Bronchiolitis

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Bronchiolitis
RSV.PNG
An X-ray of a child with RSV showing the typical bilateral perihilar fullness of bronchiolitis.
Specialty Emergency medicine, pediatrics
Symptoms Fever, cough, runny nose, wheezing, breathing problems [1]
Complications Shortness of breath, dehydration [1]
Usual onsetLess than 2 years old [2]
Causes Viral disease (respiratory syncytial virus, human rhinovirus) [2]
Diagnostic method Based on symptoms [1]
Differential diagnosis Asthma, pneumonia, heart failure, allergic reaction, cystic fibrosis [1]
Treatment Symptomatic treatment (oxygen, support with feeding, intravenous fluids) [3]
Frequency~20% (children less than 2) [2] [1]
Deaths1% (among those hospitalized) [4]

Bronchiolitis is inflammation of the small airways in the lungs. Acute bronchiolitis is due to a viral infection usually affecting children younger than two years of age. [5] Symptoms may include fever, cough, runny nose, wheezing, and breathing problems. [1] More severe cases may be associated with nasal flaring, grunting, or the skin between the ribs pulling in with breathing. [1] If the child has not been able to feed properly, signs of dehydration may be present. [1]

Contents

Chronic bronchiolitis is the general term used for small airways disease in adults, notably in chronic obstructive pulmonary disease. [5] [6]

Acute bronchiolitis is usually the result of infection by respiratory syncytial virus (72% of cases) or human rhinovirus (26% of cases). [2] Diagnosis is generally based on symptoms. [1] Tests such as a chest X-ray or viral testing are not routinely needed. [2]

There is no specific treatment. [3] [7] Symptomatic treatment at home is generally sufficient. [1] Occasionally, hospital admission for oxygen, support with feeding, or intravenous fluids is required. [1] Tentative evidence supports nebulized hypertonic saline. [8] [ needs update ] Evidence for antibiotics, antivirals, bronchodilators, or nebulized epinephrine is either unclear or not supportive. [9]

About 10% to 30% of children under the age of two years are affected by bronchiolitis at some point in time. [1] [2] It commonly occurs in the winter in the Northern Hemisphere. [1] It is the leading cause of hospitalizations in those less than one year of age in the United States. [10] [7] The risk of death among those who are admitted to hospital is about 1%. [4] Outbreaks of the condition were first described in the 1940s. [11]

Signs and symptoms

Video explanation

Bronchiolitis typically presents in children under two years old and is characterized by a constellation of respiratory symptoms that consists of fever, rhinorrhea, cough, wheeze, tachypnea and increased work of breathing such as nasal flaring or grunting that develops over one to three days. [10] Crackles or wheeze are typical findings on listening to the chest with a stethoscope. The child may also experience apnea, or brief pauses in breathing. After the acute illness, it is common for the airways to remain sensitive for several weeks, leading to recurrent cough and wheeze.[ citation needed ]

Some signs of severe disease include: [12]

Causes

Acute inflammatory exudate occluding the lumen of the bronchiole and acute inflammation of part of the wall of the bronchiole Acute bronchiolitis (8519105494).jpg
Acute inflammatory exudate occluding the lumen of the bronchiole and acute inflammation of part of the wall of the bronchiole

The term usually refers to acute viral bronchiolitis, a common disease in infancy. This is most commonly caused by respiratory syncytial virus [13] (RSV, also known as human pneumovirus). Other agents that cause this illness include human metapneumovirus, influenza, parainfluenza, coronavirus, adenovirus, rhinovirus and mycoplasma. [14] [15]

Risk factors

Children are at an increased risk for progression to severe respiratory disease if they have any of the following additional factors: [7] [10] [15] [16]

Diagnosis

The diagnosis is typically made by clinical examination. Chest X-ray is sometimes useful to exclude bacterial pneumonia, but not indicated in routine cases. [17] Chest x-ray may also be useful in people with impending respiratory failure. [18] Additional testing such as blood cultures, complete blood count, and electrolyte analyses are not recommended for routine use although may be useful in children with multiple comorbidities or signs of sepsis or pneumonia. [7] [18]

Testing for the specific viral cause can be done but has little effect on management and thus is not routinely recommended. [17] RSV testing by direct immunofluorescence testing on nasopharyngeal aspirate had a sensitivity of 61% and specificity of 89%. [15] [18] Identification of those who are RSV-positive can help for disease surveillance, grouping ("cohorting") people together in hospital wards to prevent cross infection, predicting whether the disease course has peaked yet, and reducing the need for other diagnostic procedures (by providing confidence that a cause has been identified). [7] Identification of the virus may help reduce the use of antibiotics. [18]

