​Kembara Xtra - Medicine - Bronchiolitis

​Kembara Xtra - Medicine - Bronchiolitis

Basic Description: Upper respiratory infection (URI) prodrome followed by increased respiratory effort, crackles, and wheezing. Small airway inflammation and blockage that typically affects newborns and young children.
Usual course: sneaky, acute, and escalating
Leading reason for pediatric hospitalisation in the majority of Western nations. When a child is under 24 months old, it is the most frequent cause of lower respiratory infections (LRTI).
Newborn to 2 years old, with a peak age of 6 months. Despite the transmission of maternal antibodies, newborns are not protected.
Male is more prevalent than female.

Incidence and prevalence 
The United States spends $1.7 billion on healthcare due to incidence.
Estimated incidence is 3.2/1,000. RSV virus affects nearly all children by two seasons.
RSV is typically seasonal (October to May in the Northern Hemisphere) and frequently occurs in epidemics; it is endemic all year round in subtropical areas.
Involved in 18.8% (90,000 yearly) of all pediatric hospitalizations in children under the age of two (live births excluded).
Since 1980, the incidence has increased (along with a parallel rise in the hospitalization rate from 2002 to 2007); among individuals having the condition for at least 12 months, the hospitalization rate is between 2 and 3 percent.
Prevalence
In children under the age of 12 months, bronchiolitis prevalence ranges from 21–25%; this number drops to 13% between the ages of 12 and 24 months.

Pathophysiology and Etiology 

Rhinovirus, parainfluenza virus, adenovirus, influenza virus, Mycoplasma pneumoniae, and Chlamydophila pneumoniae have all been linked to RSV, which is responsible for 70–85% of all cases in children under the age of 12 months.

Epithelial cells become necrotic and lyse, and this causes the release of inflammatory mediators.
Airflow obstruction is caused by edema, mucus secretion, accumulated necrotic material, and cilia clearance loss.
Hypoxia is caused by a mismatch between ventilation and perfusion.
Bronchospasm appears to have little or no effect on air trapping, which is caused by dynamic airways narrowing during expiration, which increases the work of breathing.

Risk factors include secondhand smoking, low birth weight, premature birth, immunodeficiency, formula feeding (little or no breastfeeding), contact with sick people (the main way that an infection spreads), childcare environments, congenital cardiopulmonary illness, and children under 12 weeks of age.


Prevention
Hand washing or the use of alcohol-based hand sanitizers (preferred): This straightforward action is thought to have the biggest influence on transmission prevention.
Contact seclusion for infants who are infected
People who have colds should limit their interaction with young children.
Infants who are breastfed for at least 6 months have a lower rate of illness morbidity.

 Palivizumab (Synagis), a monoclonal medication used ONLY for RSV prevention in high-risk individuals, is given monthly, from October to May, at a dose of 15 mg/kg IM. 
Child Safety Considerations
It doesn't appear that prior infection confers subsequent immunity.

Upper respiratory congestion, conjunctivitis, pharyngitis, otitis media, diarrhea, and pharyngitis are all associated conditions.



The diagnosis of bronchiolitis should be based on a patient's medical history and physical examination; ancillary testing should only be recommended if the clinical picture is uncertain (there is no one test or set of tests that can confirm bronchiolitis).

Irritability, Anorexia, Fever, Noisy Breathing (Due to Rhinorrhea), Cough, Grunting, Cyanosis, Apnea, Vomiting, and Presenting History

Clinical examination findings include tachypnea, retractions (increased strain of breathing), rhinorrhea, wheezing, and upper respiratory infections such as pharyngitis, conjunctivitis, and otitis.

Differential diagnosis: Aspiration; Vascular ring; Foreign body; Asthma; Heart failure; Gastroesophageal reflux; Cystic fibrosis; Other pulmonary diseases, such as pertussis, croup, or bacterial pneumonia;

Diagnostic and Laboratory Tests 
If bronchiolitis is the clinical diagnosis, laboratory and other ancillary testing, including chest x-rays, are not necessary.
Recent meta-analyses revealed that neither a single physical characteristic nor a history could predict airspace illness on a chest radiograph.


Initial examinations (lab, imaging)
Pulse oximetry arterial oxygen saturation. Results must be understood in the context of clinical practice. Infants in good health frequently have transient hypoxemia, and capnography has not been proven to be useful in predicting the severity of an illness or the need for hospitalization. AAP recommendations advise weighing the pros and downsides of intermittent versus continuous pulse oximetry.
Rapid respiratory viral antigen testing may be helpful for epidemiologic, hospital cohorting, or in the very young to reduce unnecessary other workup; it is also indicated in infants admitted while receiving palivizumab prophylaxis (If positive, prophylaxis may be discontinued as recent data suggests no benefit in using palivizumab). Rapid respiratory viral antigen testing is not necessary during RSV season because the disease is managed symptomatically.
The AAP advises against routine RSV testing in bronchiolitis-suffering infants and kids.
AAP and others do not advise frequent chest radiographs in the clinical picture of acute bronchiolitis. Chest x-ray abnormalities can include atelectasis, peribronchial cuffing, hyperinflation, and perihilar infiltrates.

in accuracy comparable to radiography, ultrasound (POCUS) is used in diagnostic procedures to help in the diagnosis of pneumonia in bronchiolitis. A POCUS-derived score system may also be used to predict which patients require their therapy to be escalated.


