Bronchiolitis

• Bronchiolitis, a lower respiratory tract

infection that primarily affects the small
airways (bronchioles), is a common cause of
illness and hospitalization in infants and
young children.

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 Bronchiolitis
• It results from inflammatory obstruction of
the small air ways.
• It commonly affects infants and young
children under the age of yrs with peak
incidence of approximately 6 mo of age.

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 Bronchiolitis
• Bronchiolitis → a clinical syndrome that
occurs in children <2 years of age and
• It is characterized by upper respiratory
symptoms (eg, rhinorrhea) followed by lower
respiratory infection with inflammation, which
results in wheezing and or crackles (rales).

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 Bronchiolitis

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 Bronchiolitis
• The incidence is highest during the winter and
early spring
• The illness occur sporadically and
epidemically

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 Etiology
• Acute bronchiolitis is predominantly a viral illness.
• Occurs in association with viral infections RSV in
more than 50% of cases.
• There is no firm evidence that bacteria cause
bronchiolitis.
• Re-infection during the single season is possible.

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 Etiology
• Respiratory syncytial virus (RSV) is the most
common cause, followed by rhinovirus .
• Less common causes include:
– Parainfluenza virus, human metapneumovirus,
influenza virus, adenovirus, coronavirus, and
human bocavirus

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 Disease burden
• Around 70% of all infants will be infected with RSV in
their first year of life and 22% develop symptomatic
disease.
• Around 3% of all infants younger than one year are
admitted to hospital with bronchiolitis
• Children with underlying medical problems
( prematurity, cardiac disease or underlying
respiratory disease) are more susceptible to severe
disease and so have higher rates of hospitalization.

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 Pathogenesis
•  Bronchiolitis occurs when viruses infect the
terminal bronchiolar epithelial cells, causing
direct damage and inflammation in the small
bronchi and bronchioles.
• Edema, excessive mucus, and sloughed
epithelial cells lead to obstruction of small
airways and atelectasis.

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 Pathogenesis
• Acute bronchiolitis is characterized by
bronchiolar obstruction due to :
• Edema and accumulation of mucus
• Cellular debris and
• By invasion of the small bronchial radicles by virus
• The pathological process impairs the normal
exchange of gases in the lung.

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 Epidemiology
• Risk factors for severe or complicated bronchiolitis
include:
– Prematurity (gestational age <37 weeks)
– Age less than 12 weeks
– Chronic pulmonary disease, particularly bronchopulmonary
dysplasia (also known as chronic lung disease)
– Congenital and anatomic defects of the airways
– Congenital heart disease
– Immunodeficiency
– Neurologic disease

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 Epidemiology
• Environmental and other risk factors, such as
passive smoking, crowded household, daycare
attendance, concurrent birth siblings, older
siblings, and high altitude (>2500 meters) can
also contribute to more severe disease.

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 Epidemiology
• Bronchiolitis most commonly occur in male
infant between 3 and 6 mo of age who have
not breast feed and lived in crowded
condition.
• Always there is an adult source of infection
• Infants with mother smoke cigarette are more
likely to acquire bronchiolitis .

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 Clinical manifestation
• H/o exposure to older children or adult with
minor respiratory illness.
• increasing rate of breathing (tachypnea),
increasing heart rate (tachycardia ), wheezing,
a hacking cough, and difficulty breathing.
• Dyspnea, and irritability, nasal flaring.
• Widespread crakles and wheeze.
• In severe cases, there may be cyanosis.

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 Clinical manifestation
• Roentgenogram anteroposterior examination
reveals hyperinflation of the lungs and
increased anterorposterior diameter on
lateral view scattered areas of consolidation.
• If there is severe obstruction of the airways, it
may also show areas of collapsed lung units
(called atelectasis) and associated patchiness
of the lungs.

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 Clinical Course
• The duration of the illness due to bronchiolitis
depends upon age, severity of illness,
associated high-risk conditions (eg,
prematurity, chronic pulmonary disease), and
the causative agent.
• Bronchiolitis usually is a self-limited disease.
Most children who do not require
hospitalization recover by 28 days

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 Clinical Course
• Typical illness with bronchiolitis begins with
upper respiratory tract symptoms, followed
by lower respiratory tract signs and
symptoms on days two to three, which peak
on days five to seven and then gradually
resolve.

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 Clinical Course
• In a cohort of 181 children, the median
duration of caretaker-reported symptoms was
12 days .
• Approximately 20 % continued to have
symptoms for at least three weeks, and 10 %
had symptoms for at least four weeks.

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 Complication
• In most previously healthy infants,
bronchiolitis resolves without complications.
• Severely affected patients are at increased risk
for complications, the most serious of which
are apnea and respiratory failure .

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 Complication
• Infants who require mechanical ventilation for
apnea or respiratory failure may develop air
leak, such as pneumothorax or
pneumomediastinum.

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 Apnea
• In a three-year multicenter prospective study
(2007-2010), apnea was documented in the
medical record of 5 % (95% CI 4 to 6 percent)
of 2156 children <2 years hospitalized with
bronchiolitis

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 Respiratory Failure
• In a multicenter study, respiratory failure
occurred in 14 % of 684 infants younger than
12 months who were hospitalized for
management of bronchiolitis.
• In another multicenter study, 16 % of infants
hospitalized with RSV required intensive care
support (with or without mechanical
ventilation)

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 Secondary Bacterial Infection
• With the exception of otitis media, secondary
bacterial infection is uncommon among infants
and young children with bronchiolitis or RSV
infection.
• In a nine-year prospective study of 565
children (<3 years) hospitalized with
documented RSV infection, subsequent
bacterial infection developed only 1.2 % and
subsequent bacterial pneumonia in 0.9 %.
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 Diagnosis
• The diagnosis of bronchiolitis is made upon
clinical symptoms and the course of the
illness.
• Chest radiographs and laboratory studies are
not necessary to make the diagnosis of
bronchiolitis .

