Transcript A clinical pathway for bronchiolitis is effective in reducing

Acute Bronchiolitis
Acute Bronchiolitis
By: Dr. Manzoor
Ahmed
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By: Dr. Manzoor
Ahmed
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A CASE PRESENTATION BY DEPT: OF
PAEDIATRICS;
Acute Bronchiolitis:
By: Dr. Manzoor Ahmed
Registrar , paediatrics ,AKMICH
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BRONCHIOLITIS:
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A common resp. illness chracterized by
inflammation of bronchioles.
 Consists:
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acute inflammation
edema and necrosis of epithelial cells lining
small airways
increased mucus production
bronchospasm
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Anatomy of the Respiratory
system:
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Lower Respiratory Tract
Infections in Children:
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Normal
lungs &
alveoli
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Histological changes in acute bronchiolitis,showing inflamatory changes, edema
and mucus .
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Epidemiology
Statistics:
typically occurs in 1st 2 years of life
 Peak occurrence = 3 to 6 months
 90% of children 0-2 yrs, are infected with
RSV(respiratory synctial virus)
 20% have lower respiratory infection
 3% hospitalized
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0.002% mortality.
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MICROBIOLOGY:
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Typically caused by viruses:
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RSV-most common(80-90%)
Parainfluenza
Human Metapneumovirus
Influenza
Rhinovirus
Coronavirus
Human bocavirus
Occasionally associated with Mycoplasma pneumonia infection
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It is a RNA virus.
RSV is distributed globally and an epidemic personality.
RSV belongs to the family of paramyxoviruses and is classified in the genus
pneumoviruses.
ssRNA enveloped virus, 120 - 300 nm in size
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Pathophysiology:
Inflamation  swelling fill with
mucus make it difficult to breath.
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RISK FACTORS:
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Prematurity
Chronic heart/lung disease
Weakened immune system due to illness and
medications
More common in males
Children who have not been breast fed
Who live in crowded conditions
Day care attendence
Exposure to ciggerate smoke
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RISK FACTORS FOR SEVERE
DISEASE:
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Prematurity
Low birth weight
Age less than 6-12 weeks
Chronic pulmonary disease
Hemodynamically significant cardiac disease
Immunodeficiency
Neurologic disease
Anatomical defects of the airways
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History:
Flu , cough,low grade fever,
 Breathing difficulty,
 poor feeding,
 cyanosis,
 Elder family member with flu and cough.
 Underlying cardiac and lung disease.
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PHYSICAL EXAMINATION
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Clinical features
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SIGN & SYMPTOMS:
Symptoms of common cold
Stuffiness
Runny nose
Mild cough
After 1 day or two; worsening of the cough & apperence of
wheezes
Rapid shallow breathing
Rapid heart beat
Drawing in of chest & neck
flaring of the nostrils
Irratibility, difficult sleep & fatigue
Fever
poor appetite
May vomit after cough
In severe cases cyanosis&signs of dehydration
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contagiousness
Air borne droplets thru infected
person nose & mouth while coughing
sneezing & laughing.
 and also from things the person
has touched, such as used tissues
or toys, door handle, .
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DURATION & COURSE:
Incubation period days to one week.
 Typically last about 7 days
 In severe cases can cough for weeks
 Peak about the 2nd and 3rd day
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Severity
Clinical course:
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0
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Typically lasts about 7 days
In severe cases can cough for weeks
Peak about the 2nd and 3rd day
Days
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DIFFERENTIAL DIAGNOSIS:
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Viral-triggered asthma
Bronchitis
pneumonia
Foreign body aspiration
Gastroesophageal reflux or dysphagia leading
to aspiration
 Congenital heart disease or heart failure
 Vascular rings, bronchomalacia, complete
tracheal rings or other anatomical
abnormalities
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Complications:
After having bronchiolitis, some babies may be more
likely to have a wheezy chest or cough, particularly
while they have a cold.
Neonates can develop APNEA,
Asthma and other breathing problems later in life have
also been linked with bronchiolitis
Babies with bronchiolitis can develop pneumonia,otiti
media and sinusitis, . Also, babies with a lung or heart
diseae, may find bronchiolitis makes their condition
much worse,can lead to resp: failure and DEATH.
