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Bronchiolitis in children : summarized


Bronchiolitis
Dr M Tauseef Omer

DEFINITION:Bronchiolitis is a lower respiratory tract infection that occurs in children < 2 years age , that begins as a flu like prodrome of 1-3 days followed by cough and tachypnoea with/without chest recessions and with ronchi and/or crackles on auscultation.
DISEASE COURSE:Flu-like upper respiratory tract symptoms for 1- 3 days.
Lower respiratory symptoms and signs develop on days 2 - 3 , peak on days 3 - 5, and gradually resolve over the course of 2 to 3 weeks.

INVESTIGATIONS:
When patients are  diagnosed on the basis of history and physical examination and managed on Out Patient basis, CXR is not recommended.
CXR is recommended for all patients admitted to Intensive Care, or where pneumothorax or high suspicion of pneumonia is present.
CBC is not indicated routinely. (An abnormal white blood cell count is not useful for predicting a concurrent bacterial infection)
ABGs are not recommended. Capillary blood gases may be acquired if there is suspected impending respiratory failure.
PCR for viral culture is not recommended as RSV is the causative agent in 75% of hospitalized cases. However, if a patient is receiving monthly prophylaxis with palivizumab PCR should be performed.
OUTPATIENT MANAGEMENT:
Educate: the care giver regarding Disease, its Nature, Course , the Treatment, and Complications .
Instruct: about how to monitor at home for Red Flag Symptoms
Assess: the Care Givers Confidence level to manage at home, his/her social circumstances, and the ability to understand Red Flag Symptoms.
Redflag Symptoms:
Worsening breathing effort ( indicated by grunting, nasal flaring,marked chest recessions)
Oral fluid intake reduced to 50% of usual.
No wet nappy for 12 hours
Apnoea or cyanosis
Exhaustion (wakes up with prolonged stimulation)

When to admit:
Decreased oral fluid intake(taking only 50% of usual volume)
Grunting ,RR >70/minute ,Marked chest retractions
Apnoeic spell
Persistently low O2 sat (<92%)   (NICE guidelines) (contrasts with AAP guidelines where children may be managed at home upto 89% O2 sat)
Presence of Risk Factors for Severe Bronchiolitis (chronic lung disease , congenital heart disease, age <3 months, premature birth,neuromuscular disorders ,immunodeficiency, genetic disease)
Low confidence of Care giver to manage at home, lower skill of care  giver to identify Red Flag symptoms, and certain other social circumstances.

INPATIENT MANAGEMENT:

Supplemental Oxygen: Give oxygen supplementation to children with bronchiolitis if their oxygen saturation is persistently less than 92%. (NICE)
It contrasts with AAP guidelines where O2 saturation threshold is 90 % with argument that spO2 >89% is adequate to oxygenate tissues and  the risk of hypoxemia with oxyhemoglobin saturation >89% is minimal.
Do NOT administer albuterol or salbutamol. Bronchodilators may improve clinical symptom scores, but they do not affect disease resolution, need for hospitalization, or length of stay.
Do NOT administer epinephrine .
Epinephrine nebulization has been found to reduce hospitalization on the day of ED visit ,but it raises concern regarding progression of illness at home.
Hypertonic saline should not be administered in ER.
Hypertonic saline may be administered to infants and children who are hospitalized.
Hypertonic saline is effective in improving symptoms after 24 hours of use by increasing muco-ciliary clearance.
Systemic Steroids are not recommended .
These do not reduce admissions. Rather corticosteroid therapy may prolong viral shedding in patients with bronchiolitis.
Chest Physiotherapy is not recommended.
Deep suctioning could lead to trauma and edema of airways and is not recommended.
Antibiotics are not recommended unless there is a concomitant bacterial infection.
It is because a  child with a distinct viral illness such as bronchiolitis, has a <1% risk of bacterial infection of the cerebrospinal fluid or blood.
Administer nasogastric or intravenous fluids to infants who cannot maintain hydration orally .
When respiratory rate is >70/min feeding may be compromised and risk of aspiration with oral feeding is increased. Patients may receive Nasogastric or intravenous iv fluids.
Prevention:
All people should use alcohol-based rubs for hand decontamination when caring for children with bronchiolitis. If rubs are not available, wash hands with soap and water.
All people should disinfect hands before and after direct contact with patients, inanimate objects in the direct vicinity of the patient, and after removing gloves.
Palivizumab for prevention:
Palivizumab is a monoclonal antibody designed to provide passive immunity against RSV and so it prevents or reduces the severity of RSV infection.
5 monthly Doses of  15mg/kg/dose are given to infants who qualify for it.
It is not administered to healthy infants with gestational age of 29 weeks or more.
It is administered during 1st year of life to infants with Congenital heart disease, chronic lung disease or premature infants(>32 weeks who required O2 inhalation for >28 days).
If patient develops RSV infection during prophylaxis, then monthly doses should be stopped.
Inquire about the exposure of the infant or  child to tobacco smoke when assessing infants and children for bronchiolitis.
counsel caregivers about exposing the infant or child to environmental tobacco smoke and smoking cessation.
Encourage exclusive breastfeeding for at least 6 months to decrease the morbidity of respiratory infections.
Causes of FITS in Bronchiolitis/Pneumonia patients:
Hypoxic fits
Febrile fits
Hyperventilation causing hypocalcemic fits
Hypoglycemia
Meningitis

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