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SC IN MICROBIOLOGY

Semester- IV Examination 2019

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Impacts of Bronchiolitis Obstacles on the Health of
Indian Adults and Infants

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 Abstract

Objectives

The major focus of this research was to determine the impact of Bronchiolitis obstacles

within the health of Indian people, especially the infants of India. Several health hazardous

conditions are to be seen due to the impact of Bronchiolitis and thus, the research has

concentrated on its impacts amid the people. Moreover, another objective of this research is

to determine the proper medication in order to recover the health condition of the people.

Research Methods

The methodology part of the project signifies the various methods applied and incorporated

in the research in order to obtain the desired outcome. In this case, positivism philosophy had

been taken under consideration as it was proved to be more suitable in satisfying the aims of

the projects. The current research had taken the aid of embracing descriptive research design.

That helped the study to explain the facts in an in-depth manner. The research had been

incorporated in a mixed research method where both the primary and secondary data were

collected and for this reason, deductive research approach was chosen to analyse the subject

properly. In order to perform the quantitative research, a questionnaire survey was conducted

by designing questions, setting an environment of the survey, selecting respondents. In terms

of collecting qualitative data- already existing research works, academic books, journal

articles and various types of observation sources provided a wide extent of data.

Findings

The authentic analysis of the facts helps to derive the genuine findings. This research study

involved two kinds of data collection processes and so, the relevance of the collected data

with the topic had to be judged. The authenticity of the qualitative information had been

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checked in order to ensure the assertion is relevant to the topic.The feedbacks gathered from

the respondents in the conducted questionnaire survey of the primary data collection process

had been analysed through using graphs, charts, and tables with providing illustrations.The

projected questions were framed to collect the varying viewpoints of the people, who are

suffering from Bronchiolitis obstacles. Bronchiolitis is the most common reason for

admission to hospital in the first year of life.

There is tremendous variation in the clinical management of this condition across Canada and

around the world, including significant use of unnecessary tests and ineffective therapies.

This statement pertains to generally healthy children ≤2 years of age with bronchiolitis. The

diagnosis of bronchiolitis is based primarily on the history of illness and physical

examination findings. Laboratory investigations are generally unhelpful. Bronchiolitis is a

self-limiting disease, usually managed with supportive care at home. Groups at high risk for

severe disease are described and guidelines for admission to hospital are presented. Evidence

for the efficacy of various therapies is discussed and recommendations are made for

management. Monitoring requirements and discharge readiness from hospital are also

discussed.

Conclusion

In conclusion, clarithromycin has statistically significant effects on the clinical and laboratory

findings in respiratory syncytial virus bronchiolitis. Therefore, clarithromycin treatment may

be helpful in reducing the short-term effects of respiratory syncytial virus

bronchiolitis.Supportive care, comprising of taking care of oxygenation and hydration,

remains the corner-stone of therapy in bronchiolitis. Pulse oximetry helps in guiding the need

for oxygen administration. Several recent evidence-based reviews have suggested that

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bronchodilators or corticosteroids lack efficacy in bronchiolitis and should not be routinely

used.

A number of other novel therapies (such as nebulized hypertonic saline, heliox, CPAP,

montelukast, surfactant, and inhaled furosemide) have been evaluated in clinical trials, and

although most of them did not show any beneficial results, some like hypertonic saline,

surfactant, CPAP have shown promising results.

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 Table of Contents
Chapter 1: Introduction .............................................................................................................. 9

1.1 Background of the Research ............................................................................................ 9

1.2 Research Aims and Objectives ...................................................................................... 10

1.3. Rationale of the Research Study ................................................................................... 11

1.4. Significance of the research .......................................................................................... 12

1.5. Structure of the research ............................................................................................... 12

Chapter 2: Literature Review ................................................................................................... 14

2.1 Epidemiology ................................................................................................................. 14

2.2 Pathogenesis ................................................................................................................... 16

2.3 Clinical Features ............................................................................................................ 21

2.4 Airway Obstruction ........................................................................................................ 23

2.5 Diagnosis........................................................................................................................ 23

2.6 Treatment ....................................................................................................................... 24

2.7 Prophylaxis or Prevention .............................................................................................. 25

2.8 Mediation ....................................................................................................................... 26

2.8.1 Randomisation and Investigational Therapy .......................................................... 26

2.8.2 Clinical Data ........................................................................................................... 27

2.9 Therapeutic Options ................................................................................................... 27

2.10 Presentation .................................................................................................................. 31

2.11 Literature Gap .............................................................................................................. 32

2.12 Conclusion ................................................................................................................... 32

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Chapter 3: Research Methodology........................................................................................... 33

3.1 Chapter Overview .......................................................................................................... 33

3.2 Research Philosophy ...................................................................................................... 33

3.3 Research Design............................................................................................................. 34

3.4 Research Approach ........................................................................................................ 36

3.5 Research Sampling......................................................................................................... 37

3.6 Data Collection Process ................................................................................................. 37

3.7 Data Analysis Process .................................................................................................... 39

3.8 Ethical Consideration ..................................................................................................... 41

Chapter 4: Findings .................................................................................................................. 43

4.1 Primary Data Analysis ................................................................................................... 43

4.2 Qualitative Analysis ....................................................................................................... 52

Chapter 5: Discussion .............................................................................................................. 56

5.1 Overview ........................................................................................................................ 56

5.2 Disease Course and Prediction of Severity .................................................................... 57

5.3 Therapy .......................................................................................................................... 58

5.4 Supportive Care ............................................................................................................. 59

5.5 Summary ........................................................................................................................ 64

Chapter 6: Conclusion and Recommendation.......................................................................... 66

6.1 Conclusion ..................................................................................................................... 66

6.2 Recommendation ........................................................................................................... 67

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 6.3 Future Research Scope ................................................................................................... 68

References ................................................................................................................................ 69

8. Appendices ........................................................................................................................... 75

8.1 Appendix1: Primary Questionnaire ............................................................................... 75

8.2 Interview Questions ....................................................................................................... 78

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Chapter 1: Introduction

1.1 Background of the Research

Bronchiolitis is an acute lower respiratory tract infection in early childhood caused by

different viruses, with coughing, wheeze and poor nutrition as the major symptoms (Bagci et

al., 2011). A substantial proportion of children will experience at least one episode with

bronchiolitis, and as much as 2-3% of all children will be hospitalized with bronchiolitis

during their first year of life (Beck-Broichsitter et al., 2011). Bronchiolitis is the most

common reason for hospitalization of children in many countries, challenging both economy,

area and staffing in paediatric departments. ‘Respiratory Syncytial Virus’ (RSV) is the most

common virus causing bronchiolitis, occurring in epidemics during winter months (Bergeron

et al., 2013).

Some infants, particularly those with risk factors, will have a severe course of bronchiolitis.

Bronchiolitis is the most common medical reason for admission of children to intensive care

units (ICU), providing challenges regarding ventilation, fluid balance and general support

(Cao et al., 2011). This may be a particular challenge for ICUs without a specialised

paediatric section. On the other hand it is to be conducted that Bronchiolitis is blockage of

the small airways in the lungs due to a viral infection(Cona et al., 2011). It usually only

occurs in children less than two years of age(Da Dalt et al., 2013). Symptoms may

include fever, cough, runny-nose and wheezingalong with breathing problems. More severe

cases may be associated with nasal flaring, grunting, or the skin between the ribs pulling in

with breathing(Date and Oto, 2011). If the child has not been able to feed properly, signs

of dehydration may be present.

Bronchiolitis is usually the result of infection by Respiratory Syncytial Virus (72% of cases)

or Human Rhinovirus (26% of cases)(de Jong et al., 2011). Diagnosis is generally based on

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symptoms.Tests such as a chest X-ray or viral testing are not routinely needed. Urine testing

may be considered in those with a fever. There is no specific treatment. Supportive care at

home is generally sufficient. Occasionally hospital admission for oxygen, support with

feeding, or intravenous fluids is required(Dong et al., 2015). Tentative evidence

supports nebulised hypertonic saline. Evidence for antibiotics, antiviral, bronchodilators, or

nebulised epinephrine is either unclear or not supportive(Hachem, 2013).

About 10% to 30% of children under the age of two years are affected by bronchiolitis at

some point in time(Han, 2011). It more commonly occurs in the winter in the Northern

hemisphere(Hangartner et al., 2016). The risk of death among those who are admitted to

hospital is about 1%(Hayes, 2011). Outbreaks of the condition were first described in the

1940s.Bronchiolitis, defined as inflammation of the bronchioles, usually is caused by an

acute viral infection. Viral bronchiolitis is the most common lower respiratory tract infection

in infants and children who are 2 years of age and younger(Hosseini-Baharanchi et al.,

2016).Other identified pathogens include adenovirus, human metapneumovirus, influenza

virus, and par-influenza virus.The pathophysiology of bronchiolitis begins with an acute

infection of the epithelial cells lining the small airways within the lungs(Huddleston, 2011).

Such infection results in edema, increased mucus production, and eventual necrosis and

regeneration of these cells. The clinical presentation of bronchiolitis includes rhinitis, cough,

tachypnoea, use of accessory respiratory muscles, hypoxia, and variable wheezing and

crackles on auscultation(Iuppa et al., 2011).

1.2 Research Aims and Objectives

The following research study intends to investigate the impacts of bronchiolitis obstacles over

the human beings especially the children in India and to explore the effectiveness of this

disease in an effective manner. The intention of this research study is to display the relevant

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as well as reliable information concerning the disease as well as its impact on the infant in

India. The main aim of the research study is mentioned hereunder:

 To recognize the clinical presentation of bronchiolitis.

 Be aware of the recommendations made in the current American Academy of Pediatrics

clinical practice guideline for diagnosis and management of bronchiolitis.

 Describing the role of laboratory testing in the diagnosis of bronchiolitis.

 Delineate the efficacy of current therapeutic interventions in the treatment of

bronchiolitis.

 Discussing the evaluation for serious bacterial infections in patients who have

bronchiolitis.

 Outlining the prognosis and risk of recurrent wheezing in patients diagnosed with

bronchiolitis.