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Otitis media
 Otitis
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media a common complication
Cohort study of 42 infants with bronchiolitis
62% acute OM (tympanocentesis confirmed)
 24% otitis media with effusion
 14% normal throughout course
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Bronchiolitis Obliterans:
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Inflammation of the BRONCHIOLES leading to
an obstructive lung disease. Bronchioles are
characterized by fibrous granulation tissue
with bronchial exudates in the lumens. Clinical
features include a non productive cough and
DYSPNEA.
 Mainly associated with adeno virus and
mycoplasma.
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RSV and asthma link:
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40-50% of hospitalized bronchiolitis will wheeze
again
 Increased risk if > 12 months, atopy, eosinophilia
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HOSPITALIZATION:
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Children with severe disease
Toxic with poor feeding, lethargy, dehydration
Moderate to severe respiratory distress (RR > 70,
dyspnea, cyanosis)
Apnea
Hypoxemia(O2 sat: <90%)
Parents unable to care for child at home.
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INVESTIGATIONS:
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Diagnosis should be made clinically, without routine
use of laboratory or radiologic tests
 But useful in children with complicating signs and
symptoms.
 CBC--to help determine bacterial illness
 Blood gas--evaluate respiratory failure
 Nasopharyngeal secretions 4 immunoflourescence
+ VE for RSV or other viruses (adeno , influenza
and para -influenza viruses)
Chest X-ray: not routinely recommended;
should b done if atypical presentation or
Suspecting complications
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Hyper inflation+peri hilar infiltrates
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hyperinflation, flattened diaphragms, peribronchial cuffing, patchy
infiltrates, atelectasis
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A chest radiography revealing lung hyperinflation with a flattene diaphragm
and bilateral atelectasis in the right apical and left basal areas.Other
findings may include bronchial wall thickening, air trapping, flattened
diaphragm, increased AP diameter, peribronchial cuffing, tiny nodules,
linear opacities, and patchy alveolar opacities. Opacities on radiographs
do not suggest bacterial pneumonia and incorrectly lead to inappropriate
treatment with antibiotics.
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Treatment:
HOME TREATENT:
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Plenty of fluids; in small
amounts,frequently.
Cool-mist vapuorizer duirng winter
Avoid hot water & steam humidifiers
Tilt the child matress up
Keep baby nose clear using bulb syringe
and saline
Acetaminophen for fever
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TREATMENT:
HOSPITAL TREATMENT:
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SUPPORTIVE:
Most cases are mild and reqiure no specific
treatment
Monitor heart & resp. rate & o2 saturation
Look 4 apnea & bradycardia
Give O2 if tachypaenic, or O2 sat:
< 90%
N.G or I.V fluids
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TREATMENT
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DRUGS:
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Bronchodilators are NOT recommended ; but have some
benefits on clinical grounds.
Nebulized & inhaled Epinephrine ( racemic and levo(1)epinephrine) has been shown to decrease hospitalization
rates.
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Inhaled hypertonic saline:
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Inhaled hypertonic saline (3%) appears to be effective in
improving clinical outcomes and shortening the duration of
hospital stay.
steroids are ineffective.
Ribavirin is an antiviral drug which does not appear to be
effective
Antibiotics; are not indicated unless evidence of bacterial
pneumonia
Ventilation therapy; on clinical grounds.
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Discharge criteria:
Tolerating feeds.
Parents can handle well to baby at home and can identify ,if baby,s
condition deteriorates.
family education complete
Respiratory Status :
respirations less than 70 per minute and/or no
clinical evidence of increased work of breathing or
distress
parent can clear the infant’s airway using bulb
suctioning
patient’s oxygen saturation remains >92 % on
room air
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Follow Up :
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follow-up appointments to check for,
Any complications like, otitis media, effusion or
asthma.
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PREVENTION:
Hand washing is strongly recommended :
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preferably with alcoholbased rubs , antimicrobial
soaps
before and after contact
with patient or with
objects in patient’s
vicinity
after removing gloves
void contact with viral
infections.
Educate personnel and
family members on hand
hygiene
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RSV immunoprophylaxis(passive immunization) RSV IVIG /monoclonal
antibody
: Palivizumab
(Synagis®)
Attempts to provide immunity to RSV:
 Passive immunity via hyper immune globulin.
 Monoclonal antibody to F protein (palivizumab)
 55%  hospitalizations for preterm/chronic lung disease
 45%  hospitalizations for congenital heart disease
 Palvizumab injection, is given on monthly basis during rsv
season.