Infants with bronchiolitis between the age of two and three months have a second infection by bacteria (usually a urinary tract infection) less than 6% of the time. [19] When further evaluated with a urinalysis, infants with bronchiolitis had a concomitant UTI 0.8% of the time. [20] Preliminary studies have suggested that elevated procalcitonin levels may assist clinicians in determining the presence of bacterial co-infection, which could prevent unnecessary antibiotic use and costs. [21]

Differential diagnosis

There are many childhood illnesses that can present with respiratory symptoms, particularly persistent cough and wheezing. [10] [22] Bronchiolitis may be differentiated from some of these by the characteristic pattern of preceding febrile upper respiratory tract symptoms lasting for 1 to 3 days followed by the persistent cough, tachypnea, and wheezing. [22] However, some infants may present without fever (30% of cases) or may present with apnea without other signs or with poor weight gain prior to onset of symptoms. [22] In such cases, additional laboratory testing and radiographic imaging may be useful. [10] [22] The following are some other diagnoses to consider in an infant presenting with signs of bronchiolitis:[ citation needed ]

Prevention

Prevention of bronchiolitis relies strongly on measures to reduce the spread of the viruses that cause respiratory infections (that is, handwashing, and avoiding exposure to those symptomatic with respiratory infections). [7] [10] Guidelines are mixed on the use of gloves, aprons, or personal protective equipment. [7]

One way to improve the immune system is to feed the infant with breast milk, especially during the first month of life. [16] [23] Respiratory infections were shown to be significantly less common among breastfed infants and fully breastfed RSV-positive hospitalized infants had shorter hospital stays than non or partially breastfed infants. [10] Guidelines recommend exclusive breastfeeding for infants for the first 6 months of life. [10]

The US Food and Drug Administration (FDA) has currently approved two RSV vaccines for adults ages 60 and older, Arexvy (GSK plc) and Abrysvo (Pfizer). [24] Abrysvo is also approved for "immunization of pregnant individuals at 32 through 36 weeks gestational age for the prevention of lower respiratory tract disease (LRTD) and severe LRTD caused by respiratory syncytial virus (RSV) in infants from birth through 6 months of age." [25]

Nirsevimab, a monoclonal antibody against RSV, is recommended by the CDC for all children younger than 8 months in their first RSV season. [24] Additionally, children aged 8 to 19 months who are at increased risk may be recommended to receive Nirsevimab as they enter their second RSV season. [26] [27]

A second monoclonal antibody, Palivizumab, can be administered to prevent bronchiolitis to infants less than one year of age that were born very prematurely or that have underlying heart disease or chronic lung disease of prematurity. [10] Passive immunization therapy requires monthly injections during winter. [10] Otherwise healthy premature infants that were born after a gestational age of 29 weeks should not be administered Palivizumab, as the harms outweigh the benefits. [10] Passive protection through the administration of other novel monoclonal antibodies is also under evaluation. [18]

Tobacco smoke exposure has been shown to increase both the rates of lower respiratory disease in infants, as well as the risk and severity of bronchiolitis. [10] Tobacco smoke lingers in the environment for prolonged periods and on clothing even when smoking outside the home. [10] Guidelines recommend that parents be fully educated on the risks of tobacco smoke exposure on children with bronchiolitis. [10] [22]

Management

Treatment of bronchiolitis is usually focused on the hydration and symptoms instead of the infection itself since the infection will run its course and complications are typically from the symptoms themselves. [28] Without active treatment, half of cases will go away in 13 days and 90% in three weeks. [29] Children with severe symptoms, especially poor feeding or dehydration, may be considered for hospital admission. [7] Oxygen saturation under 90%-92% as measured with pulse oximetry is also frequently used as an indicator of need for hospitalization. [7] High-risk infants, apnea, cyanosis, malnutrition, and diagnostic uncertainty are additional indications for hospitalization. [7]

Most guidelines recommend sufficient fluids and nutritional support for affected children. [7] Measures for which the recommendations were mixed include nebulized hypertonic saline, nebulized epinephrine, chest physiotherapy and nasal suctioning. [1] [7] [30] [31] [32] Treatments which the evidence does not support include salbutamol, steroids, antibiotics, antivirals, heliox, continuous positive airway pressure (CPAP), and cool mist or steam inhalation. [1] [33] [34] [35]

Diet

Maintaining hydration is an important part of management of bronchiolitis. [10] [18] [36] Infants with mild pulmonary symptoms may require only observation if feeding is unaffected. [10] However, oral intake may be affected by nasal secretions and increased work of breathing. [10] Poor feeding or dehydration, defined as less than 50% of usual intake, is often cited as an indication for hospital admission. [7] Guidelines recommend the use of nasogastric or intravenous fluids in children with bronchiolitis who cannot maintain usual oral intake. [10] [22] [18] The risk of health care caused hyponatremia and fluid retention are minimal with the use of isotonic fluids such as normal saline, breast milk, or formula. [10]

Oxygen

A newborn wearing a nasal CPAP device. CPAP NASAL.jpg
A newborn wearing a nasal CPAP device.

