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BRONCHIOLITISBRONCHIOLITIS

Helmi M. Lubis, dr, SpA(K)

Ridwan M. Daulay, dr, SpA(K)

Wisman Dalimunthe, dr, SpA

Rini Savitri Daulay, dr, M.Ked(Ped), SpA

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� Definition: bronchioles inflammation

� Clinical syndromes: fast breathing, breathing difficulties, retractions, wheezing, poor feeding, cough, irritability, (very young) apnoe.

� Predominantly < 2 years of age (2 – 8 months)

� Difficult to differentiate with pneumonia

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Pathology

�Necrosis of the respiratory tract epithelium

�Destruction of ciliated epithelial cells

�Peribronchial infiltration with lymphocites & neutrophils

�Sub mucosal edematous

�No destruction of collagen, muscle, or elastic tissue

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Pathophysiology4

� Edema + accumulation of mucous & cellular debris � narrow of peripheral airway � partially / totally occluded � over distention / atelectasis

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Etiology

�Predominantly RSV (Respiratory Syncytial Virus) � 95%

�Other viruses :

�Human metapneumovirus

�Rhinovirus

�Adenovirus

�Influenza virus

�Parainfluenza virus

�Entero virus

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� Increase severity in:

�Prematurity

�Underlying medical condition

�Group A RSV strain

�Age < 3 mo

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Diagnosis

�Etiological diagnosis

�Microbiologic examination (viral culture)

�Clinical diagnosis

�Signs and symptoms

�Age

�Resource of infection � epidemic of RSV

�Laboratory finding

�Radiological examination

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Clinical Manifestation

� Mild rhinorrhea

� Cough

� Low-grade fever

� 1-2 days later:

� Fast breathing

� Cyanosis

� Grunting

� Chest retraction

� Wheezing

� Irritable

� Vomitus

� Poor intake

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Physical Examinations

� Tachypnea

� Tachycardia

� Retraction

� Prolonged expiration

� Wheezing

� Fever

� Mild conjunctivitis

� Pharyngitis

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Radiologic examination

�Diffuse hyperinflation

�Patchy infiltrates

�Flat diaphragm

� Intercostal space >

�Retrosternal space > (lateral view)

�Peribronchial infiltrates / thickening

�Atelectasis � segmental collapse

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Laboratory Finding

�Microbiologic examination

�WBC : 5000 – 24.000 cells/mm3, predominantly PMN & bands

�Blood Gas Analysis

�Arterial saturation �

�pCO2 �

�Mild respiratory alkalosis

�Metabolic acidosis

�Acute respiratory acidosis

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�Respiratory rate � : Arterial saturation �

pCO2 �

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Differential Diagnosis

� Asthma

� Pneumonia

� Acute Bronchitis

� Congestive Heart Failure

� Pulmonary Edema

� Obstruction in the lower respiratory tract

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Management

�Mild � treated at home

�Moderate / severe disease :

�Hospitalization

�Support :

�Oxygen

�Intra venous fluid drip (antibiotics)

�Detect & treat possible complication

�Prevent the spread of infection

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�Controversial :

�Bronchodilator

�Corticosteroid

�Antiviral

�Antibiotic

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ββββ2 – Agonist

� Flores and Horwitz, 1997

� Meta-analysis of RCT inhaled β2 – Agonist

� Sample : 3 inpatient & 5 outpatient studies

� Treatment : nebulized albuterol

� Outcome : clinical score, satO2, LOS

� Result : unavailable evidence of β2 –Agonist efficacy

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Corticosteroid

� Treatment : Prednison equivalent 1 mg/kgBW

� Outcome : LOS, duration of symptoms (DOS), clinical scores

� Result : � LOS and DOS ↓

� Clinical score ↓

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Corticosteroid

Clinical score :

� Wheezing

� SaO2

� Accessory muscle use

� RR

Conclusion :

Benefits depend on severity and initiation of treatment

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� Natural history & complications� Regeneration of bronchiolar epithelium after 3 or 4 d

� Cilia after 9 d

� Improved clinical findings : in 3-4 days

� Improved radiological features: in 9 days

� Persistent respiratory obstruction : 20%

� Respiratory failure : 25 %

� Lung collaps

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Prognosis

� 23% infant � asthma at 3 years,

Control � 1% asthma

OR : 28; 90% CI 4-1235

(Garrison et al. 2000 after Sigurs et al. 1995)

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� Correlation with Asthma

�30 % - 50 % becomes asthmatic patients

�Similarity in :

�Pathogenic mechanisms

�Pathologic disorders

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