Evidence based guideline for the management of bronchiolitis

Turner T, Wilkinson F, Harris C, Mazza DOn behalf of the Health for Kids Guideline Development Group

Pembimbing:Prof. dr. M. Sidhartani Zain, MSc, SpA(K)

dr. Dwi Wastoro Dadiyanto, Sp.A(K)dr. MS Anam, MSi Med, SpA

Islammiyah Dewi YuniantiRio Santy Anjarwati

Bronchhiolitis• Viral infection of the respiratory tract commonly

caused by RSV

• Also caused by parainfluenza, adenovirus and influenza

• Occur during autumn and winter (most cases)

• Some types of parainfluenza virus are present during other months can be seen troughout the year

Characteristic of bronchiolitis• Acute inflamation, oedema, necrosis of epithelial

cells lining the bronchioles

• Increased mucos production

• Bronchospasm

• Obstruction of the small airways

Infant and children with bronchiolitis featured by both upper and lower respiratory

Duration of illness• Approximatelt 2 weeks

• 20% having sympptoms longer than 3 weeks

Why was this guideline developed?

• Bronchiolitis is the most common lower respiratory tract infection in infants

• In Australasia, Europe and north America up to 3% of all children are hospitalised in their first year of life

• Most of them mild bronchiolitis outpatient basis

• In Australia, 13.500 children are admitted to hospital with bronchiolitis each year (80% < 1 year of age)

The scope of this guideline

• Refers to a child presenting to either a hospital emergency or general practice with bronchiolitis

Not apply to :

•Children over 18 months of age

•Infants or children with pre-existing airway abnormalities (cystic fibrosis)

•Cyanotic cardia anomalies

•Admitted to ICU

Extra caution and consult with appropriate specialist clinicians when caring for

Speciql care to exclude other diagnoses in

presenting with recurrent wheezing

Recommendations• Diagnosis clinical-no diagnostic test confirms the

disease

• Fever, hypoxia and accessory muscle may be present

• Chest examination may be clear, prolonged expiratory phase with wheeze, rhonchi, and crepitation may be found

• Dehydration : combination of difficulty feeding and increase IWL due to tacyhpnoea

An infant or child < 18 months of age presenting with initial symptoms and signs of upper respiratory tract infection

followed by cough, tachypnoea, inspiratory crepitations and wheeze bronchiolitis

Differential diagnoses• Asthma

• Pneumonia

• Whooping cough

• Cystic fibrosid

• CHF

• Inhaled foreign body

• Consider other diagnosis in infants or children with recurrent-bouts of bronchiolitis-like symptoms (D)

• An infant or child with bronchiolitis-like symptoms who responds to treatment with a bronchodilator should be treated according to asthma management guidelines (D)

Differential diagnoses

Investigation

Investigation• Urine culture

Should not be routinely performed in infants or children with bronchiolitis(D)

• Blood gas analysis

should not be routinely performed in infants or

children with bronchiolitis(D)

Should be performed in infants or children with

life threatening or severe disease(D)

Consider blood gas analysis in infants or children with moderate disease(D)

Assessment of bronchiolitisFocused on classification of severity of disease :

• mild

• moderate

• severe, or

• life threatening

• Seven studies →examined the relationship between severity of bronchiolitis and clinical indicators.

• These included:

- oxygen saturation and the need for:

- oxygen supplementation

-mechanical ventilation

-hospital admission

-intensive care unit admission.

Classification of severity

Patients at high risk of more severe

• Infants < 3 months of age / born at < 36 weeks gestation

• infants or children →

• cardiorespiratory disease

Nonpharmacological management

• Oxygen

It is a mainstay of therapy in the hospital setting.

• Feeding and hydration

bronchiolitis →dehydrated as a result →poor oral intake & water loss →↑ RR and work of breathing.

the GDG made the following consensusrecommendations:

• Infants/children with mild/moderate bronchiolitis→continue oral feeding→≠ , iv or NGT.(D)

• Chest physiotherapy

Chest physiotherapy →not be routinely used (A)

• Mist, steam or nebulised saline

Should not be routinely used →bronchiolitis(D)

• Saline drops

Saline nasal drops should be trialled in infants with bronchiolitis→ nasal congestion, particularly before feeds(D)

• Suctioning

Nasal suctioning may be trialled(D)

• Apnoea management

Bronchiolitis → increased risk → age < 3 months, premature birth or previous apnoea(D)

• Positioning

Infants allowed to adopt the position they find most comfortable(D)

Pharmacological management• Nebulised adrenaline

Adrenaline should not be routinely used for the treatment of bronchiolitis (A)

• β2 agonist bronchodilators

β2 agonist bronchodilators should not be routinely (A)

Consider a trial of a single dose of β2 agonist bronchodilators in patients over 9 months of age, particularly those with recurrent wheezing(D)

β2 agonist bronchodilators should not be continued if an infant or child does not respond to an initial trial(D)

• Ipratropium bromide

Should not be routinely used for the treatment of bronchiolitis(A)

• Antibiotics

Should not be routinely used for the treatment of bronchiolitis(A)

Consider antibiotics → a secondary bacterial infection(D)

• Corticosteroids

Should not be routinely used for the treatment of bronchiolitis(A)

• Ribavirin

Should not be routinely used for the treatment of bronchiolitis(A)

• Immunoglobulin

Should not be routinely used for the treatment of bronchiolitis(A)

• Analgesics and antipyretics

Bronchiolitis and fever →paracetamol / ibuprofen to bring their temperature down and reduce irritability(D)

• Oral antitussives, expectorants or decongestants

Should not be routinely used for the treatment of bronchiolitis(D)

• Level of care

May be managed by a GP and sent home for observation if the GP (D)

Moderate bronchiolitis ≠require oxygen or fluid therapy →GP,

Otherwise the infant or child should be sent to a hospital(D)

If a GP is not available→ taken to a hospital emergency department

• When should an ambulance be called?

Severe or life threatening bronchiolitis sent by ambulance to a hospital emergency department

Summary of important points

• infant <18 months of age → initial signs and symptoms of an upper respiratory tract infection →(cough, tachypnoea, inspiratory crepitations, and wheeze)

• no diagnostic test confirms the disease.

• Chest X-rays should not be used to diagnose bronchiolitis

• Differentiating between bronchiolitis and viral pneumonia is difficult→ supportive

• a trial of a single dose of β2 agonist bronchodilators in > 9 months of age→with recurrent wheezing

• Responds to treatment with a bronchodilator, such as salbutamol→treated according to asthma management guidelines.

• duration of illness is 2 weeks, approximately 20% of patients have symptoms > 3 weeks

• mild or moderate cases tolerating feeds and not requiring oxyen:

– suggest small, frequent feeds

– provide parent information

– offer review.

• In moderate cases not tolerating feeds and/or requiring oxygen:

– provide parent information

– send to hospital.

• In severe or life threatening cases:

– give oxygen

– call an ambulance.