bronchiolitis
BRONCHIOLITIS
Bronchiolitis is a clinical diagnosis preceding upper respiratory illness and/or rhinorrhea.
Signs of respiratory illness which may include wheezing, retractions, oxygen desaturation, color change, nasal flaring.
There is also presence of apnea especially in premature or low birthweight infants, signs of dehydration and exposure to persons with viral upper respiratory infections.
Symptoms are usually worst on the 3rd-5th day of illness and then improve gradually.

Principles of Therapy

  • Treatment depends upon the etiology of the disease

The presence of the following signs & symptoms necessitate hospital admission:

  • Apnea, cyanosis, hypoxia, severe dyspnea, moderate to severe chest retractions, nasal flaring, grunting
  • Infants at high risk for respiraotry distress:
    • History of prematurity (<32 weeks gestation)
    • With congenital heart disease
    • With chronic lung disease
    • With underlying immunodeficiency/neuromuscular disorders
    • <3 months of age
    • With Down syndrome
  • Infants with oxygen saturation of (SaO2) <92%
  • Dehydration
  • Age <4-6 months
  • Poor feeding/inadequate oral fluid intake
  • Lethargy

Pharmacotherapy

Inhaled Bronchodilator

  • May be considered in patients with strong family history of allergy, atopy, or asthma
  • No definite evidence to support their routine use; not recommended for patients <6 months
  • May produce modest short-term improvement in clinical features
  • A trial may be considered with further therapy based on the presence of a documented clinical response in a particular patient [ie improved wheezing, respiratory rate (RR), respiratory effort, oxygen saturation (SaO2)]
    • Should be discontinued if no significant improvement within 15-30 minutes after trial inhalation therapy

Epinephrine

  • No longer considered a treatment option for infants and children with bronchiolitis
  • Several studies have concluded that use of nebulized Epinephrine is not beneficial and does not improve the length of stay of hospitalized pediatric patients when compared to Salbutamol and placebo

Ipratropium

  • Not recommended but may be considered as trial treatment for the symptoms of acute bronchiolitis in emergency setting
    • Discontinue if no treatment response is seen

Salbutamol/Albuterol

  • Not recommended in infants & children diagnosed with bronchiolitis
  • Adverse effects in studies done outweighs the benefits of administration of Albuterol in infants with bronchiolitis

Nebulized Saline Solution

  • Recommended for admitted patients, to be nebulized alone or with bronchodilators, in repeated doses
    • Some studies show a decrease in the length of hospital stay
    • Should not be given in emergency room settings

Ribavirin

  • Antiviral agent specific to respiratory syncytial virus (RSV)
  • No convincing evidence that the drug decreases mortality or length of hospital stay
  • Rarely indicated except in certain patients with severe immunodeficiency, when unrestricted replication of the causative virus may result in severe disease
  • Given by small-particle aerosol for 3-5 days

Xanthines

  • May be considered for the treatment of apnea in ex-premature infants with acute bronchiolitis
  • Should be given by intravenous (IV) drip

Other Medications

  • Antibiotics
    • Should only be used in patients with radiologic and hematologic [blood count, C-reactive protein (CRP), procalcitionin (PCT)] evidence of bacterial infection
    • Consider use in patients with severe acute bronchiolitis requiring mechanical ventilation
  • Corticosteroids (Systemic or Inhalation)
    • No evidence of benefit and should not be used for routine management
  • Antihistamines are not recommended for routine treatment
  • Oral decongestants and nasal vasoconstrictors are not recommended for routine treatment
    • Although, they can be used in the presence of severe nasal congestion and rhinorrhea
    • Young infants are obligate nose breathers and will not be able to breathe in the presence of nasal congestion

Non-Pharmacological Therapy

  • Bronchiolitis patients usually feed poorly & are dehydrated
  • If patient only has mild-moderate respiratory distress, small frequent feedings may be attempted
  • Nasogastric tube feeding may be tried in patients who refuse to feed or have difficulty sucking due to tachypnea
    • May be employed to decompress dilated stomach
  • Administer intravenous (IV) fluids to infants with severe respiratory distress, cyanosis and apnea
  • For patients with swallowing difficulties, feeds should be mashed or thickened prior to feeding
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