1.3. Rationale of the Research Study

With the changing environment, the effectiveness of bronchiolitis is spreading in an

excessive manner throughout the globe. A substantial proportion of children will experience

at least one episode with bronchiolitis, and as much as 2-3% of all children will be

hospitalized with bronchiolitis during their first year of life. Within this context, the rational

of the study is to analyse the clinical presentation of bronchiolitis. On the other hand, to

determine the practise guideline for diagnosis and management of bronchiolitis. Moreover,

the study also focuses on the role of laboratory testing for ensuring the adequate treatment for

curing bronchiolitis amid the people. Accordingly, the research is about to highlight the

contemporary therapeuticinterventions in the treatment of bronchiolitis. On the basis of the

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research, the study is about to discuss the evaluation for serious bacterial infections in

patients who have bronchiolitis.

1.4. Significance of the research

The significance of this research study is to attain important and relevant information on the

impact of bronchiolitis. The idea is to attain knowledge and gain insight regarding

Bronchiolitis and its impact along with its adequate treatment as it is a wide topic. The

motive of this research study is to mitigate research gap and attain understanding to meet the

predetermined aims and objectives.Thorough analysis is being done in this research study to

attain the desired outcome on factors of Bronchiolitis in India.The issues and challenges

along with the aspect of local delivery are being considered which was lacked in various

studies in the past.

The significance of this research study is to gather valid and reliable information on the

subject for effective future work.The significance of the study is that very few studies have

been conducted on the aspect of Bronchiolitisin India and factors to overcome the negative

impact of Bronchiolitis in the health of human being especially the children.The significance

of the study is that no past researches have been done in this order on the stated topic

discussing the aspect of Bronchiolitis and its impact on the health of children in India along

with the adequate trertment for developing the state of health of the Indian children.

1.5. Structure of the research

For the research study to be effective and to meet the desired outcome within stipulated time

it is vital to manage the structure and plan actions. For this research study to be effective it

has been divided into six vital chapters to attain knowledge and understanding. The first

chapter is ‘Introduction’ wherein brief overview of the entire study is provided along with the

rationale for the study. The objectives and aims that are to be met in this study are mentioned.

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The second chapter is ‘literature review’ wherein the analysis of researchers on the similar

topic is done. The opinion of the authors and their viewpoints are presented to attain in-depth

knowledge. The gathered data are attained from credible sources for increasing the efficiency.

The third chapter is ‘Research Methodology’ which states the use of methods that are

implemented in this research study to augment the relevance and validity. In this section

techniques and the process of data analysis is explained.

The approach of data collection increases the effectiveness in order to acquire reliable and

valid information to meet the stated objectives. In this research study, primary and secondary

data collection is used so that the work efficiency along with the desired outcome can be

acquired. ‘Analysis and Findings’ is the fourth chapter of the research study. In this section,

the gathered data on the topic is analysed precisely so that objectives can be met. The

intention is to attain knowledge and greater insights on the subject matter to increase the

effectiveness. The fifth chapter of the research study is ‘Discussion’ which elaborates the

gathered and analysed data accordingly to acquire in-depth understanding by meeting the

research aims and objectives.

The results attained from the gathered information are stated in this chapter. The importance

of the impact of Bronchiolitis obstacles within the health of the Indian people mostly, the

Indian children and its effectiveness on the health of the people is elaborated from gathered

understanding. ‘Conclusion and recommendation’ are the last chapters of the research study

which summarizes the entire study. The objectives mentioned are met through the

information gathered. For augment, the effectiveness of the study recommendation is

provided. Owing to this structure the research study will ensure timely completion.

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Chapter 2: Literature Review

2.1 Epidemiology

Bronchiolitis is an acute, highly contagious disease of the lower respiratory tract of infants

with the highest incidence in the winter in temperate climates, and in the rainy season in

warmer countries(Jiang et al., 2011). Bronchiolitis all over the world, is the leading cause of

the infants' visit to the doctors. In United States, this is the leading cause of infant

hospitalization and is associated with progressively increasing morbidity and cost of

treatment over the last few years. The studies over time have shown that there is high degree

of morbidity in bronchiolitis but mortality is low(Joshi, Reyesand Araque, 2011). Usually

around one third of children do develop bronchiolitis in their first 2 years. The hospitalization

rates vary from 3% to over 7%, depending upon the type of infant population being studied.

The data from India shows that the mortality rate from bronchiolitis is low(Kato et al., 2011).

Most deaths in bronchiolitis occur in infants younger than 6 months of age. In previously well

children, bronchiolitis is usually a self-limiting disease that responds well to supportive care

within the home. However, young infants and those having pre-existing medical conditions

form a vulnerable group that may need inpatient admission(Lewin, Brauerand Ostad, 2011).

The premature, infants with underlying cardiopulmonary diseases or with immunodeficiency

disorders are more at risk.

Most admissions are in younger than 1 year of age, while infants below 3 months are at

increased risk of apnea and severe respiratory distress. Prematurity and Caesarean section are

another risk factor for severe bronchiolitis, especially with a previous history of neonatal

respiratory distress syndrome(Bagci et al., 2011). Patients with unrepaired congenital heart

disease, especially with pulmonary over-circulation, and children with chronic lung disease

have diminished pulmonary reserve, thus increasing the hospitalization rate in such children.

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Children born with airway abnormalities such as laryngomalacia, tracheomalacia or cleft

lip/palate usually need supportive care to clear off the upper airway secretions. Also, the

children with neurologic abnormalities associated dystonia may need additional support for

managing secretions(Beck-Broichsitter et al., 2011). The infants older than 60 days, having

bronchiolitis and fever, have low risk of serious bacterial infection (SBI) while those younger

than 60 days require a full septic screen for urinary tract infection, meningitis and

bacteraemia. But the evaluation and treatment for sepsis is associated with parental

dissatisfaction, increasing antibiotic resistance, and iatrogenic complications(Bergeron et al.,

2013).

For very young febrile infants who have obvious bronchiolitis, there are no current guidelines

for the management. Based on the current literature, the risk of SBI among infants younger

than 30 days remain substantial and they should continue to have full evaluation for SBI and

administration of empiric antibiotics(Cao et al., 2011). The prophylactic immune therapies

like palivizumab have shown a decrease in RSV related hospitalization rates for specific

high-risk groups. Accordingly, AAP did modify its recommendations, recently. Presently

there is a lot of research to find out the risk factors associated with the development of severe

bronchiolitisand attempts are continued to identify the clinical predictors of hospitalization in

outpatient population(Cona et al., 2011). The data demonstrates that individual clinical

findings on physical examination have limited predictive value in terms of outcome. This

may be because of the typical minute-to-minute variability of these findings among children

with bronchiolitis.

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Figure: 1. American Academy of Paediatrics Guidance for Diagnosis and Management

of Bronchiolitis

(Source: Da Dalt et al., 2013)

2.2 Pathogenesis

The immune response elicited by Respiratory Syncytial Virus or RSV may be both protective

and pathogenic, and there appear to be functional differences between an initial infection in a

seronegative infant and reinfection in an older child or adultDate and Oto, 2011. RSV

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reinfections occur throughout life, despite the induction of both antibody and T-cell responses

after a primary infection and the absence of a detectable antigenic change in RSV surface

glycoproteins. How RSV evades or inhibits host defences is not fully understoodde Jong et

al., 2011.

Results from a controlled clinical trial, conducted in the 1960s, of a formalin-inactivated RSV

vaccine showed that a protective immune response did not develop in recipients of the

vaccine. Vaccine recipients who subsequently acquired natural RSV infection had more

severe illness than did control participants (Dong et al., 2015). In addition, evidence suggests

that both the relative balance between type 1 and type 2 helper T cells that respond to

antigenic stimulation by the virus and the profile of evoked chemokines and cytokines

determines the extent of RSV disease expression (Hachem, 2013). On the basis of these

observations, most theories regarding the pathogenesis of bronchiolitis due to RSV implicate

an exaggerated immune response as well as direct cellular damage from viral replication.

Although neutralizing antibodies to viral surface glycoproteins are important for the

prevention of RSV infection, T-cell–mediated responses appear to be crucial for viral

clearance during infection(Han, 2011). Post-mortem studies of lung tissue obtained from

infants who died from RSV infection reveal macrophages and neutrophils and a relative

absence of cytotoxic T cells, along with low concentrations of classic T-lymphocyte– derived

cytokines (released by CD4+ and CD8+ T cells)(Hangartner et al., 2016). These findings are

not consistent with a pathologic inflammatory response. Rather, the presence of abundant

viral antigen suggests active RSV replication and direct virally induced cytotoxicity.

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 Figure: 2. Pathogenesis of Bronchiolitis Due to Respiratory Syncytial Virus (RSV)

(Source: Hayes, 2011)

At least in infants who have not had a previous infection, overwhelming RSV disease appears

to be related to the lack of an adaptive cytotoxic T-cell response in the host; the result is

dependence on the less effective innate immune response for the termination of viral

replication(Hosseini-Baharanchi et al., 2016). T-cell response does not develop in such

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infants is supported by reports of a direct correlation between RSV load, as measured in

nasopharyngeal aspirates obtained from children who have been hospitalized with

bronchiolitis, and more severe disease, defined as a higher risk of apnea, a longer hospital

stay, and a greater need for intensive care(Huddleston, 2011). However, not all reports are

consistent with an association between a high viral load in respiratory secretions and greater

severity of disease. A reasonable deduction is that direct cytotoxic injury induced by the virus

and a robust host inflammatory response both contribute to the pathogenesis of RSV

bronchiolitis, although the relative contribution of each remains uncertain(Iuppa et al., 2011).

Resolution of this issue will determine whether a potent antiviral agent administered early in

the course of bronchiolitis can reduce the duration and severity of illness without the need for

immune modulation(Jiang et al., 2011).

