dr. SAK Indriyani, SpA, MKesDepartment of Child HealthRSU Mataram

DEFINITIONBronchiolitis

bronchiolus inflammatory disease that commonly caused by viral infection, characterized by wheeze

ETIOLOGYRSV*Parainfluenza virusAdenovirusRhinovirusInfluenza virusM. pneumonia

EPIDEMIOLOGYAge < 2 years old (2-6 months*).69%(75%) < 1 year old95% < 2 years old2,2 cases per 100 child/year1% from admission in child aged 1 years oldMale > female (1,5:1; 1,25:1).Almost all years (peak in winter, rainy season)

..........epidemiologyTransmission >> by direct contact with nasal dischargeSAFE if distance > 6 feetRSV can survive until 6 hours in contaminant area nosocomialIMPORTAT : wash your hand after contact !!Virus can shed until 10 days

epidemiologi

>> in non breastfeeding infant Minimal or no ventilation room, dense population

transmission >>>

PATHOPHYSIOLOGYVirus

Colonization & replication in bronchiolus terminalis mucosa

Cilliary epithelium necrotic

Cells proliferation (lymphocyte, plasma cell, macrophage) in peribronchial area

patofisiologiSubmucosa edema & congestionBronchiolus plugging with mucous & cellular debrisAbnormal mucociliary clirens

respiratory tract lumen

patofisiologiFunctional residual capacityLung compliance , resistance resp. tractDead space , shunt

Breath effort

Ventilation perfusion changed

O2 , CO2

CLINICAL MANIFESTATIONSymptoms:1-4 days before: runny nose, congestionSubfebrile fever (except secondary bacterial infection)Peak day 5: cough, difficult to breath, wheeze, unable to drink, apneu, cyanotic

Sign: Nasal flare (+) Muscle involvement Difficult to breath, takipneu, apneu Chest hyperinflation Retraction, expiratory effort Rhonchi in the end of inspiration/beginning of expiration Prolonged expiration, wheeze Palpable H/L

Degree of illness in bronchiolitis

Mild RR below thresholdsand Good air exchangeand Minimal or no retractionsand No sign of dehydration

2. Moderate

RR > thresholdsor Moderate retractionsor Prolonged expiratory phase with decreased air exchange

3. Severe High risk patient, or RR > 70/minutes, or Marked retractions, or Minimal (poor) air exchange, or Grunting respirations, or O2 sat

4. Very severe Apnea or respiratory arrest, or Cyanosis with oxygen, or Inability to maintain PaO2 > 50 mmHg with FiO2>80%, or Inability to maintain PaCO2 < 55 mmHg, or Signs of shock

DIAGNOSIS Clinically Laboratory & radiologic findings confirm & predict the outcome:* gold standard: nasopharing swab (RSV culture) * Rapid RSV test: Elisa, direct fluorescent antibody staining (sensitivity & specificity 90%)

Serologic: need 7-10 days to seroconversion after inoculation Pulse oxymetry: severity of hypoxia & evaluate O2 therapy response BSA: evaluate respiratory failure Blood: not specific

Chest x ray:* Hyperinflation, peribronchial hiperdense, interestitial infiltrate, atelectasis* 10% normal* No correlation between severity of clinical manifestation with chest x ray result

PREDICTOR OF SEVERE MANIFESTATION Toxic appearance Sa O2 < 95% Gestation < 34 weeks RR >70x/minute Chest x ray: atelectasis Age < 3 months

THERAPY Supportive, oxygenation & adequately hydration, complication monitoringOxygen:* Decrease hypoxemia* Nasal prongs, facemask2. Bronchodilator: Controversy

Pre eliminary study: not effective (small sample)

Meta-analysis: clinically improvement [RR 0,76 (IK 95% 0,60;0,95)], no decrease in admission

Albuterol + ipratropium bromide vsalbuterol: no different

Racemic epinephrine vs saline:clinical improvement (+), safe & effective in age < 18 months old

Racemic epinephrine vs salbutamol,in 30 minute: clinical improvement (+) in racemic epinephrine, but not in salbutamol

Racemic epinephrine vs albuterol:Racemic epinephrine safe & clinical improvement >> recommended as first line

3. Glucocorticoid* Theory: decrease inflammation

good 2-adrenergic response* Result: controversy* RCT: dexamethasone oral/im no benefit ??* RCT: dexamethasone oral 0,5 mg/kgBW admission, followed by 0,3 mg/kgBW/day in two days after no different

4. Antibiotic:* Controversy

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