Bronchiolitis

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Not to be confused with bronchitis.
Bronchiolitis
Classification and external resources
RSV.PNG
An X-ray of a child with RSV showing the typical bilateral perihilar fullness of bronchiolitis.
ICD-10 J21
ICD-9 466.1
DiseasesDB 1701
MedlinePlus 000975
eMedicine emerg/365
Patient UK Bronchiolitis
MeSH D001988

Bronchiolitis is inflammation of the bronchioles, the smallest air passages of the lungs. It usually occurs in children less than two years of age with the majority being aged between three and six months.[1] It presents with coughing, wheezing and shortness of breath which can cause some children difficulty in feeding. This inflammation is usually caused by respiratory syncytial virus (70% of cases)[2] and is much more common in the winter months. Treatment is typically supportive and may involve the use of nebulized epinephrine or hypertonic saline. Bronchiolitis is common with up to one third of children being affected in their first year of life.

Signs and symptoms[edit]

In a typical case, an infant under two years of age develops cough, wheeze, and shortness of breath over one or two days. Crackles and/or wheeze are typical findings on listening to the chest with a stethoscope. The infant may be breathless for several days. After the acute illness, it is common for the airways to remain sensitive for several weeks, leading to recurrent cough and wheeze.

Some signs of severe disease include:[3]

  • poor feeding (less than half of usual fluid intake in preceding 24 hours)
  • lethargy
  • history of apnea
  • respiratory rate >70/min
  • presence of nasal flaring and/or grunting
  • severe chest wall recession
  • cyanosis

Causes[edit]

The term usually refers to acute viral bronchiolitis, a common disease in infancy. This is most commonly caused by respiratory syncytial virus[4] (RSV, also known as human pneumovirus). Other viruses which may cause this illness include metapneumovirus, influenza, parainfluenza, coronavirus, adenovirus, and rhinovirus.

Studies have shown there is a link between voluntary caesarean birth and an increased prevalence of bronchiolitis. A recent study by Perth's Telethon Institute for Child Health Research has shown an 11% increase in hospital admissions for children delivered this way.[5] Children born prematurely (less than 35 weeks), with a low birth weight or who suffer from congenital heart disease may have higher rates of bronchiolitis and are more likely to require hospital admission. There is evidence that breastfeeding provides some protection against bronchiolitis.[6]

Diagnosis[edit]

The diagnosis is typically made by clinical examination. Chest X-ray is sometimes useful to exclude pneumonia, but not indicated in routine cases.[7]

Testing for the specific viral cause can be done but has little effect on management and thus is not routinely recommended.[7] RSV testing by direct immunofluorescence testing on nasopharyngeal aspirate had a sensitivity of 61% and specificity of 89%.[8] Identification of those who are RSV-positive can help for: disease surveillance, grouping ("cohorting") people together in hospital wards to prevent cross infection, predicting whether the disease course has peaked yet, reducing the need for other diagnostic procedures (by providing confidence that a cause has been identified).

Infant with bronchiolitis between the age of two and three months have a second infection by bacteria (usually a urinary tract infection) less than 6% of the time.[9] Preliminary studies have suggested that elevated procalcitonin levels may assist clinicians in determining the presence of bacterial coinfection, which could prevent unnecessary antibiotic use and costs.[10]

Prevention[edit]

Prevention of bronchiolitis relies strongly on measures to reduce the spread of the viruses that cause respiratory infections (that is, handwashing, and avoiding exposure to those symptomatic with respiratory infections). In addition to good hygiene an improved immune system is a great tool for prevention. One way to improve the immune system is to feed the infant with breast milk, especially during the first month of life.[11] Immunizations are available for premature infants who meet certain criteria (some cardiac and respiratory disorders) such as Palivizumab (a monoclonal antibody against RSV). Passive immunization therapy requires monthly injections every winter.

Management[edit]

Treatment and management of bronchiolitis is usually focused on the symptoms instead of the infection itself since the infection will run its course and complications are typically from the symptoms themselves.[12] Without active treatment half of cases will go away in 13 days and 90% in three weeks.[13]

Bronchodilators[edit]

Although inhaled epinephrine has been shown to decrease initial hospital admissions and overall length of stay compared to placebo in some studies, meta-analyses have found that it has no effect on the rate of one week post-emergency department visits or length of stay (although it does lead to shorter stay versus salbutamol).[14][15] Nebulized and inhaled salbutamol (sold in the USA as Ventolin HFA) has been shown to decrease initial hospital admission rates in some studies, but no clear effect on length of stay in meta-analysis.[14][15] The Society of Hospital Medicine recommends against routine use of these or other bronchodilators in children with bronchiolitis: "Published guidelines do not advocate the routine use of bronchodilators in patients with bronchiolitis. Comprehensive reviews of the literature have demonstrated that the use of bronchodilators in children admitted to the hospital with bronchiolitis has no effect on any important outcomes. There is limited demonstration of clear impact of bronchodilator therapy upon the course of disease. Additionally, providers should consider the potential impact of adverse events upon the patient."[16]

Inhaled hypertonic saline[edit]

Inhaled hypertonic saline (3%) appears to be effective in improving clinical outcomes and shortening the duration of hospital stay.[7]

Non-effective[edit]

Currently other medications do not yet have evidence to support their use.[15] Ribavirin is an antiviral drug which does not appear to be effective for bronchiolitis.[17] Antibiotics are often given in case of a bacterial infection complicating bronchiolitis, but have no effect on the underlying viral infection.[17][18] Corticosteroids have no proven benefit in bronchiolitis treatment and are not advised.[17] DNAse has not been found to be effective.[19]

Epidemiology[edit]

90% of the patients are aged between 1 and 9 months old. Bronchiolitis is the most common cause of hospitalization up to the first year of life. It is epidemic in winters.