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Guidelines for RSV Prophylaxis:
Premature, no CLD, no CHD
≤28 wks GA
Palivizumab if ≤12 months
at start of RSV season
29-32 wks GA
Palivizumab if ≤6 months
at start of RSV season
32-35 wks GA
Palivizumab if ≤6 months
at start of RSV season with
two risk factors present
Hemodynamically Significant CHD
Palivizumab if ≤2 years old
at start of RSV season
Chronic Lung Disease* (CLD)
*Receiving
medical therapy35
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American Academy of Pediatrics (AAP)
Guidelines for palvizumab:
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Infants born at 32 weeks of gestation or earlier may benefit from RSV
prophylaxis, even if they do not have CLD. For these infants, major risk
factors to consider include their gestational age and chronologic age at the
start of the RSV season. Infants born at 28 weeks of gestation or earlier may
benefit from prophylaxis during their first RSV season, whenever that occurs
during the first 12 months of life. Infants born at 29 to 32 weeks of gestation
may benefit most from prophylaxis up to 6 months of age.
Prophylaxis should be considered for infants between 32 and 35 weeks of
gestation who are younger than 6 months of age at the start of the RSV
season if 2 or more of these risk factors are present.
Epidemiologic data suggest that RSV infection is more likely to lead to
hospitalization for these infants when the
following risk factors are present: child care attendance, school-aged siblings,
exposure to environmental air pollutants, congenital abnormalities of the
airways, or severe neuromuscular disease.
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Palivizumab or RSV-IGIV prophylaxis should be considered for infants and children
younger than 2 years of age with CLD who have required medical therapy
(supplemental oxygen, bronchodilator, diuretic or corticosteroid therapy) for CLD
within 6 months before the anticipated start of the RSV season.
Children who are 24 months of age or younger with hemodynamically significant
cyanotic and acyanotic congenital heart disease will benefit from 5 monthly
intramuscular injections of palivizumab (15 mg/kg).
Once a child qualifies for initiation of prophylaxis at the start of the RSV season,
administration should continue throughout the season and not stop at the point an
infant reaches either 6 months or 12 months of age.
Synagis® (palivizumab) is preferred for most high-risk children because of its ease
of administration, safety, and efficacy. It also does not interfere with live vaccines
such as MMR and varicella.
Children with more severe CLD may benefit from two consecutive years of RSV
prophylaxis. This should be individualized for each patient, as should the duration
of prophylaxis.
RSV prophylaxis should be initiated just before the onset of the RSV season and
terminated at the end of the RSV season, based on local hospitalization and
virology data.
Strict observance of infection control practices, including screening and isolation of
RSV-infected children, especially in NICU and PICU settings is critical.
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Future Investigations
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development of rapid, cost-effective tests for viruses
other than RSV that may also play a role in bronchiolitis
studies to determine if there are selected patients who
may benefit from bronchodilators or corticosteroids
clinical studies of the target SpO2 for the most efficient
use of oxygen and oxygen monitoring
development of new therapies including new antiviral
medications
continued research into the development of an RSV
vaccine
continued development of immunoprophylaxis that would
require fewer doses and decreased cost
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Message to take home.
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Diagnosis should be made clinically, without routine use of
laboratory or radiologic tests, and should include assessment of risk
factors for severe disease (e.g., prematurity, underlying lung or
heart disease, and immunodeficiency)
Bronchodilators should not be used routinely for management. An
optional trial of an - or ß-agonist should be continued only if
objective evaluation indicates a clinical response.
Routine use of corticosteroids is not recommended
Routine use of ribavirin is not recommended
Antibiotics should be used only when bacterial infection is clearly
present
Assessment of hydration status and oral intake is strongly
recommended. IV fluids should be given as necessary
Routine chest physiotherapy is not recommended
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Message to take home
Encourage breast feeding.
 Avoid contact with smoking.
 Pay more attention to high risk group.
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Message to take home
8.
Supplemental O2 and continuous monitoring are not
routinely recommended unless Spo2 persistently falls
below 90%. The infant’s clinical work of breathing may
also be used to determined need for supplemental
oxygen
9. Prophylactic palivizumab is recommended in selected
high-risk children with prematurity or heart or lung
disease
10. Hand washing is strongly recommended, preferably
with alcohol-based rubs or antimicrobial soaps
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