Direct viral inoculation of respiratory epithelium leads to inflammation of small airways. The

mechanisms by which RSV spreads along the respiratory tract are still not fully known, but

likely include cell-to-cell transfer along intracytoplasmic bridges or aspiration of

nasopharyngeal secretions(Joshi, Reyesand Araque, 2011). RSV can also damage cells of the

structural airway and impair immune cells residing in the lungs. The host’s inflammatory

response contributes to the pathophysiology and symptomatology: Host cells recognize RSV

via toll-like receptors, and secrete inflammatory cytokines (e.g. IFN-γ, IL-1β, IL-4, IL-

8)(Kato et al., 2011). These effectors influence the local tissue environment directly, and also

further the inflammatory process by drawing immune cells from the periphery.Many

cytokines have known roles in the pathogenesis of RSV bronchiolitis, and some are even

implicated in sustaining the infection. For example, the helper T cell’s main cytokine, IL-17,

enhances RSV infection by increasing mucus production, inhibiting CD8 T cell activation,

and reducing viral clearance(Lewin, Brauerand Ostad, 2011).

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Figure: 3. Viral Bronchiolitis in Children

(Source: Munakata et al., 2011)

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 2.3 Clinical Features

The first signs and symptoms of bronchiolitis (and in many children, the extent of disease

manifestations) are those of an upper respiratory tract infection:

 Nasal discharge and congestion

 Fever

 Decreased appetite

 Decreased energy, irritability

I. In up to 30% of infected children younger than 2, there is extension of the infection into

the lower airways. Cough, tachypnoea and increased respiratory effort follow the upper

airway prodrome(Norman et al., 2010). Lower tract involvement ranges in severity, from

mild to life-threatening respiratory failure.

II. In very young infants, especially those who have a history of prematurity, apnea may be

the sole presenting sign. Infants may also have copious production of secretions(Park et

al., 2015).

III. The most clinically significant parameters in determining illness severity are respiratory

rate, work of breathing, and hypoxia(Pletcherand Rodi, 2011).

Signs and Symptoms Mechanisms

Rhinorrhoea, cough Viral infection leads to irritation and

inflammation of mucosal tissues

Tachypnoea and increased work of Infection of lower airways results in

breathing inflammation, causing airway obstruction,

decreasing effective gas exchange and

causing ventilation-perfusion mis-

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 match(Ralston et al., 2014).

Crackles/wheezing Lower airway inflammation leads to collapse

of smaller alveoli, leading to crackles heard

on auscultation. Intrathoracic obstruction

causes airway collapse during expiration,

leading to wheezing(Redman et al., 2011).

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 Figure: 4. Pathophysiology and Clinical Features of Bronchiolitis

(Source: Reid et al., 2011)

2.4 Airway Obstruction

I. Upper

Upper airway obstruction by mucous secretions, which may be copious, contributes to poor

feeding and increased respiratory effort.

II. Lower

i. Dynamic airway obstruction leads to increased work of breathing and wheezing,

while complete obstruction can lead to atelectasis.

ii. Either form contributes to ventilation-perfusion mismatch and resultant hypoxia,

hypercarbia and tachypnoea.

(Source: Shah, 2011)

2.5 Diagnosis

i. Diagnosis is made clinically on the basis of a thorough history and physical

examination.

ii. Chest radiography is not required to confirm diagnosis unless pneumonia is equally

suspected. Chest x-rays have been shown to increase the likelihood of overdiagnosis

of pneumonia with subsequent use of antibiotics without difference in recovery time.

Radiographic findings do not correlate well with clinical manifestations of

disease(Sharma,Guptaand Rafik,2013). The appearance of bronchiolitis on a chest x-

ray may include hyperinflation, and patchy opacification representing infiltrates

and/or atelectasis.

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 iii. Nasopharyngeal swab (NPS) may be done for viral testing to confirm an infection and

identify the specific virus, but this test does not change clinical decision making or

outcomes(Shi et al., 2011). Many viruses can produce the same clinical presentation,

and clinical signs guide isolation procedures, not virus type.

2.6 Treatment

The managements strategies for bronchiolitis are largely supportive, with hydration and

oxygenation as the primary interventions

I. Hydration

Intravenous fluids are often necessary to correct dehydration and maintain hydration in a

child with poor oral intake secondary to their infection(Shieldsand Thavagnanam, 2013). Oral

rehydration with preparations such as Pedialyte, which delivers electrolytes and

carbohydrates, may be used if the child expresses interest in oral intake, but should be used

with caution in children with significant work of breathing due to aspiration risk(Skjerven et

al., 2013). Some infants may benefit from nasogastric feeding until feeding improves.

II. Oxygen

i. Oxygen to maintain saturation >90-92%, delivered by an appropriate method (e.g.

nasal prongs, rebreathing or nonrebreathing masks).

ii. Bronchodilators, inhaled epinephrine, corticosteroids, antiviral agents, antibacterial

agents, chest physiotherapy, nasal suction and decongestant drops are therapies that

have been and continue to be used in variable measure(Tagawa et al., 2011).But none

have demonstrated significant impact on duration of illness, severity of clinical

course, or subsequent clinical outcomes (e.g. post-bronchiolitis wheezing)(Teshome,

Gattuand Brown, 2013). Many of these treatments are used in emergency department

settings nonetheless, often on the basis that some therapies such as nasal suction or

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 bronchodilator and/or epinephrine, may ease symptoms. Some sources suggest a trial

of these therapies, with discontinuation in the absence of effect.

iii. Given the predictable course of bronchiolitis, the “day of illness” can guide changes

to supportive care: a child on Day 4 who continues to have intermittent desaturation

on pulse oximetry may not require continued oxygen therapy (as a child on Day 2

with the same clinical picture might)(Thompson et al., 2013).

2.7 Prophylaxis or Prevention

i. Hand washing and routine infection control practices remain crucial to prevention of

infection spread, as well as to re-infection

ii. Breastfeeding, particularly of longer duration, seems to have protective effective

iii. Palivizumab (Synagis) prophylaxis for high risk patients. This monoclonal RSV-

specific antibody, given during peak RSV season, confers passive immunity to infants

at high-risk for severe illness.

(Source: Ulloa-Gutierrez et al., 2011)

Passive immunity Acquired immunity

Relies on antigen presentation by antigen

Natural’ mechanisms
presenting cells (i.e. dendritic and B cells) to
i. IgG antibodies transfer from maternal activate specific cell-mediated and humoral
to fatal circulation through the placenta
ii. IgA antibodies transfer from mother to response(Valapour et al., 2013).

infant via breastfeeding

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Artificial mechanism Memory B and T cells develop in response to

Short-lived antibodies can be put into infection

circulation for the purpose to combatting a

specific antigen (i.e. Palivizumab use against

the RSV virus)

Short-term immunity Long-term immunity

2.8 Mediation

All children admitted to hospital with bronchiolitis were treated according to the same

clinical pathway to minimise the variability of the results. A nasopharyngeal aspiration

sample (NPA) was obtained routinely from all patients for detection of RSV(Vissing,

Chawesand Bisgaard, 2013). RSV infection was diagnosed by direct immunofluorescent

staining of the NPA. An infant was considered ready for discharge when he/she had not

received supplemental oxygen for 10 h, had minimal or no chest retractions and was feeding

adequately without the need for intravenous fluids. Supplemental oxygen was administered to

those cases showing oxygen saturation (Sp,O2) levels <94%, as determined by pulse

oximetry (Trusat pulse oximeter; Datex-Ohmeda, Louisville, CO, USA)(Watanabe et al.,

2012). Supplemental oxygen was discontinued when Sp,O2 was consistently >93% or when

the infant's condition had been stable for 4 h and he/she was starting to tolerate oral feeding.

2.8.1 Randomisation and Investigational Therapy

After written informed parental consent had been obtained and the NPA had been found to be

positive for RSV, the infants were randomised by a single study nurse to receive

clarithromycin (15 mg·kg-1) or placebo daily for 3 weeks(Wilkes, 2011). Simple

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randomisation was used 24. Patients, parents and investigators were kept blinded to the

randomisation until completion of the study. The primary outcome was LOS. Secondary

outcomes included changes in the IL-4, IL-8, eotaxin and IFN-γ levels, readmission rate and

wheezing after discharge(Munakata et al., 2011).

2.8.2 Clinical Data

Detailed clinical histories, including the duration of symptoms before presentation at the

hospital, the medical history, the infant's ability to feed, previous medication, parental

smoking history and family history of atopy were recorded(Norman et al., 2010).

Observations at admission included respiratory and heart rate while the infant was quiet,

temperature, respiratory effort, Sp,O2 while breathing room air, presence of wheezing or

crackles on auscultation of the chest, and level of hydration. Each infant's condition was

classified as mild, moderate or severe according to a severity score 14 calculated from the

Sp,O2, respiratory rate and respiratory effort observed at admission(Park et al., 2015). Six

months following completion of clarithromycin or placebo therapy, parents were asked

whether their child had experienced wheezing during the previous 6 months(Pletcherand

Rodi, 2011).

2.9 Therapeutic Options

There are multiple therapeutic options like bronchodilators, corticosteroids, antiviral agents,

antibacterial agents, chest physiotherapy, nasal suction, and decongestant drops (Ralston et

al., 2014). But all these interventions have not demonstrated any significant impact on

duration of illness, severity of clinical course, or subsequent clinical outcomes, such as post-

bronchiolitis wheezing (Redman et al., 2011).

I. Supportive care

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Newer recommendations emphasize supportive care with hydration and oxygenation as a

primary intervention.

i. Hydration

The dehydration is consequent to faster breathing, copious secretions, fever and poor feeding

and may require intravenous fluids or nasogastric feedings until feeding improves. The

rehydration may be corrected with isotonic fluids as the release of antidiuretic hormone

secondary to the bronchiolitis and administration of hypotonic fluids may lead to iatrogenic

hyponatremia (Reid et al., 2011).

ii. Feeding

The infants whose nutrition is compromised with severe disease may be given nasogastric

feeding until feeding improves. It has been shown that increasing protein intake of infants

increases the anabolism in critically ill infants with bronchiolitis (Shah, 2011).

iii. Oxygen

Oxygen administration is a key therapeutic intervention. The goal is to maintain oxygen

saturation to prevent hypoxia or insufficient delivery of oxygen to metabolically active tissue.