Management and Therapy 
Supportive measures, such as upper airway suctioning, the avoidance of substantial and sustained hypoxia, and dehydration, form the basis of treatment. Despite several research, the different therapies mentioned historically have varying effects on how the condition develops. The routine use of corticosteroids, bronchodilators, or epinephrine is not recommended by recent clinical practice guidelines. Despite the warnings against such treatments, it is estimated that 50% of patients take a pharmaceutical combination over the course of treatment (3). Support and education for parents are essential.


It is advised that caregivers use alcohol-based skin cleaners on their hands before and after coming into touch with patients in order to reduce the spread of RSV, the most prevalent infectious cause of bronchiolitis. Similar strategies to limit transmission should be taught to family members as well.


The First Line of Medicine
Humidified oxygen for hypoxia of less than 90% (many believe that transitory pulse oximetry in the range of 85 to 90% during sleep in a clinically healthy infant may be detected).
Although it is not advised to utilize nebulized hypertonic saline (3%) in emergency departments, more recent literature reviews have shown some evidence of benefit.
Antibiotics should only be used in the unusual case of a subsequent bacterial infection; routine use is not recommended.

In cases of respiratory failure, continuous positive airway pressure (CPAP) or positive-pressure ventilation (PPV) may be utilized. Other than observational research, there is not much clinical data.
High-flow nasal cannula oxygen is frequently used in a variety of contexts to increase oxygen saturation, which reduces end-tidal CO2 (ETCO2) and respiratory rate, although its overall efficacy has not yet been established.
High-flow oxygen treatment is useful in treating patients who may require escalated therapy, according to a recent RCT.

Furthermore Treated 
Palivizumab and ribavirin for patients at high risk (as prophylaxis per CDC/AAP recommendations)
In moderate to severe bronchiolitis, heliox therapy (70 percent helium and 30 percent oxygen) may help lower the degree of respiratory discomfort brought on by airflow limitation, although the Cochrane Review found little evidence of a sustained benefit after 24 hours.
Inhaled -agonists (albuterol) are sometimes beneficial, despite not being generally advised (especially in patients with a history of bronchospasm). To evaluate the clinical response to a main presentation, many doctors will perform an empiric trial of bronchodilators (others contend that this condition may be asthma's counterpart).

Admission
Children under the age of six weeks old may have apnea in addition to bronchiolitis.
Respiratory distress or apnea with a respiratory rate of more than 45 breaths per minute
Because hypoxia is frequent, clinical criteria are more useful (many use a pulse oximetry limit of 94%).
A sickly or poisonous appearance An underlying immune suppression, respiratory issue, or cardiac disease
Preterm delivery (37 weeks) and high risk for apnea (age 30 days)
Dehydration or inability to eat (hospitalization should be considered if feeding is less than 50% of normal intake)
Questionable home care

The use of a respiratory distress assessment tool may help with admission decisions. Age, respiration rate, heart rate, oxygen saturation, and length of symptoms are the five best indicators of admission and have recently been added to a scoring system.
If clinically necessary (e.g., retractions, increased WOB, etc.), additional oxygen for pulse oximetry at 94% on room air. The AAP advises O2 saturation >90% if the infant is otherwise healthy.
Only if tachypnea prevents oral feeding are IV fluids advised; weight-based maintenance rate plus insensible losses
Normal respiratory rate and no need for oxygen are the requirements for discharge:
Recent small studies indicate that children can be safely discharged on home oxygen with home health follow-up after a period of observation. Although it may have a comforting appearance, the clinical course can change, making follow-up and parental education crucial.


Patient Follow-Up Monitoring
Hospitalization is typically only necessary if a patient needs oxygen or is unable to eat or drink.
Depending on the infection's severity, monitor a patient who is in the hospital as necessary.
Follow up with the patient daily by phone for 2 to 4 days if they are receiving care at home; they might require numerous office visits.


Recovery times are unpredictable. 40% of people can experience symptoms at 14 days, and 10% at 4 weeks.
Mortality rates vary, although they are probably around 1%.
Infants at high risk (congenital heart disease, bronchopulmonary dysplasia) may experience a protracted course.

Bronchiolitis obliterans, bacterial superinfection, apnea, respiratory failure, death, and an increased risk of developing reactive airway disease (asthma) are all complications.