Inadequate oxygen supply to the tissue is one of the main concerns during severe bronchiolitis and oxygen saturation is often closely associated with both the need for hospitalization and continued length of hospital stay in children with bronchiolitis. [18] However, oxygen saturation is a poor predictor of respiratory distress. [10] Accuracy of pulse oximetry is limited in the 76% to 90% range and there is weak correlation between oxygen saturation and respiratory distress as brief hypoxemia is common in healthy infants. [10] [18] Additionally, pulse oximetry is associated with frequent false alarms and parental stress and fatigue. [10] Clinicians may choose not to given additional oxygen to children with bronchiolitis if their oxygen saturation is above 90%. [10] [22] [18] Additionally, clinicians may choose not to use continuous pulse oximetry in these people. [10]

When choosing to use oxygen therapy for a child with bronchiolitis, there is evidence that home oxygen may reduce hospitalization rate and length of stay although readmission rates and follow-up visits are increased. [10] Also, the use of humidified, heated, high-flow nasal cannula may be a safe initial therapy to decrease work of breathing and need for intubation. [10] [37] However, evidence is lacking regarding the use of high-flow nasal cannula compared to standard oxygen therapy or continuous positive airway pressure. [18] [37] [38] [ needs update ] These practices may still be used in severe cases prior to intubation. [22] [39] [40] [ needs update ]

Blood gas testing is not recommended for people hospitalized with the disease and is not useful in the routine management of bronchiolitis. [18] [22] People with severe worsening respiratory distress or impending respiratory failure may be considered for capillary blood gas testing. [22]

Hypertonic saline

Guidelines recommend against the use of nebulized hypertonic saline in the emergency department for children with bronchiolitis but it may be given to children who are hospitalized. [10] [18]

Nebulized hypertonic saline (3%) has limited evidence of benefit and previous studies lack consistency and standardization. [8] [9] [41] A 2017 review found tentative evidence that it reduces the risk of hospitalization, duration of hospital stay, and improved the severity of symptoms. [8] [42] The majority of evidence suggests that hypertonic saline is safe and effective at improving respiratory symptoms of mild to moderate bronchiolitis after 24 hours of use. [43] However, it does not appear effective in reducing the rate of hospitalization when used in the emergency room or other outpatient settings in which length of therapy is brief. [10] Side effects were mild and resolved spontaneously. [8]

Bronchodilators

Guidelines recommend against the use of bronchodilators in children with bronchiolitis as evidence does not support a change in outcomes with such use. [10] [22] [44] [45] Additionally, there are adverse effects to the use of bronchodilators in children such as tachycardia and tremors, as well as adding increased financial expenses. [46] [44]

Several studies have shown that bronchodilation with β-adrenergic agents such as salbutamol may improve symptoms briefly but do not affect the overall course of the illness or reduce the need for hospitalization. [10] However, there are conflicting recommendations about the use of a trial of a bronchodilator, especially in those with history of previous wheezing, due to the difficulty with assessing an objective improvement in symptoms. [7] [10] [18] Bronchiolitis-associated wheezing is likely not effectively alleviated by bronchodilators anyway as it is caused by airway obstruction and plugging of the small airway diameters by luminal debris, not bronchospasm as in asthma-associated wheezing that bronchodilators usually treat well. [44]

Anticholinergic inhalers, such as ipratropium bromide, have a modest short-term effect at best and are not recommended for treatment. [22] [47] [48]

Epinephrine

The current state of evidence suggests that nebulized epinephrine is not indicated for children with bronchiolitis except as a trial of rescue therapy for severe cases. [10] [22]

Epinephrine is an α and β adrenergic agonist that has been used to treat other upper respiratory tract illnesses, such as croup, as a nebulized solution. [49] A Cochrane meta-analysis in 2011 found no benefit to the use of epinephrine in the inpatient setting and suggested that there may be utility in the outpatient setting in reducing the rate of hospitalization. [50] [31] However, current guidelines do not support the outpatient use of epinephrine given the lack of substantial sustained benefit. [10]