A variable hypoxemia does occur in bronchiolitis from impaired diffusion across the blood-

gas membrane and ventilation-perfusion mismatch caused by heterogeneous plugging of

distal bronchioles. For most authors, pulse oximetry saturations higher than 90% are

acceptable, as this saturation is associated with appropriate oxygen delivery on the

oxyhaemoglobin dissociation curve(Sharma,Guptaand Rafik,2013). A complete assessment

of the baby is required to decide for the need and duration of the supplemental oxygen.

II. Bronchodilators

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The bronchodilators are abundantly used in the management of bronchiolitis at outpatients

and inpatients facilities in our country and worldwide. So, no surprise that their role in the

treatment of bronchiolitis has been the subject of many studies and systematic evidence-based

reviews of literature (Shi et al., 2011). It is an uphill task to compare these studies because of

a wide range of study designs, a variety of therapies assessed and outcome measures that

have ranged from short term improvement in clinical scores obtained soon after the

intervention to a broader clinical outcome such as need for subsequent hospitalization or

duration of hospital stay or illness.

Generally, the score-based studies are easy to compare but this is not the case in bronchiolitis

because the scoring parameters used do not have established validity or proven correlation

with clinically significant improvement (Shieldsand Thavagnanam, 2013). Pooling the results

of such large studies may result in a statistically significant difference that is of questionable

clinical importance. In a Cochrane collaboration systematic review, studies that dichotomized

patients into those who responded and did not responded to bronchodilators were compared.

A high rate of response (43%) seen in control subjects may result from clinical variability

usually observed in bronchiolitis or from a response to other supportive measures and

mistakenly being attributed to a bronchodilator response in an uncontrolled setting (Skjerven

et al., 2013).

III. Corticosteroids

Another area of controversy is the use of steroid for the treatment of bronchiolitis. Ambiguity

regarding their use has arisen form a heterogeneous and difficult to interpret body of variably

designed studies with variable sample size (Tagawa et al., 2011). However, the studies with

large sample size reveal that steroid administration is not associated with significant

reductions in clinical scores, hospitalization rates or length of hospitalization (Teshome,

Page | 29
Gattuand Brown, 2013). On the other hand, steroids do have well established undesirable

adverse effect profile. So, steroids are no more recommended for the treatment of

bronchiolitis.

The studies have noted that the children who received dexamethasone combined with 2 doses

of nebulized epinephrine had a lower admission rate over 7 days than the placebo (17.1% Vs.

26.4 %). However, this difference does not reach the statistical significance (p=0.07). The use

of corticosteroids in synergy with adrenergic agents has been well established for asthmatic

children (Thompson et al., 2013). But for bronchiolitis we need to wait further studies to

confirm the same beneficial effect before this can be employed as a routine therapy for

bronchiolitis.

Figure: 5. Cochrane collaboration systematic review of studies that assessed the

difference in rate of improvement after B2-agonist bronchodilators or placebo among

children with bronchiolitis

(Source: Ulloa-Gutierrez et al., 2011)

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2.10 Presentation

Children with bronchiolitis typically present with a viral upper respiratory prodrome

comprising of rhinorrhoea, cough, and on occasion, a low-grade fever. The onset of these

symptoms is acute(Valapour et al., 2013). Within 1-2 days of these prodromal symptoms, the

cough worsens and child may also develop rapid respiration, chest retractions, and wheezing.

The infant may show irritability, poor feeding, and vomiting. Though, in majority of cases,

the disease remains mild and recovery starts in 3-5 days, some of these children may continue

to worsen(Vissing, Chawesand Bisgaard, 2013).

The importance of a detailed clinical assessment of these children cannot be overemphasized.

The components of this assessment include, in-depth review of the child’s symptoms, impact

of these symptoms on his feeding (respiratory distress often prevents adequate oral fluid

intake and causes dehydration), assessment of the child’s responsiveness and alertness,

identification of various co-morbidities like underlying chronic lung disease, congenital heart

disease or immuno-compromised state, and complete physical examination(Watanabe et al.,

2012).

Most of the children with bronchiolitis have tachycardia and tachypnoea. Pulse oximetry

helps us in deciding about the need for supplemental oxygen. The chest may appear hyper-

expanded and may be hyper resonant to percussion. Wheezes and fine crackles may be heard

throughout the lungs. Severely affected patients have grunting, marked retractions(Wilkes,

2011). They may be cyanosed, and may have impaired perfusion. Apnea may occur in those

born prematurely and in younger than two months of age (15). Other associated problems that

may occur in children with bronchiolitis include conjunctivitis, otitis media and pharyngitis.

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2.11 Literature Gap

There is an important knowledge gap regarding the use of resources for bronchiolitis in

emergency departments; studies characterizing bronchiolitis hospitalizations do not identify

patients receiving evidence-based supportive therapies (EBSTs)(Bagci et al., 2011). The

information presented here may help minimize potentially unnecessary hospitalizations.

2.12 Conclusion

As in the general Indian population, a heavy burden of illness and death among Indians is

related to behaviour and impact of Bronchiolitis. While these illness-producing behaviours

become more manifest from young adulthood, prevention must begin in the early years. In

this article, all current mortality and morbidity patterns of young Indians were reviewed in

detail. Behavioural Indian and Alaska Native Mental Health Research Copyright: Centres for

Indian and Alaska Native Health Colorado School of Public Health/University of Colorado

Anschutz Medical Campus TilE HEALTH STATUS OF INDIAN CHILDREN changes, in

either the parents or young children, and environmental interventions hold great promise for

reducing current high rates of morbidity and mortality from birth defects-especially

bronchiolitis other infectious and parasitic diseases.

Environmental and simple behaviour changes which can bring major reductions in the above

problems are: (a) increased rates of early and overall prenatal care, (b) cessation of prenatal

alcohol consumption, (c) a safer and more hygienic environment for infants and youth, (d)

increased breast feeding of infants to 6 to 8 months of age, (e) careful and informed use of

baby bottle feeding at all ages, and (f) the use of car seats and other protective devices for

infants and all youth. So often social and health programs for Indians have been instituted in

an unfocused and confusing manner that allows Indian people little opportunity for input or

control.

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Chapter 3: Research Methodology

3.1 Chapter Overview

The main focus of this chapter is to provide a clear outline of the processes and techniques

that have been undertaken to conduct the overall study work. It has been designed with the

purpose of making a simple structure of the steps and stages associated with the research

study to ascertain the basic aim and objectives of the research. Therefore, the chapter includes

a clear assessment of the philosophy and research design under which the whole research has

been carried out.

In addition, a critical argument about the research approach along techniques undertaken for

data collection and data analysis activities are also few major parts of this chapter. In each

discussion area, the chapter also provides appropriate justifications and defines their

contributions to performing all the key functions of the research. In this regard, the validation

of the techniques and processes has been justified with an appropriate theory-based facts and

information. The process of validating each key area of the chapter has provided valuable

insight into this research to meet research standard as well as achieve expected outcome of

the activities.

3.2 Research Philosophy

According to the primary defined problem of the research, a positivist research philosophy

has been undertaken while conducting all the necessary activities related to the current study.

In research, philosophy is defined as a set of beliefs to pertain principles as well as different

techniques for undertaking the expected research activities. Research philosophy is often

characterized into three broad types namely, positivism, pragmatism, and realism or

interpretivism philosophy. The main purpose of using positivism philosophy is that the

philosophy significantly helps researchers to maintain values in terms of retrieving facts,

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knowledge, and ideas from resources which are attributed to various credible scientific

mechanisms.

Moreover, positivism research philosophy also includes beliefs of the results that are

generally examined by any experimentation approach(s). Therefore, the incorporation of

positivism philosophy in this research has provided a valuable insight on the current research

to successfully draw a valid and credible set of findings. Additionally, the philosophy is also

regarded as one of the most successful processes in this research study to critically meet the

underlying aim and objectives of the study.

3.3 Research Design

The research study has been carried out with a structured descriptive design technique. The

technique was mainly used in structuring all the primary and secondary activities of the

research along with applying theoretical assumptions and analysis works. From a general

perspective, there are basically three types of designs including, a descriptive, exploratory

and casual design that can be applied while conducting an academic research work. The main

purpose of using descriptive design is that it usually facilitates researchers to conduct a

critical investigation of each fact and information and justifies them with evidence based

theoretical and realistic descriptions. In the current research work, embracing descriptive

research design has enabled the study to analyze facts retrieved from various sources and

conduct in-depth explanation of information using pertinent theoretical assumptions.

Moreover, numbers of evidence-based facts are also used in order to ensure that the findings

are credible and are successfully analyzed to address the primary research aim and objectives.

The approval of descriptive design in this research has also enabled to improve quality and

credibility of each fact retrieved in this study. The discussion made in this research provides

valid justification of the findings. In this context, an appropriate use of theoretical

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frameworks and a wide range of evidence-based information have critically enabled to draw a

justifiable conclusion of the research. Additionally, the use of descriptive format to critically

analyze both primary and secondary data has increased scope for the research to bring a large

volume of findings relating to the current impact of bronchiolitis obstacles on the health of

people especially over the Indian children. In this regard, it can be said that the use of

descriptive design has provided a valuable insight into this research to critically describe facts

and come up with a relevant set of findings associated with the primary subject area as well

as the basic aim and objectives of the research.

A questionnaire has been developed to gather the viewpoint of the Indian parents and patients

along with the doctors, who are familiar with the impact and the outcome of Bronchiolitis.

That will help to recognize the immense negative affect of Bronchiolitis amid the people and

will help to recognise the possible necessary actions those are needed to be taken. Gathered

viewpoint of 100 respondents on the basis of this questions also help to produce reliable and

validate outcome of this research. The main intention of Analyst is to recognize the research

variables such as the key state of health during illness, patients’ condition, impact of

Bronchiolitis on the health as well as the mentality of the patients as well as the family

members of the patients, for that reason these specific questions have been selected. This

selected research variable questions generally help to fulfil the objectives of this particular

research project.

