosis or pallor

Page 13

Investigations

A chest ray is not routinely requiredbut

recommended for children with

1)severe respiratory distress

2)unusual clinical features

3)an underlying cardiac or chronic respiratory

disorder

4)Admission to intensive care

Page 14

Chest radiography reveals hyperinflationsegmentallobar collapseconsolidation

The white blood cell and differential counts are usually normal Viral testing (usually rapid immunofluorescence polymerase chain reaction or viral culture)

Page 15

15

chest X-ray shows hyperinflation of the lungs with flattening of the diaphragm horizontal ribs and increased hilar bronchial markings Note chest X-ray is rarely helpful in bronchiolitis

Page 16

The diagnosis is clinical particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

Page 13

Investigations

A chest ray is not routinely requiredbut

recommended for children with

1)severe respiratory distress

2)unusual clinical features

3)an underlying cardiac or chronic respiratory

disorder

4)Admission to intensive care

Page 14

Chest radiography reveals hyperinflationsegmentallobar collapseconsolidation

The white blood cell and differential counts are usually normal Viral testing (usually rapid immunofluorescence polymerase chain reaction or viral culture)

Page 15

15

chest X-ray shows hyperinflation of the lungs with flattening of the diaphragm horizontal ribs and increased hilar bronchial markings Note chest X-ray is rarely helpful in bronchiolitis

Page 16

The diagnosis is clinical particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

Page 14

Chest radiography reveals hyperinflationsegmentallobar collapseconsolidation

The white blood cell and differential counts are usually normal Viral testing (usually rapid immunofluorescence polymerase chain reaction or viral culture)

Page 15

15

chest X-ray shows hyperinflation of the lungs with flattening of the diaphragm horizontal ribs and increased hilar bronchial markings Note chest X-ray is rarely helpful in bronchiolitis

Page 16

The diagnosis is clinical particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

Page 15

15

chest X-ray shows hyperinflation of the lungs with flattening of the diaphragm horizontal ribs and increased hilar bronchial markings Note chest X-ray is rarely helpful in bronchiolitis

Page 16

The diagnosis is clinical particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

Page 16

The diagnosis is clinical particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

A majority of chidren with viral bronchiolitis has mild illness and about 1 of these children require hospital admission

Guideline for hospital admission

Home Management Hospital Management

Ageltthan 3 months No YesToxic looking No YesChest recession Mild ModeratesevereCentral cynosis No YesWheeze Yes YesCrepitations on auscultation Yes YesFeeding Well DifficultApnoe No YesOxygen saturation gt95 lt93High risk group No Yes

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

Management outline

1)General measures

bullcareful assessment of the respiratory status and oxygenation is critical

bullArterial oxygenation by pulse oximetry Sp02 should be performed at presentation and maintain above 93-administer supplemental humidified oxygen if necessary

bullMonitor for signs of impending respiratory failure-inability to maintain satisfactory Spo2 on inspired oxygengt40 or a rising pCO2

bullVery young infants are at risk of apnoea require greater vigilance

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

2)Nutrition and Fluid therapyFeedingInfants admitted with viral brochiolitis frequently have poor feeding are at risk of aspiration and may be dehydratedSmall frequent feeds as tolerated can be allowed in children with moderate respiratory distressNaso gastric feeding maybe useful in these children who refuse to feed and also to empty the dilated stomachIntravenous fluids for children with severe respiratory distresscyanosisapnoeaFluid therapy should be restricted to maintenance requirement of 100mlkgday for infants

3)PharmacotherapybullInhaled β-2 agonistsA trial of nebulised β-2 agonistsgiven in oxygenmay be considered in infants with viral bronchiolitisVigilant and regular assessment of the child should be carried out if such a traetment is provided bullInhaled steroidsRandomised controlled trials of the use of inhaled steroids for treatment of viral brochiolitis demonstrated nomeaningful benefit

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

4Antibiotic

Recommended for all infants withbull recurrent apnoea and circulatory impairmentbull - possibility of septicaemiabull - acute clinical deterioration1048991bull - high white cell countbull - progressive infiltrative changes on chest

radiograph

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

Prevention

Passive immunization with humanised RSV

specific monoclonal antibodies (Palivizumab)

prophylaxis is given during the expected

annual RSV outbreak season and is effective

in reducing the incidence of hospitalization

and severe respiratory disease in infants in

the hisk risk categories

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

Recommended catagories of infants for passive immunization

1Chronic lung diseaseChildren or infantslt24 months of age who requiredmedical treatment in the last 6 months before the anticipated RSV seasonMedical treatment includes supplementary oxygencorticosteroidsbrochodilators and diuretic

2Premature infants less thyan 32 weeks getation without chronic lung diseasebullInfants less than 28 weeks gestation up to 12 months of age at the start of the RSV seasonbullInfants between 28-32 weeks gestation up to 6 months of age at the start of the RSV season

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

Reference

1Nelson Textbook Of Pediatrics

18th Edition

2Pediatric Protocol 2nd Edition

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

CASE A CHESTY INFANT Max is a 3-month-old boy seen in the community by his GP He

developed a runny nose and bit of a cough 2 days ago but has become progressively more chesty and has now gone off his feeds and is having far fewer wet nappies He has two older siblings who also have colds He was born at 34 weeksrsquo gestation but had no significant neonatal problems and went home at 2 weeks of age Both parents smoke but not in the houseHis mother had asthma as a child

Examination Max is miserable but alert His airway is clear He is febrile

(378C) and has copious clear nasal secretions and a dry wheezy cough His respiratory rate is 56 breathsmin with tracheal tug and intercostal and subcostal recession On auscultation there are widespread fine crackles and expiratory wheeze The remainder of the examination is unremarkable

bull What is the most likely diagnosisbull What is the commonest causative organismbull What are the indications for referral to hospitalbull What is the management in hospital

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^

Thank you for your attention ^v^

• Bronchiolitis
• PowerPoint Presentation
• Epidemiology
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 10
• Clinical features
• Slide 12
• Slide 17
• Slide 18
• Slide 19
• 4Antibiotic
• Prevention
• Slide 22
• Reference
• CASE A CHESTY INFANT
• Thank you for your attention ^v^