A 2017 review found inhaled epinephrine with corticosteroids did not change the need for hospitalization or the time spent in hospital. [51] Other studies suggest a synergistic effect of epinephrine with corticosteroids but have not consistently demonstrated benefits in clinical trials. [10] Guidelines recommend against its use currently. [10] [7]

Fluid therapy

Approximately 50% of infants who are hospitalized due to bronchiolitis require fluid therapy. [52] Some are dehydrated and others cannot be fed fluids safely by mouth. [52] There are two main approaches to fluid therapy: intravenous (IV) fluid therapy and enteral tube fluid therapy (nasogastric or orogastric). [52] Both approaches to fluid therapy are associated with a similar length of hospital stay. [52] Enteral tube fluid therapy may reduce the risk of local complications, but the evidence for or against each approach is not clear. [52]

Unclear evidence

Currently other medications do not yet have evidence to support their use, although they have been studied for use in bronchiolitis. [10] [50] Experimental trials with novel antiviral medications in adults are promising but it remains unclear if the same benefit will be present. [18]

Non-effective treatments

Epidemiology

Bronchiolitis typically affects infants and children younger than two years, principally during the autumn and winter. [18] It is the leading cause of hospital admission for respiratory disease among infants in the United States and accounts for one out of every 13 primary care visits. [7] Bronchiolitis accounts for 3% of emergency department visits for children under 2 years old. [14] Bronchiolitis is the most frequent lower respiratory tract infection and hospitalization in infants worldwide. [18]

Related Research Articles

<span class="mw-page-title-main">Asthma</span> Long-term inflammatory disease of the airways of the lungs

Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath. These may occur a few times a day or a few times per week. Depending on the person, asthma symptoms may become worse at night or with exercise.

<span class="mw-page-title-main">Pneumonia</span> Inflammation of the alveoli of the lungs

Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity of the condition is variable.

<span class="mw-page-title-main">Common cold</span> Common viral infection of the upper respiratory tract

The common cold or the cold is a viral infectious disease of the upper respiratory tract that primarily affects the respiratory mucosa of the nose, throat, sinuses, and larynx. Signs and symptoms may appear fewer than two days after exposure to the virus. These may include coughing, sore throat, runny nose, sneezing, headache, and fever. People usually recover in seven to ten days, but some symptoms may last up to three weeks. Occasionally, those with other health problems may develop pneumonia.

<span class="mw-page-title-main">Respiratory failure</span> Inadequate gas exchange by the respiratory system

Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a rise in arterial carbon dioxide levels is called hypercapnia. Respiratory failure is classified as either Type 1 or Type 2, based on whether there is a high carbon dioxide level, and can be acute or chronic. In clinical trials, the definition of respiratory failure usually includes increased respiratory rate, abnormal blood gases, and evidence of increased work of breathing. Respiratory failure causes an altered mental status due to ischemia in the brain.

<span class="mw-page-title-main">Otitis media</span> Inflammation of the middle ear

Otitis media is a group of inflammatory diseases of the middle ear. One of the two main types is acute otitis media (AOM), an infection of rapid onset that usually presents with ear pain. In young children this may result in pulling at the ear, increased crying, and poor sleep. Decreased eating and a fever may also be present. The other main type is otitis media with effusion (OME), typically not associated with symptoms, although occasionally a feeling of fullness is described; it is defined as the presence of non-infectious fluid in the middle ear which may persist for weeks or months often after an episode of acute otitis media. Chronic suppurative otitis media (CSOM) is middle ear inflammation that results in a perforated tympanic membrane with discharge from the ear for more than six weeks. It may be a complication of acute otitis media. Pain is rarely present. All three types of otitis media may be associated with hearing loss. If children with hearing loss due to OME do not learn sign language, it may affect their ability to learn.

<span class="mw-page-title-main">Acute bronchitis</span> Medical condition

Acute bronchitis, also known as a chest cold, is short-term bronchitis – inflammation of the bronchi of the lungs. The most common symptom is a cough. Other symptoms include coughing up mucus, wheezing, shortness of breath, fever, and chest discomfort. The infection may last from a few to ten days. The cough may persist for several weeks afterward with the total duration of symptoms usually around three weeks. Some have symptoms for up to six weeks.