There are different limitations have been faced to carry out this particular survey work. The

limitations are - the provided information by the respondents are inadequate to understand so

that. There are no ways to measure the truthfulness of the respondents. Some of the

respondents do not think with a view to full context of this situation. Moreover, by

conducting the survey the research is most likely to attain knowledge on the public perception

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on the impact of Bronchiolitis on the health that may vary from the critical and more accurate

perceptions of the disease.

3.4 Research Approach

In this research, a mixed research approach has been implemented while determining the key

impacts of Bronchiolitis obstacles and discussing how the challenges are addressed by the

doctors and the health and social care organisations as well. The use of mixed research

approach has enabled the overall research to gather and critically analyze both primary and

secondary data. Theoretically, mixed research approach is a well-known method in the field

of research to critically determine and analyze facts associated with the chosen subject area.

The research method usually consists of characteristics and principles of both qualitative and

quantitative research approaches. Therefore, it is one of the most successful techniques in

research to gather facts and analyze results that are gathered from both primary and

secondary data sources. As the method deals with both qualitative and quantitative data, a

mixed research approach has critically enabled the current research to gather a large volume

of pertinent data associated with the context of Bronchiolitis obstacles and its negative impact

on the health of the Indian children and the native people as well. The method has helped to

gather both primary and secondary data and analyze facts using different analytical

techniques.

In addition, this is worth to mention that the research study also includes a deductive research

approach with the process of testing theoretical concepts and frameworks while revealing a

set of desirable objectives and determine the expected findings of the study. The concept of

deductive research is a technique used for testing theory and determines expected outcomes

of the study based on its primary aim and objectives (Saunders et al., 2007). The approach

has facilitated the research to critically identify the key issues by testing challenges with

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respect on their current influences that have been critically undermining several health

institutes and the health and social care organisations in India. With due consideration to the

aim and objectives of the research, the deductive approach was mainly implemented to

conduct an in-depth analysis of the influences derived from the key factors associated with

Bronchiolitis obstacles and its hazardous impact on the health of Indian people, mostly over

the children of India.

3.5 Research Sampling

In order to gather rich primary data, it was of prime necessity to develop a comprehensive

research sampling on the basis of which conclusive primary data can be gathered. In this

regard, snowball sampling has been adopted as an efficient model for conducting the survey.

Snowball sampling can be defined as a non-probability sampling method where the

previously recruited participants recruits the new ones the same way a rolling snow ball

becomes larger by gathering more snows. For this reason, initially a handful of people who

are the patients or the family members of the patients and who are admitted to several health

care organisations in India and who on the later phase recruited their families, friends and

other people they know as respondents for the survey. By means of resorting to this particular

sample method the potential adversity of lack of participants has been successfully dodged by

the researcher.

3.6 Data Collection Process

The current research has been conducted with a mixed research approach with an adequate

emphasis on the key philosophy and principles of deductive research method. Therefore,

based on the selected research method, the data collection process has been carried out in two

different techniques such as qualitative data collection and quantitative data collection

process. In general, qualitative data are the information or facts retrieved from various

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sources non-numerical findings. They are typically a type of descriptive data and can be

gathered from numerous sources such as past research works, academic books, peer-reviewed

journal articles and various types of observational sources. Facts gathered in the form of

qualitative data are usually more complex to analyze in comparison to the quantity data. This

is owing to the fact that the interpretation process for these types of data often requires

appropriate and credible justifications with a wide range of theoretical concepts and

frameworks. In addition to these, for conducting a qualitative research an interview has been

organized with several doctors and health consultant of health care organisations to gather

such qualitative information that the survey respondents could not have provided. In this

regard, several questions were asked to the interviewee regarding the impact of Bronchiolitis

on the health of the patients as well as the proper and appropriate medication for resolving the

physical state of the patients.

On the other, the current research also includes quantitative data in order to validate findings

regarding the primary research aim and objectives. Quantitative data are regarded as a set of

facts that can be quantified using numerical techniques. This type of data can be gathered

from a wide range of processes such as questionnaire survey, structured personal interview

process, and various observatory processes (Creswell, 2008). In this current research study, a

questionnaire survey has been designed with setting numbers of questions in respect to the

primary research aim and objectives.

In order to gather a bunch of quantitative data associated with the current research problem,

the study has conducted a structured questionnaire survey process with a group of randomly

selected individuals from hospitals and health and social care organisations. In data collection

process, a sample size of 100 was expected to provide valuable feedbacks of all the questions.

However, due to an average of almost 90 respondents have completely addressed all the

questions in the survey. The survey has provided a major support in this research not only to

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gather a large volume of data but also to ascertain various valuable facts about the negative

and hazardous impact of Bronchiolitis over the people especially over the children, who are

below of an average age group. The process has further contributed the research through

delivering credible quantifiable data to gather an adequate understanding of the current

challenges of Bronchiolitis and its effects on the patients, mostly the children of India.

For the development of this research study exploratory research method has been adhered as

the research has been taken place on the basis of the observation that the doctors and the

health care organisations are now able to cure the disease in an effective manner but not

entirely. Till there are some limitations those are making a boundary in front of the doctors

and health care service providers, for which the service providers can not properly provide

medication to resolve the physical state of the patients of India. The desire of the analyst to

attain in-depth understanding on the topic has led to the implementation of exploratory

research. Additionally, though this research method lacks statistical data still its ability to

determine the roots causes behind certain incidents make it’s a suitable method to conduct the

research. In this regard, three types of exploratory research have been put into use such as

literature research, interviews and Focus Group research.

3.7 Data Analysis Process

The data analysis process in this research was conducted in two different phases as the study

incorporates gathering of relevant facts and information from both qualitative and

quantitative techniques. In order to evaluate the qualitative data, gathered from different

secondary sources, a critical investigation regarding the credibility of the facts has been

conducted. In this process, it has been ensured that the data gathered from secondary sources

are well-structured and are apparently linked with the primary research aim and objectives.

Additionally, the sources were also investigated based on a set of research credibility criteria.

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In this research study, the qualitative data have been evaluated using relevant theoretical

approaches. Additionally, the analysis process also includes assessing the facts based on the

real-world case examples associated with the impact of Bronchiolitis amid the India People.

Therefore, in order to successfully examine the qualitative data and retrieve credible findings,

the data analysis process provides pertinent case examples that apparently reflect the

influence of few major concerns and factors that negatively hampers the health of children

throughout the Indian region. Correspondingly, a critical emphasis upon integrating relevant

theoretical models and frameworks has also been considered when justifying the impact of

Bronchiolitis obstacles and its negative approaches amid the health of the Indian people and

children.

On the other hand, the research also includes quantitative data that have been gathered from a

questionnaire survey. The data or feedbacks gathered from the respondents are quantifiable

with numerous processes. In this current study, the facts collected from the survey have been

analyzed with a simple and easily understandable technique by using graphs, charts, and

tables. The results have been interpreted with graphical illustrations which provide an

apparent view of the responses provided by the individuals incorporated in the questionnaire

survey. From a general perspective, the interpretation of survey data is a crucial function for

the researchers as they deliver clear understanding about the current situation over any

specific concern and help the readers to come up with a justifiable conclusion. Moreover,

illustrating results with the appropriate figure in each survey question can further provide a

clear understanding ofpossible facts and findings with respect to the research problem

(Creswell, 2003; 2008; 2011). Hence, in this research, the qualitative data gathered from

primary sources have been analyzed using a relevant set of graphs and charts in order to

ensure that the results are demonstrated based on the findings of the survey.

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3.8 Ethical Consideration

Research ethics is often termed as a collective set of principles and regulations that are

expected to meet with the researchers when designing structure and implement all the

activities (Smith, 2006). These are the generic policies that have been proven as the most

effectual forms of guidelines for the researchers while conducting any research. In this

research work, he ethical norm and principles have been considered as the topmost priority

when analyzing factors leading to impact Bronchiolitis obstacles on the health of the Indian

Children. The primary purpose of embracing research ethics in this research was to ensure

that the activities are performed based on an equality and fairness while designing structure

and implementing actions in various research activities (Oliver, 2010). Therefore, to meet the

ethical norms and principles, the data collection and data analysis process is considered as the

most important areas while incorporating ethics in this research. In this context, the research

work mainly focused on meeting the expected criteria associated with three broad ethical

norms or principles including informed consent, unharmed and security and privacy. Firstly, I

have been ensured that the research activities, specifically in data collection process, have

been gathered agreement of the participants with providing informed consent to each

individual. In data collection process, the respondents have been included with their personal

interest and are given with informed consent form prior to giving their valuable feedbacks on

the survey questions.

Secondly, it has also been ensured that the respondents are unharmed or they are not forced to

provide relevant feedbacks on survey questions. A major step towards respecting the interest

of the respondents has been laid upon while gathering facts from the questionnaire survey. In

this process, the respondents have given an independent choice of participating in the survey

and it was further ensured that none of them are hurt by any physical or emotional context.

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And thirdly, providing adequate safety and security in data collection and assessment

processes were also an essential ethical principle considered in this research. In this context,

it was ensured that data gathered from the respondents are free from any possible risk of

misuse or any data exploitation related issues. Therefore, the data storage facility has been

designed with a technology-based software which cannot be accessed by any unauthorized

users. Moreover, to protect privacy, the research strictly avoids representing any personal

identity of the participants or their any sensitive information that may create any threat on

their personal or professional fields. Additionally, a major emphasis upon avoiding the use of

names of the respondents along with their professional backgrounds that may increase the

risk of any redundancy related issues.

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Chapter 4: Findings

4.1 Primary Data Analysis

For the effectiveness of the research study and to meet the stated objectives questionnaire

survey is conducted. The questions are well framed and are analyzed to meet the research

aims. Total of 100 respondents was asked questions but 10 respondents were unable to

complete the questionnaire. The questions are well framed and tend to meet the objectives

ofthe impact of Bronchiolitis obstacles and its hazardous impact on the health of the Indian

people.