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 Diagnosis
• In infants and young children with moderate
or severe respiratory distress radiographs
usually are indicated.
• Radiographs also may be indicated to exclude
alternate diagnoses in children who fail to
improve at the expected rate

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 Diagnosis
• Radiographic features of bronchiolitis, which
are variable and nonspecific, include
hyperinflation and peribronchial thickening.
• Patchy atelectasis with volume loss may result
from airway narrowing and mucus plugging.

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 Differential diagnosis
• Bronchiolitis sometimes mimics asthma.
• Condition favors the diagnosis of asthma are:
• Family history of asthma or other allergic disorders
• Repeated episodes in the same infant
• Sudden onset without preceding infection
• Eosinophilia and immediate response to single dose of
aerosolized ventolin or albuterol.

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 Differential diagnosis cont’
• Cystic fibrosis
• Heart failure
• Foreign body aspiration
• Pneumonia

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 Management
• Children with respiratory distress should be
hospitalized
• Supportive treatment to maintain oxygenation
and hydration.

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 Inhaled Bronchodilators
•  A trial of inhaled bronchodilators (albuterol
[salbutamol] or epinephrine) →for infants
and children with bronchiolitis and moderate
to severe respiratory distress.
• Meta-analyses of randomized trials and
systematic reviews provide little evidence of
benefit from bronchodilators in children with
bronchiolitis

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 Study
• In a meta-analysis of 28 trials comparing
bronchodilators other than epinephrine with
placebo, there were no significant differences in
improvement in clinical score, oxygenation,
hospitalization rate, or duration of hospitalization.
• A modest improvement was noted in average clinical
score, but, as noted above, the results may have
been biased by the inclusion of studies that enrolled
infants with recurrent wheezing/asthma.

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 Study
• Another meta-analysis of 19 trials compared
nebulized epinephrine with placebo or other
bronchodilators .
• Compared with placebo, epinephrine
decreased admissions within 24 hours of
administration (risk ratio 0.67, 95% CI 0.50-
0.89) and was associated with short-term
clinical improvements, but did not affect
admissions within one week or length of stay.
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 Study
• Compared with albuterol, epinephrine was
associated with short-term clinical
improvements, but did not affect admission
rate.
• Although epinephrine was associated with
decreased length of stay compared with
albuterol (mean difference -0.28, 95% CI -0.46
to -0.09), epinephrine did not decrease length
of stay when compared with placebo.
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 Study
• In a subsequent multicenter randomized trial
comparing nebulized epinephrine with
nebulized saline in infants (<12 months)
hospitalized with moderate to severe acute
bronchiolitis, length of stay, use of
supplemental oxygen, ventilatory support
nasogastric tube feeding, and improvement in
clinical score compared with baseline were
similar between groups.
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 Oral Bronchodilators
• It is not recommended the use of oral
bronchodilators in the management of
bronchiolitis.
• In randomized trials, oral bronchodilators
have neither shortened clinical illness nor
improved clinical parameters, but were
associated with adverse effects (increased
heart rate).

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 Treatment
• Ribavarin( vibrazole) is indicated for serious
case( infants with congenital heart disease or
bronchpulmonary dysplasia)
• Antibiotics have no therapeutic value
• Corticosteroids are not beneficial and may be
harmful

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 Systemic Glucocorticoids
•  The antiinflammatory effects of
glucocorticoids are thought to reduce airway
obstruction by decreasing bronchiolar
swelling. However, most studies show little
effect in bronchiolitis.

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 Systemic Glucocorticoids
• A 2013 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) included 17 trials with 2596 patients .
• In pooled analyses, no significant differences
were found in hospital admission rate, length of
stay, clinical score after 12 hours, or hospital
readmission rate.
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 Bronchodilators Plus
Glucocorticoids 
•  We do not suggest combination therapy with
bronchodilators plus glucocorticoids for
infants and children with bronchiolitis.

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 Study
• In this multicenter trial, 800 infants presenting
to the emergency department (ED) with
bronchiolitis were randomly assigned to one of
four treatment groups:
– Nebulized epinephrine and oral placebo;
– Oral dexamethasone (1.0 mg/kg in the ED and 0.6
mg/kg per day for five days) and inhaled placebo;
– Nebulized epinephrine and oral dexamethasone;
– And nebulized and oral placebo
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 Study
• Outcomes in the dexamethasone and epinephrine
monotherapy groups did not differ significantly from
those in the placebo group.
• Treatment with dexamethasone and epinephrine
was associated with a decreased rate of
hospitalization within one week of the ED visit (17
versus 24 to 26 percent in the other groups), but the
result was not significant when adjusted for multiple
comparisons (relative risk, 0.65, adjusted 95% CI
0.41-1.03) .
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 Prevention
• RSV immune globulin intravenous or IM is
indicated for:
• Infant less than 2 years with chronic lung disease
( bronchopulmonary dysplasia) and prematurity
• Should not be given to infants with
symptomatic congenital heart disease b/o
increased mortality

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 Prognosis and complication
• Critical phase is the first 24-72 hours of the
illness after the onset of dyspnea
• Death usually is due to apneic spells , acidosis
and dehydration
• Bacterial complication such as
bronchopneumonia and sepsis is uncommon
• Otitis media and cardiac failure can occur

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 Thank you for your attention

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