You are on page 1of 24

BRONCHIOLITIS

Helmi M. Lubis, dr, SpA(K)


Ridwan M. Daulay, dr, SpA(K)
Wisman Dalimunthe, dr, SpA
Rini Savitri Daulay, dr, M.Ked(Ped), SpA

Definition: bronchioles inflammation

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

Predominantly < 2 years of age


(2 8 months)

Difficult to differentiate with pneumonia

Pathology
3

Necrosis

of the respiratory tract epithelium


Destruction of ciliated epithelial cells
Peribronchial infiltration with lymphocites &
neutrophils
Sub mucosal edematous
No destruction of collagen, muscle, or elastic
tissue

Pathophysiology
4

Edema + accumulation of mucous & cellular debris

narrow of peripheral airway partially / totally


occluded over distention / atelectasis

Etiology
6

Predominantly

95%

Other

RSV (Respiratory Syncytial Virus)

viruses :

Human

metapneumovirus
Rhinovirus
Adenovirus
Influenza virus
Parainfluenza virus
Entero virus

Increase severity in:


Prematurity
Underlying

medical condition
Group A RSV strain
Age < 3 mo

Diagnosis
8

Etiological

diagnosis
Microbiologic examination (viral culture)
Clinical diagnosis
Signs and symptoms
Age
Resource of infection epidemic of RSV
Laboratory finding
Radiological examination

Clinical Manifestation
9

Mild rhinorrhea

1-2 days later:

Cough

Fast breathing

Low-grade fever

Cyanosis

Grunting

Chest retraction

Wheezing

Irritable

Vomitus

Poor intake

Physical Examinations
10

Tachypnea
Tachycardia
Retraction

Prolonged expiration
Wheezing
Fever
Mild conjunctivitis
Pharyngitis

Radiologic examination
11

Diffuse

hyperinflation
Patchy infiltrates
Flat diaphragm
Intercostal space >
Retrosternal space > (lateral view)
Peribronchial infiltrates / thickening
Atelectasis segmental collapse

12

Laboratory Finding
13

Microbiologic

examination
WBC : 5000 24.000 cells/mm3, predominantly
PMN & bands
Blood Gas Analysis
Arterial saturation
pCO2
Mild respiratory alkalosis
Metabolic acidosis
Acute respiratory acidosis

14

Respiratory

rate : Arterial saturation


pCO2

Differential Diagnosis
15

Asthma
Pneumonia

Acute Bronchitis
Congestive Heart Failure
Pulmonary Edema

Obstruction in the lower respiratory tract

Management
16

Mild

treated at home
Moderate / severe disease :
Hospitalization
Support :
Oxygen
Intra venous fluid drip (antibiotics)
Detect & treat possible complication
Prevent the spread of infection

17

Controversial

:
Bronchodilator
Corticosteroid
Antiviral
Antibiotic

2 Agonist
18

Flores and Horwitz, 1997


Meta-analysis of RCT inhaled 2 Agonist
Sample : 3 inpatient & 5 outpatient studies
Treatment : nebulized albuterol
Outcome : clinical score, satO2, LOS
Result : unavailable evidence of 2
Agonist efficacy

Corticosteroid
19

Treatment : Prednison equivalent 1 mg/kgBW


Outcome : LOS, duration of symptoms (DOS),

clinical scores
Result :

LOS and DOS


Clinical score

Corticosteroid
20

Clinical score :
Wheezing
SaO2
Accessory muscle use
RR

Conclusion :
Benefits depend on severity and initiation of
treatment

21

Natural history & complications


Regeneration of bronchiolar epithelium after 3 or 4 d
Cilia after 9 d
Improved clinical findings : in 3-4 days
Improved radiological features: in 9 days
Persistent respiratory obstruction : 20%
Respiratory failure : 25 %
Lung collaps

Prognosis
22

23% infant asthma at 3 years,

Control 1% asthma
OR : 28; 90% CI 4-1235
(Garrison et al. 2000 after Sigurs et al. 1995)

23

Correlation with Asthma


30

% - 50 % becomes asthmatic patients


Similarity in :
Pathogenic mechanisms
Pathologic disorders

24