From the first question of the questionnaire the gender of respondents is determined. The

question tends to ask participants to specify their gender. It is noted that about 68 respondents

are male and 32 are female. The responses of the respondents are depicted hereunder:

32%

68%

Male Female

Figure 6: Gender Specification

(Source: As Created by Author)

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The second question in the questionnaire is framed to determine the age of the respondents. It

is vital to understand the changing perception of people from different age group. It is

analysed that 40 respondents are between the age group of 26 years to 45years. Amid the age

group of 46 years to 65 years it is observed that 21 respondents are of this group. 20 People

above the age of 65years presented their opinion on the topic and remaining 19 respondents

are between the age group of 15years to 25years. The responses are depicted through

graphical representation hereunder:

21%
40%

41%

20%
19%

15 years to 25 years 26 years to 45 years 46 years to 65 years Above 65 years

Figure: 7. Specify Age Group

(Source: As Created by Author)

The third question of the questionnaire is framed to understand the frequency of fallingillness

due to Bronchiolitis. However, the survey was initiated with 100 respondents but only 90

respondents completed the survey for gathering relevant information. This question is framed

to understand regularity of falling illness of people and the frequency of visiting doctors for

treatment. It is determined from the study that 23 respondents stated that they are visiting

several doctors and health care organisations for Bronchiolitis obstacles. Routine Check-up is

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preferred by people as determined from the study 16 and 15 respondents stated that they are

visiting the health care service providers to obtain the best treatment form the doctors. The

frequency of getting treatment is more during the months. The responses of the respondents

are depicted hereunder:

17% 40%

65%

18% 25%

Once a week Twice a week Once a month Twice a month

Figure: 8. Frequency of Visit Health Care Organisations

(Source: As Create by Author)

The fourth question of the questionnaire is framed to understand the fact whether the patients

of Bronchiolitis are getting sufficient treatment and medication from the health care

organisations or not. Based on the survey, it has been followed that the maximum numbers of

respondents said ‘Yes’, which means they are getting sufficient treatment from the doctors of

the health care organisations. On the other hand, rest of the respondents have stated that the

health care organisations are accessible for the patients but they are not getting the adequate

treatment of Bronchiolitis and thus, they have stated ‘No’ to this survey question. The

responses for the same are depicted hereunder using graphical representation:

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 45%
55%

Yes No

Figure: 9. Frequency of Visiting Health Care Organisations

(Source: As Created by Author)

The 5th question of the questionnaire is set on the survey report in order to obtain the

acknowledgement from the valuable respondents regarding getting the best treatment from

the health care organisations and the professional practitioners, which is doctors. In this case,

the respondents were asked whether they are getting better service from the health care

organisations instead of doctors or not. In this case, 45 respondents have stated that they are

getting better treatment from the health care organisations. On the other hand, 25 respondents

have stated that they are not getting better service from the health care organisations and thus

they rely on professional practitioners. Simultaneously, 16 respondents have conducted that

they are not sure concerning the question. However, 14 respondents did not provide any

information regarding the question.

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 45
40
35
30
25
20
15
10
5
0
Yes No Maybe No Comment

Figure: 10. Comparison between the Health Care Organisations and Professional Practitioners

(Source: As Created by Author)

The 6th question has been set up in the questionnaire in order to obtain the most appropriate

acknowledgement from the valuable respondents. In this questionnaire, the sixth question

was asked to the valuable respondents whether they are getting fastest service from the health

care organisation in order to resolve the physical state of the patients, who are suffering from

Bronchiolitis. During the survey, the most numbers of respondents have stated ‘Yes’, which

means they are getting the fastest service i.e. treatment from the health care organisations.

The numbers of respondents, who have stated yes is 70. On the other hand, another 30

respondents have stated ‘No’, which indicates they are not getting fastest treatment from the

health care organisations.

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 30%

70%

Yes No

Figure: 11. Fastest Service Getting from the Health Care Organisation

(Source: As Created by Author)

The 7th Question in the survey questionnaire is set to get the adequate information from the

valuable respondents concerning the best medication method of the health care organisations.

In this case, 100 respondents were taken into consideration, whose valuable opinion was

excessively helpful for getting the information that whether the health care organisations are

providing the bets medication for Bronchiolitis or not to the patients. In that case, 60

respondents strongly agreed about the fact. On the other hand, 25 respondents also agreed

about the fact. However, 6 respondents did not provide any comment concerning the

question. Accordingly, 5 respondents disagreed about the asked question. Moreover, 4

respondents strongly disagreed about the fact.

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 25%
5%
6%
9%

60% 4%

Strongly Agree Agree Neutral Disagree Strongly disagree

Figure: 12. Health Care Organisations Provides Proper Medication for Bronchiolitis

(Source: As Created by Author)

The 8th question in the survey questionnaire is set for obtaining the best recovery result of the

patients from Bronchiolitis obstacles. In that case, 100 respondents have been taken into

consideration from several health care organisations in order to obtain their recovery result by

acquiring medication from several health care organisations. On the basis of that, astonishing

result has been seen from the viewpoints of the respondents. By asking the question, major

numbers of respondents have stated they are getting the best results by acquiring the

medication and in this case, 72 respondents have conducted that they have recovered from the

physical state had by Bronchiolitis obstacles. However, in the meantime, 28 respondents have

stated that they have not recovered from the physical state.

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 28%

72%

Yes No

Figure: 13. Recovery Result of the Patients of Bronchiolitis Obstacles

(Source: As Created by Author)

The 9th question has been set in order to acknowledge the numbers of patient in the family of

the respondents. In that case, several options have been provided to the respondents which

indicates the sick persons’ number. On the basis of that, respondents have informed that how

many people are sick in the family due to Bronchiolitis obstacles. In that case, most of the

respondents that is 40 have conducted that there is one person is sick in the family.

Accordingly, 30 respondents have conducted that there are two people are infected due to

Bronchiolitis obstacles. Moreover, 12 respondents have stated that 3 family members are sick

in their family. Likewise, 11 respondents have stated that four members in their family are

sick due to bronchiolitis obstacles. Lastly, 7 respondents have informed that above five

members in their family are sick.

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 30% 12% 11%

18%

7%

40%

One Two Three Four Above Five

Figure: 14. Numbers of Sick People in the Family due to Bronchiolitis Obstacles

(Source: As Created by Author)

The last question that is no 10 of the survey questionnaires is set to get the information from

the valuable respondents concerning the medicines those are provided by the professionals or

the health care organisations. Several medicines are provided by the health and social care

organisation and doctors as well in order to recover the physical state of the patients of

Bronchiolitis obstacles. During the survey, 100 respondents were taken into consideration to

accomplish the survey in an adequate manner. In that case, the respondents were asked

whether the medicines are worked well or not. On the basis of that, major numbers of

respondents have stated that the medicines those were prescribed by the doctors have worked

well and they are now feeling much better. The numbers of people, who have said yes are 79.

On the other hand, a few numbers of respondents that is 21 people have claimed that the

medicines are not worked well. Therefore, the research has concentrated on the opinions of

major respondents. However, both the positive and negative opinions have taken into

consideration in this survey.

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 80
70
60
50
79
40
30
20 21
10
0
Yes No

Figure: 15. Respondents’ Opinion on the Adequate Prescribed Medicines

(Source: As Create by Author)

4.2 Qualitative Analysis

For serving the purpose of the conducting a proper qualitative analysis, the analyst conducted

an interview with several doctors concerning the impact of Bronchiolitis obstacles on the

health of the people. In the interview session several questions have been asked to the

individual doctors to derive their understanding on the impact of Bronchiolitis obstacles and

its proper medication to recover the physical state. The response of the interviewee in relation

to the questions asked has been scripted below:

Q1:“Can it be stated that Bronchiolitis Obstacles is contagious?”

In response to this question the interviewee responded“The infections that cause bronchiolitis

are contagious. The germs can spread in tiny drops of fluid from an infected person's nose

and mouth via sneezes, coughs, or laughs. Infected droplets also can end up on things the

person has touched, such as used tissues or toys. Moreover, infants in childcare centres have

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a higher risk of getting an infection that may lead to bronchiolitis because they're in close

contact with lots of other young children. Furthermore, Bronchiolitis is contagious to adults

also. Viral infections spread through droplets in the air, so you can contract it the same way

you get infected with colds or flus. While it's hard to stop a viral infection, you can lower

your child's chance of getting it if you: Stay away from others who are sick.”

Q2: “In your opinion, who get affected by the Bronchiolitis obstacles most?”

While answering this question the professional practitioner mentioned that “most often

affects infants and young children because their noses and small airways can easily get

blocked is most common during the first 2 years of life, especially in babies 3‒6 months old is

more common in males, premature babies, children who weren't breastfed, and those who

live in crowded conditions. Also, those kids, who go to childcare or are around second-hand

smoke also are at risk for bronchiolitis.”

Q3: “Can you please mention what are the major reasons that causes Bronchiolitis

Obstacles?”

During emphasises the reasons those are excessively noteworthy for causing Bronchiolitis

obstacles, the renowned health practitioner stated that “Bronchiolitis usually is a viral

infection. Respiratory syncytial virus (RSV) causes more than half of all cases. Other viruses

that can cause bronchiolitis included a) rhinovirus (the common cold), b) the flu, c) human

metapneumovirus, d) adenovirus, e) coronavirus and f) parainfluenza.”

Q4: “What kinds of problems are to be seen due to Bronchiolitis obstacles?”

This question was asked to the interviewee for extracting his ideas on theproblems caused by

Bronchiolitis obstacles. In this regard, the interviewee answered that“Bronchiolitis often is a

mild illness. But some babies are at risk for severe illness, including those who

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were bornprematurely. Moreover, who have a chronic heart disease or lung disease. On the

other hand, the people, who have a weakened immune system due to illness or medicines. In

that case, these babies need treatment for bronchiolitis in a hospital. Accordingly, kids who

have had bronchiolitis might be more likely to develop asthma later in life. It's not clear

whether the illness causes or triggers asthma, or whether kids who later develop asthma were

more prone to bronchiolitis as infants.”

Q5: “In your opinion, how is Bronchiolitis treated?”

While answering this question the professional practitioner mentioned that “Most cases of

bronchiolitis are mild and don't need specific medical treatment. Antibiotics can't help

because bronchiolitis is caused by a virus. Antibiotics work only against bacterial infections.