References[edit]

  1. ^ Paediatric Society of New Zealand. (2005). "Best Practice Evidence Based Guideline: Wheeze and Chest Infection in Infants Under 1 Year". The Society. 
  2. ^ Papadopoulos NG; Moustaki M; Tsolia M; Bossios A; Astra E; Prezerakou A (2002). Am J Respir Crit Care Med. 
  3. ^ BRONCHIOLITIS IN CHILDREN (Sign Guideline 91). Scottish Intercollegiate Guidelines Network. 2006. ISBN 9781905813018. 
  4. ^ Smyth RL, Openshaw PJ (July 2006). "Bronchiolitis". Lancet 368 (9532): 312–22. doi:10.1016/S0140-6736(06)69077-6. PMID 16860701. 
  5. ^ http://www.abc.net.au/news/2011-10-31/elective-caesarean-heightens-respiratory-risk/3611358
  6. ^ Carbonell-Estrany X, Figueras-Aloy J, (2004). "Identifying risk factors for severe respiratory syncytial virus among infants born after 33 through 35 completed weeks of gestation: different methodologies yield consistent findings.". . Pediatr Infect Dis J 2004;23(11 Suppl):S193-201. 
  7. ^ a b c Zorc, JJ; Hall, CB (February 2010). "Bronchiolitis: recent evidence on diagnosis and management". Pediatrics 125 (2): 342–9. doi:10.1542/peds.2009-2092. PMID 20100768. 
  8. ^ Bordley WC, Viswanathan M, King VJ, Sutton SF, Jackman AM, Sterling L et al. (2004). "Diagnosis and testing in bronchiolitis: a systematic review". Arch Pediatr Adolesc Med 158 (2): 119–26. doi:10.1001/archpedi.158.2.119. PMID 14757603. 
  9. ^ Ralston, S; Hill, V; Waters, A (October 2011). "Occult serious bacterial infection in infants younger than 60 to 90 days with bronchiolitis: a systematic review.". Archives of pediatrics & adolescent medicine 165 (10): 951–6. doi:10.1001/archpediatrics.2011.155. PMID 21969396. 
  10. ^ Laham, James L.; Breheny, Patrick J.; Gardner, Brian M.; Bada, Henrietta. "Procalcitonin to Predict Bacterial Coinfection in Infants With Acute Bronchiolitis". Pediatric Emergency Care 30 (1): 11–15. doi:10.1097/PEC.0000000000000026. 
  11. ^ Belderbos ME, Houben ML, van Bleek GM, et al. (February 2012). "Breastfeeding modulates neonatal innate immune responses: a prospective birth cohort study". Pediatric Allergy and Immunology : Official Publication of the European Society of Pediatric Allergy and Immunology 23 (1): 65–74. doi:10.1111/j.1399-3038.2011.01230.x. PMID 22103307. 
  12. ^ Wright, M; Mullett CJ, Piedimonte G et al. (October 2008). "Pharmacological management of acute bronchiolitis". Veterinary Research 4 (5): 895–903. PMC 2621418. PMID 19209271. 
  13. ^ Thompson, M; Vodicka, TA; Blair, PS; Buckley, DI; Heneghan, C; Hay, AD; TARGET Programme, Team (Dec 11, 2013). "Duration of symptoms of respiratory tract infections in children: systematic review.". BMJ (Clinical research ed.) 347: f7027. doi:10.1136/bmj.f7027. PMID 24335668. 
  14. ^ a b Hartling L, Bialy LM, Vandermeer B, Tjosvold L, Johnson DW, Plint AC et al. (2011). "Epinephrine for bronchiolitis.". Cochrane Database Syst Rev (6): CD003123. doi:10.1002/14651858.CD003123.pub3. PMID 21678340. 
  15. ^ a b c Hartling, L; Fernandes, RM, Bialy, L, Milne, A, Johnson, D, Plint, A, Klassen, TP, Vandermeer, B (Apr 6, 2011). "Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis". BMJ (Clinical research ed.) 342: d1714. doi:10.1136/bmj.d1714. PMC 3071611. PMID 21471175. 
  16. ^ Medicine, Society of Hospital (2014), Pediatric Hospital Medicine: Five Things Physicians and Patients Should Question, retrieved 2014-04-26 
  17. ^ a b c Bourke, T; Shields, M (Apr 11, 2011). "Bronchiolitis". Clinical evidence 2011. PMID 21486501. 
  18. ^ Farley, R; Spurling, GK; Eriksson, L; Del Mar, CB (Oct 9, 2014). "Antibiotics for bronchiolitis in children under two years of age.". The Cochrane database of systematic reviews 10: CD005189. PMID 25300167. 
  19. ^ "BestBets: Do recombinant DNAse improve clinical outcome in an infant with RSV positive bronchiolitis?". 

External links[edit]