BronchiolitisMOHAMMAD MATOUQ ALGHAMDI –PHARM.D INTERNSHIPPEDIATRIC ROTATION

Bronchiolitis Bronchiolitis is an acute viral infection of the lower respiratory tract of infants that affects ~50% of children during the first year of life and 100% by 3 years.

Respiratory syncytial virus is the most common cause of bronchiolitis, accounting for up to 75% of all cases. Parainfluenza viruses are the second most common cause. Bacteria serve as secondary pathogens in only a small minority of cases.

Clinical Presentation

Treatment • Bronchiolitis is a self-limiting illness and usually requires no therapy (other than reassurance, antipyretics, and adequate fluid intake) unless the infant is hypoxic or dehydrated. Otherwise healthy infants can be treated for fever, provided generous amounts of oral fluids, and observed closely. • In severely affected children, the mainstays of therapy for bronchiolitis are oxygen therapy and intravenous (IV) fluids.

Treatment • Aerosolized β-adrenergic therapy appears to offer little benefit for the majority of patients but may be useful in the child with a predisposition toward bronchospasm.

• Because bacteria do not represent primary pathogens in the etiology of bronchiolitis, antibiotics should not be routinely administered. However, many clinicians frequently administer antibiotics initially while awaiting culture results because the clinical and radiographic findings in bronchiolitis are often suggestive of a possible bacterial pneumonia.

Treatment • Ribavirin may be considered for bronchiolitis caused by respiratory syncytial virus in a subset of patients (severely ill patients, especially those with chronic lung disease, congenital heart disease, prematurity, and immunodeficiency (especially severe combined immunodeficiency and human immunodeficiency virus [HIV] infection).). Use of the drug requires special equipment (small-particle aerosol generator) and specifically trained personnel for administration via oxygen hood or mist tent.

INDICATIONS FOR HOSPITALIZATIONToxic appearance, poor feeding, lethargy, or dehydrationModerate to severe respiratory distress, manifested by one or more of the following signs: nasal flaring; intercostal, subcostal, or suprasternal retractions; respiratory rate >70 breaths per minute; dyspnea; or cyanosisApneaHypoxemia with or without hypercapnia

Clinical Case

Demographic and Administrative InformationAge 5 Month

Gender Female

Nationality Saudi

Date of Administration 17 – 2 - 1438

Date of Discharge 22 – 2 - 1438

Weight 6.5 KG

Laboratory DataDate Result

WBCs 13.6RBCs 5.60HGB 13.9HCT 41MCV 73.2MCH 33.9MCHC 33.9PLT 428

Chief Complaint Fever and Cough for tow day ago

Acute Medical Therapy : Cefotaxime Dexamethasone Paracetamol BromhexineNormal Saline Ventolin

Vital Signs Date 17 18 19 20 21 22

Temp 37.4 36.5 36.7 36.5 36.9 37.1

Oxygen 96% 88% 91% 90% 96% 96%

Pulse 155 140 146 130 124 129

R.R 30 34 32 33 32 30

Normal Vital Signs

Current Drug Therapy Drug name / Dose / Strength / Rout / Freq . Indication Strat Stop Discharged ( Y

/ N )Cefotaxime 125 m / I.V / Q6H LRTI 17 - 2 - Y

Dexamethasone 0.25 ml / I.V / BID Anti inflammatory 17 - 2 - Y

Paracetamol 2.3 ml / P.O / S.O.S Fever 17 - 2 20 -2 N

Normal Saline 150 ml / I.V / Q8H Fluid 17 - 2 - Y

NEB . Ventolin 0.125 mg / Q4H bronchodilators 20 - 2 22 – 2 N

Drug Interaction Drug interaction assessment worksheet

Potential interaction severity Drug 2 Drug 1

Corticosteroids may enhance the hypokalemic effect of Beta2-Agonists.

[B] No Action Needed

Dexamethasone

Albuterol

Pharmacist’s care plan Fluid management The fluid intake and output of infants and children with bronchiolitis should be assessed regularly. Children with bronchiolitis may have difficulty maintaining adequate hydration because of increased needs (related to fever and tachypnea) and decreased intake (related to tachypnea and respiratory distress).

Supplemental oxygen Supplemental oxygen should be provided by nasal cannula, face mask, or head box to maintain SpO2 above 90 to 92 percent

Nasal suctioning For children hospitalized with bronchiolitis, we suggest mechanical aspiration of the nares as necessary to relieve nasal obstruction. Saline nose drops and mechanical aspiration of nares may help to relieve partial upper airway obstruction in infants and young children with respiratory distress or feeding difficulties.

HFNC and CPAP Heated humidified high-flow nasal cannula (HFNC) therapy and/or continuous positive airway pressure (CPAP) are used to reduce the work of breathing, improve gas exchange, and avoid the need for endotracheal intubation in children with bronchiolitis who are at risk for progression to respiratory failure

Monitoring clinical status Respiratory status – Repeated clinical assessment of the respiratory system (eg, respiratory rate; nasal flaring; retractions; grunting) is necessary to identify deteriorating respiratory status .

Fluid status – The fluid intake and output of infants and children with bronchiolitis should be assessed regularly. It is also important to monitor urine output. Plasma antidiuretic hormone levels rarely may be elevated, leading to fluid retention and hyponatremia

INTERVENTIONS THAT ARE NOT ROUTINELY RECOMMENDED

Bronchodilators Inhaled bronchodilators – We do not suggest routine administration of inhaled bronchodilators for children with bronchiolitis. Meta-analyses of randomized trials and systematic reviews suggest that bronchodilators may provide modest short-term clinical improvement but do not affect overall outcome, may have adverse effects, and increase the cost of care

INTERVENTIONS THAT ARE NOT ROUTINELY RECOMMENDED

Bronchodilators Oral bronchodilators – We recommend against the use of oral bronchodilators in the management of bronchiolitis. In randomized trials, oral bronchodilators have neither shortened clinical illness nor improved clinical parameters, but were associated with adverse effects (eg, increased heart rate)

INTERVENTIONS THAT ARE NOT ROUTINELY RECOMMENDED

Glucocorticoids Systemic glucocorticoids – For healthy infants and young children with a first episode of bronchiolitis, we recommend not using systemic glucocorticoids

The anti-inflammatory effects of glucocorticoids theoretically reduce airway obstruction by decreasing bronchiolar swelling, most studies show little effect in bronchiolitis

INTERVENTIONS THAT ARE NOT ROUTINELY RECOMMENDED

Nebulized hypertonic saline — For infants and children with severe bronchiolitis who are treated in the emergency department, we suggest not routinely treating with nebulized hypertonic saline (of any concentration). In 2015 systematic reviews of randomized trials evaluating administration of hypertonic saline in the emergency department, hypertonic saline reduced the rate of hospitalization among children with bronchiolitis, but the evidence was not high quality

INTERVENTIONS THAT ARE NOT ROUTINELY RECOMMENDED

Antibiotics – Antibiotics should not be used routinely in the treatment of bronchiolitis, which is almost always caused by viruses

Bronchiolitis does not increase the risk for serious bacterial infection

Thank You