Doctors may give medicine to help open a child's airways.Babies who have trouble

breathing, are dehydrated, or seem very tired should be checked by a doctor. Those with

serious symptoms may need to be hospitalized, watched closely, and given fluids and

humidified oxygen.Rarely, in very severe cases, doctors put the baby on a respirator to help

with breathing until the baby gets better.”

Q6: “Is it possible to prevent Bronchiolitis?”

In response to this question the interviewee responded“Washing hands well and often is the

best way to prevent the spread of viruses that can cause bronchiolitis and other

infections. Also, it is necessary to keep infants away from anyone who has a cold or cough as

well as it is required to protect babies from second-hand smoke.

There's no bronchiolitis vaccine yet, but doctors can give a medicine called palivizumab to

ease the severity of the disease. It's recommended only for infants at high risk for serious

symptoms, such as those born very prematurely or those with chronic lung disease or heart

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disease. The medicine contains antibodies to respiratory syncytial virus. It's given as an

injection monthly during peak RSV season.”

Q7: “When people should visit a doctor to confirm whether they have Bronchiolitis or

not?”

While answering this question the professional practitioner mentioned that “Call your doctor

if your child is breathing quickly, especially if he or she also has retractions or wheezing.

Moreover, the child might be dehydrated due to vomiting or a poor appetite. If the child is

sleepier than usual and has a high fever, parents should immediately call a doctor tom check-

up the child.”

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Chapter 5: Discussion

5.1 Overview

Bronchiolitis is typically caused by a viral infection. With improvement in diagnostic ability

to identify viruses in respiratory secretions (nasopharyngeal aspirates) multiple viral agents

have been identified as causative agents of acute bronchiolitis: Respiratory syncytial virus

(RSV), Rhinovirus, Parainfluenza viruses, Influenza virus, Adenovirus, and Coronavirus.

RSV is the most common cause, accounting for 50-80% cases(Willner et al., 2013). In Indian

studies, RSV infection was diagnosed in 30-70% of children with bronchiolitis. The

proportion of disease caused by specific viruses varies depending upon the season and the

year, and there is a wide variation in the reported proportions among various studies. Most of

the studies implicate rhinovirus (which normally causes common cold) as the second most

common cause of bronchiolitis(Wolf et al., 2011). Molecular diagnostic techniques have also

revealed a high frequency (15-25%) of mixed viral infections among children evaluated for

bronchiolitis.

Apart from the above-mentioned viruses, newer respiratory viruses have been described in

children, including human metapneumovirus (hMPV) and human bocavirus

(HBoV)(Woolums,Leen and Moore, 2011). Some of the recent studies have found hMPV as

a common cause of respiratory tract infections in children throughout the world and often

second only to RSV as a cause of bronchiolitis in infants. In contrast to hMPV, the role of

HBoV in causing respiratory illnesses is less clear(Zoz, Lawsonand Blackwell, 2011). This is

because HBoV is associated with high coinfection rate (50-60%), and therefore the role that

HBoV alone plays in illness can be questioned. Another problem with HBoV is its lack of

cultivability and hence lack of appropriate models for pathogenesis.

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5.2Disease Course and Prediction of Severity

Bronchiolitis usually is a self-limited disease. Although symptoms may persist for several

weeks, the majority of children who do not require hospital admission may continue to have

low grade symptoms up to 4 weeks(Beck-Broichsitter et al., 2011). In previously healthy

infants, the average length of hospitalization is three to four days. The course may be

prolonged in younger infants and those with co-morbid conditions (e.g., chronic lung

disease)(Bergeron et al., 2013).

A number of risk factors and clinical findings have been proposed to predict the severity of

disease in children with bronchiolitis (Cao et al., 2011). Various studies and treatment trials

have also used clinical scores (e.g., the Respiratory Distress Assessment Instrument) to

predict the disease severity in children with bronchiolitis, but none of these scores have been

validated for clinical predictive value in bronchiolitis(Cona et al., 2011). It should be

emphasized that repeated observation over a period of time may provide a more valid overall

assessment of the disease severity than a single examination. Risk factors for mortality

include: younger age (<6 months), prematurity, underlying chronic lung disease, cyanotic

heart disease or immunocompromised state(Da Dalt et al., 2013).

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 Figure: 16. Predictors of Severe Bronchiolitis

(Source: Date and Oto, 2011)

5.3 Therapy

Acute bronchiolitis is, in the majority of cases, a mild and self-limiting illness that can be

managed on ambulatory basis with supportive care alone(de Jong et al., 2011). Management

mainly consists of educating parents or caregivers about adequate feeding and to report any

deterioration (such as increasing difficulty in breathing, chest indrawing or problems with

feeding) to an appropriate health care facility(Dong et al., 2015). Multiple intervention

studies have been carried out to improve treatment of bronchiolitis. Still there is much

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controversy, confusion, and lack of evidence over the best treatment for infants hospitalised

with moderate to severe bronchiolitis(Hachem, 2013).

Figure: 17. Summary of Interventions Used for Management of Acute Bronchiolitis

(Source: Han, 2011)

5.4 Supportive Care

Supportive care remains the cornerstone of treatment of children with bronchiolitis. It

includes maintenance of adequate hydration, provision of respiratory support as necessary,

and monitoring for disease progression(Hangartner et al., 2016).

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A. Fluid administration

Children with bronchiolitis are at an increased risk of dehydration because of their increased

needs (related to fever and tachypnoea) and reduced oral acceptance(Hayes, 2011). Clinicians

should carefully assess hydration and ability to take fluids orally. Children having

dehydration or difficulty in feeding safely because of respiratory distress should be given

intravenous fluids(Hosseini-Baharanchi et al., 2016). For children who can tolerate enteral

feedings, small frequent feedings or orogastric or nasogastric feedings may be used to prevent

dehydration. Children with bronchiolitis are also at an increased risk of fluid retention (and

subsequent pulmonary congestion) due to excessive antidiuretic hormone production, so

urine output should be carefully monitored(Huddleston, 2011).

B. Nasal Decongestion

Saline nose drops and cleaning of nostrils by gentle suction may help to relieve nasal block.

Instilling saline drops and cleaning nostrils by gentle suction before feeding may be helpful.

Parents should be educated about instilling saline drops and cleaning secretions from nose

before discharge from hospital(Iuppa et al., 2011).

C. Respiratory support

I. Supplemental oxygen

The major consequence of airway obstruction and concomitant poor distribution of

ventilation and perfusion in bronchiolitis is hypoxemia(Jiang et al., 2011). Humidified

oxygen should be administered to hypoxemic infants by any technique familiar to the nursing

personnel (nasal cannula, face mask, or head box)(Joshi, Reyesand Araque, 2011). Pulse

oximetry is the most commonly used tool to decide about oxygen supplementation. The cut-

off level of oxyhaemoglobin saturation (SpO2), at which supplementation should be started

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or stopped varies widely among different guidelines and different centres. Data are lacking to

support the use of a specific SpO2cut-off value. In the most recent clinical practice guideline

of the American Academy of Paediatrics (AAP)(Kato et al., 2011).

II. Continuous Positive Airway Pressure

In severe bronchiolitis early intervention in form of continuous positive airway pressure

(CPAP) has been used to prevent mechanical ventilation(Lewin, Brauerand Ostad, 2011).

CPAP helps in recruitment of collapsed alveoli by opening terminal bronchioles. Airway

resistance in terminal airways is reduced with CPAP and also there is decreased air trapping,

hyperinflation and work of breathing(Munakata et al., 2011). A systematic review in 2011 on

use of CPAP in acute bronchiolitis concluded that the evidence supporting the use of CPAP

to reduce PCO2 and respiratory distress in bronchiolitis was of low methodological quality,

and there was no conclusive evidence that CPAP reduced the need for intubation(Norman et

al., 2010). However, a recent randomised trial comparing nasal CPAP and oxygen inhalation

concluded that CPAP resulted in rapid reduction in work of breathing and improvement in the

respiratory distress score at 6 hours(Park et al., 2015). The improvement was proportional to

the initial severity, suggesting that, early use of CPAP in severe forms of the disease may be

beneficial.

III. Chest Physiotherapy

Chest physiotherapy clears the excessive respiratory secretions, and thus helps to reduce

airway resistance, the work of breathing, and enhances gas exchange(Pletcherand Rodi,

2011). In spite of this theoretical advantage, a systematic review of nine randomized trials

concluded that chest physiotherapy using vibration and percussion or passive expiratory

techniques did not improve respiratory parameters, reduce supplemental oxygen requirement,

or reduce length of hospital stay(Ralston et al., 2014). The use of chest physiotherapy is

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discouraged in children with bronchiolitis, because it may increase the distress and irritability

of ill infants.

D. Steroids

I. Systemic corticosteroids

Initial studies of the treatment of bronchiolitis with corticosteroids suggested that steroids

might favourably influence mortality and morbidity. However, large controlled studies have

failed to demonstrate any significant clinical effect(Redman et al., 2011). A meta-analysis

evaluating the use of systemic glucocorticoids (oral, intramuscular, or intravenous) and

inhaled glucocorticoids for acute bronchiolitis in children (0 to 24 months of age) (Reid et al.,

2011). In pooled analyses, no significant differences were found in hospital admission rate,

length of stay, clinical score after 12 hours, or hospital readmission rate. Hence, it is

recommended not to use glucocorticoids in healthy infants and young children with a first

episode of bronchiolitis(Shah, 2011). Another meta-analysis (of 3 studies) studied the role of

systemic steroids in critically ill children with bronchiolitis. It was found that systemic

corticosteroid showed no overall effect on duration of mechanical

ventilation(Sharma,Guptaand Rafik,2013).

II. Corticosteroids plus Epinephrine

A possibility of synergy between epinephrine and glucocorticoids has also been evaluated.

There is one trial which suggested that administration of epinephrine and glucocorticoids in

the outpatient setting prevents hospitalization within seven days(Shi et al., 2011). In this

multicentre trial, there was a reduction in hospitalization rates in the group that received

dexamethasone and 2 doses of epinephrine by nebulizer as compared with those who were

treated with placebo (17.1% vs 26.4%)(Shieldsand Thavagnanam, 2013). Number needed to

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prevent one admission was 11. However, the strength of evidence was low and after

adjustment for multiple comparisons, the difference did not reach statistical significance. This

may have a potential role in future treatment algorithms(Skjerven et al., 2013). Till additional

studies shows similar results and safety is established, this combination therapy may be

considered under evaluation.

III. Inhaled Corticosteroids (ICS)

Use of ICS during acute bronchiolitis has been proposed to prevent post-bronchiolitis

wheezing. A systematic review of 5 studies involving infants did not demonstrate an effect of

ICS, given during the acute phase of bronchiolitis, in the prevention of recurrent wheezing

following bronchiolitis(Tagawa et al., 2011). An additional RCT involving 243 infants with

RSV-related LRTI did not find any effect of inhaled corticosteroids on recurrent wheeze.

Hence, there is no evidence for use of inhaled corticosteroids to prevent or reduce post-

bronchiolitis wheezing after RSV bronchiolitis(Teshome, Gattuand Brown, 2013).

E. Antibiotics

Unnecessary use of antibiotics is associated with increased cost of treatment, adverse

reactions and development of bacterial resistance in community/ geographic

region(Thompson et al., 2013). In children with bronchiolitis and fever, the risk of secondary

bacterial infection is low, therefore, routine use of antibiotics is not recommended(Ulloa-

Gutierrez et al., 2011). It is recommended that antibiotics should be used only in children

having specific indications of coexistence of a bacterial infection. Presence of infiltrates or

atelectasis on X-ray film may not indicate bacterial infection(Valapour et al., 2013). Clinical

setting, with consolidation on X-ray film may indicate a possibility of bacterial pneumonia in

infants with bronchiolitis.

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A systematic review including five studies did not find significant benefits for use of

antibiotics in acute bronchiolitis(Vissing, Chawesand Bisgaard, 2013). However, the review

indicated a need for research to identify a subgroup of patients who may benefit from

antibiotics. One small study, which was included in this review, compared clarithromycin for

3 weeks with placebo in children with RSV bronchiolitis(Watanabe et al., 2012). Treatment

with clarithromycin was associated with reduction in the length of hospital stay, duration of

need for oxygen, and readmission rates. Clarithromycin was proposed to have a possible

immunomodulatory effect. More well-planned studies to clarify role of macrolides in acute

bronchiolitis are required(Wilkes, 2011).

F. Leukotriene receptor antagonists (Montelukast)

Clinical symptoms and post-bronchiolitis cough and wheeze are attributed to the increased

cysteinyl leukotrienes in airway secretions of children with bronchiolitis during acute phase

as well as in short term follow up(Willner et al., 2013). Randomized trials of montelukast as a

treatment for acute bronchiolitis have had conflicting results. Randomized trials of

montelukast for the prevention of airway reactivity and post-bronchiolitis respiratory

symptoms have also had inconsistent results(Wolf et al., 2011). However, in the largest trial

use of montelukast for 24 weeks was not associated with improvement in post-bronchiolitis

respiratory symptoms. In view of these studies, montelukast is currently not recommended

for treatment of bronchiolitis or for prevention of airway reactivity after

bronchiolitis(Woolums,Leen and Moore, 2011).

5.5 Summary

Bronchiolitis is a common respiratory tract infection in infancy; the commonest etiologic

agent being the respiratory syncytial virus. The diagnosis of bronchiolitis is mostly clinical,

and laboratory investigations have a limited role in diagnosis and management. The current

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management primarily consists of supportive care, including hydration, supplemental oxygen,

and mechanical ventilation when required. At this point, there is no specific treatment for

bronchiolitis for which there is a strong or convincing evidence of effectiveness. It may be

appropriate to administer nebulized epinephrine or salbutamol in a given child and continue

these if found beneficial and discontinue if there is no effect. Corticosteroids are judged to be

ineffective and not indicated for these infants. In absence of an effective vaccine,

Palivizumab, a monoclonal antibody against RSV may be considered for passive

immunoprophylaxis in certain high-risk infants before the RSV season.

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Chapter 6: Conclusion and Recommendation

6.1 Conclusion

Bronchiolitis is the most common reason for hospitalization during infancy, being a burden

for the child and family, and bearing huge costs for the healthcare systems. The main

principles for treatment include minimal handling, maintenance of oxygen saturation, fluid

balance and nutrition. Other therapeutic options are inhalations with epinephrine, normal

saline or hypertonic saline, but the evidences for their use are sparse. CPAP and heated

humidified high-flow nasal cannulae are commonly used in those with respiratory failure, but

more high-quality studies are needed to prove their efficacy. Very few children may be in

need of mechanical ventilation.

This project has demonstrated that infants with acute viral bronchiolitis may be managed to

an oxygen saturation target of ≥ 90% in air when observed for a period of 4 hours, including a

period of sleep, and continuously monitored. The implications for health care are that starting

and stopping points for oxygen supplementation in acute bronchiolitis could be around a

single oxygen saturation target of 90% – streamlining and coalescing care across all health-

care settings. The study does not identify an oxygen saturation point at which infants require

health-care observation (but notes a previous recommendation of ≤ 92%).

Infants could be safely discharged once they attain a stable oxygen saturation of ≥ 90% in air

for 4 continuous hours, including a period of sleep, and are feeding adequately and clinically

stable. This could take place in any health-care setting with the facility to provide this level of

evaluation. In many cases this should result in earlier discharge home with benefits

demonstrated for infants and parents in addition to cost savings for health-care providers.

The optimal management of bronchiolitis for otherwise healthy children has been debated for

some time. In a seminal review published in 1965, the admonition was made to use patience

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and avoid unnecessary and futile therapy. This prudent advice has been ignored frequently

over the past 50 years. The optimal management of bronchiolitis in otherwise healthy

children remains nested, first and foremost, in excellent supportive care. While trials

investigating other modalities are ongoing, the health care provider is reminded that ‘primum

non nocere’ should remain the key dictum in the treatment of otherwise healthy children with

bronchiolitis.

6.2 Recommendation

By means of investigating the entire research, some recommendations have been highlighted,

which might be fruitful for resolving the impact of Bronchiolitis obstacles amid the people,

especially the infants of India. The recommendations are stated under here:

I. Bronchiolitis is a clinical diagnosis based on history and physical examination.

Diagnostic studies, including chest radiograph, blood tests and viral/bacterial cultures,

are not recommended in typical cases.

II. The decision to admit to hospital should be based on clinical judgment, factoring in

the risk for progression to severe disease, respiratory status, ability to maintain

adequate hydration and the family’s ability to cope at home.

III. Management is primarily supportive including hydration, minimal handling, gentle

nasal suctioning and oxygen therapy.

IV. If using IV fluids for hydration, an isotonic solution (0.9% NaCl/5% dextrose) is

recommended, together with routine monitoring of serum Na.

V. The use of epinephrine is not recommended in routine cases. If a trial of epinephrine

inhalation is attempted in the emergency department, ongoing treatment should only

occur if there are clear signs of clinical improvement.

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 VI. The use of antibiotics is not recommended unless there is suspicion of an underlying

bacterial infection.

VII. The use of chest physiotherapy is not recommended.

VIII. Thoughtful use of oxygen saturation monitoring in hospitalized patients is

recommended. Continuous saturation monitoring may be indicated for high-risk

children in the acute phase of illness, and intermittent monitoring or spot checks are

appropriate for lower-risk children and patients who are improving clinically.

6.3 Future Research Scope

RSV is one of the last viruses to cause annual worldwide outbreaks of disease against which

no safe and effective vaccine is available. Several approaches to vaccine development are

being investigated.68 A live attenuated vaccine for intranasal administration would stimulate

both topical and systemic immunity; such a vaccine is being developed with the use of

reverse genetics to modify specific genes. Efforts to date have been hampered by the

difficulty of achievingadequate attenuation of the vaccine strain, so that symptoms do not

develop in the vaccine recipient, while at the same time maintaining adequate

immunogenicity so that immunity is conferred.

Subunit vaccines are being explored and may be appropriate for seropositive patients;

concern about possible enhancement of disease in seronegative vaccine recipients

(particularly seronegative infants) must be resolved, however, before trials can proceed. A

third approach involves maternal immunization during pregnancy with use of a

nonreplicating vaccine. Results from a trial with an RSV recombinant fusion protein

nanoparticle vaccine indicate safety and immunogenicity in women of childbearing age.69 If

neutralizing antibodies undergo transplacental passage, protection may be provided for the

infant during the first months of life.

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8. Appendices

8.1 Appendix1: Primary Questionnaire

Demographic Questionnaire

1. Please mention your gender.

Male

Female

2. Please Specify your age.

15 years to 25 years

26 years to 45 years

46 years to 65 years

Above 65 years

3.How often do you visit doctors and health care organisations?

Once a week

Twice a week

Once a month

Twice a month

Research Variable Questions

4. Are you getting sufficient treatment from the health care organisations

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Yes

No

5. Are Health Care Organisations better than Practitioners i.e. Doctors

Yes

No

Maybe

No Comment

6. Are you getting fastest service from the Health Care Service providers.

Yes

No

7. Health Care organisations provide proper medication for Bronchiolitis.

Strongly Agree

Agree

Neutral

Disagree

Strongly disagree

8. Do you recover from the impact of Bronchiolitis Obstacles?

Yes

No

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9. How many family members are infected from Bronchiolitis obstacles

One

Two

Three

Four

Above Five

10. Do you think that the medicines are working well?

Yes

No

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8.2 Interview Questions

1. Can it be stated that Bronchiolitis Obstacles is contagious?

2. In your opinion, who get affected by the Bronchiolitis obstacles most?

3. Can you please mention what are the major reasons that causes Bronchiolitis Obstacles?

4. What kinds of problems are to be seen due to Bronchiolitis obstacles?

5.In your opinion, how is Bronchiolitis treated?

6. Is it possible to prevent Bronchiolitis?

7. When people should visit a doctor to confirm whether they have Bronchiolitis or not?

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