<span class="mw-page-title-main">Croup</span> Respiratory infection often caused by a virus

Croup, also known as laryngotracheobronchitis, is a type of respiratory infection that is usually caused by a virus. The infection leads to swelling inside the trachea, which interferes with normal breathing and produces the classic symptoms of "barking/brassy" cough, inspiratory stridor and a hoarse voice. Fever and runny nose may also be present. These symptoms may be mild, moderate, or severe. Often it starts or is worse at night and normally lasts one to two days.

<span class="mw-page-title-main">Respiratory syncytial virus</span> Species of a virus

Respiratory syncytial virus (RSV), also called human respiratory syncytial virus (hRSV) and human orthopneumovirus, is a contagious virus that causes infections of the respiratory tract. It is a negative-sense, single-stranded RNA virus. Its name is derived from the large cells known as syncytia that form when infected cells fuse.

<span class="mw-page-title-main">Upper respiratory tract infection</span> Medical condition

An upper respiratory tract infection (URTI) is an illness caused by an acute infection, which involves the upper respiratory tract, including the nose, sinuses, pharynx, larynx or trachea. This commonly includes nasal obstruction, sore throat, tonsillitis, pharyngitis, laryngitis, sinusitis, otitis media, and the common cold. Most infections are viral in nature, and in other instances, the cause is bacterial. URTIs can also be fungal or helminthic in origin, but these are less common.

<span class="mw-page-title-main">Nebulizer</span> Drug delivery device

In medicine, a nebulizer or nebuliser is a drug delivery device used to administer medication in the form of a mist inhaled into the lungs. Nebulizers are commonly used for the treatment of asthma, cystic fibrosis, COPD and other respiratory diseases or disorders. They use oxygen, compressed air or ultrasonic power to break up solutions and suspensions into small aerosol droplets that are inhaled from the mouthpiece of the device. An aerosol is a mixture of gas and solid or liquid particles.

<span class="mw-page-title-main">Lower respiratory tract infection</span> Medical term

Lower respiratory tract infection (LRTI) is a term often used as a synonym for pneumonia but can also be applied to other types of infection including lung abscess and acute bronchitis. Symptoms include shortness of breath, weakness, fever, coughing and fatigue. A routine chest X-ray is not always necessary for people who have symptoms of a lower respiratory tract infection.

Transient tachypnea of the newborn is a respiratory problem that can be seen in the newborn shortly after delivery. It is caused by retained fetal lung fluid due to impaired clearance mechanisms. It is the most common cause of respiratory distress in term neonates. It consists of a period of tachypnea (rapid breathing. Usually, this condition resolves over 24–72 hours. Treatment is supportive and may include supplemental oxygen and antibiotics. The chest x-ray shows hyperinflation of the lungs including prominent pulmonary vascular markings, flattening of the diaphragm, and fluid in the horizontal fissure of the right lung.

<span class="mw-page-title-main">Non-invasive ventilation</span> Breathing support administered through a face mask

Non-invasive ventilation (NIV) is the use of breathing support administered through a face mask, nasal mask, or a helmet. Air, usually with added oxygen, is given through the mask under positive pressure; generally the amount of pressure is alternated depending on whether someone is breathing in or out. It is termed "non-invasive" because it is delivered with a mask that is tightly fitted to the face or around the head, but without a need for tracheal intubation. While there are similarities with regard to the interface, NIV is not the same as continuous positive airway pressure (CPAP), which applies a single level of positive airway pressure throughout the whole respiratory cycle; CPAP does not deliver ventilation but is occasionally used in conditions also treated with NIV.

<span class="mw-page-title-main">Bronchopulmonary dysplasia</span> Medical condition

Bronchopulmonary dysplasia is a chronic lung disease which affects premature infants. Premature (preterm) infants who require treatment with supplemental oxygen or require long-term oxygen are at a higher risk. The alveoli that are present tend to not be mature enough to function normally. It is also more common in infants with low birth weight (LBW) and those who receive prolonged mechanical ventilation to treat respiratory distress syndrome. It results in significant morbidity and mortality. The definition of bronchopulmonary dysplasia has continued to evolve primarily due to changes in the population, such as more survivors at earlier gestational ages, and improved neonatal management including surfactant, antenatal glucocorticoid therapy, and less aggressive mechanical ventilation.

<span class="mw-page-title-main">Respiratory tract infection</span> Infectious disease affecting nose, throat and lungs

Respiratory tract infections (RTIs) are infectious diseases involving the lower or upper respiratory tract. An infection of this type usually is further classified as an upper respiratory tract infection or a lower respiratory tract infection. Lower respiratory infections, such as pneumonia, tend to be far more severe than upper respiratory infections, such as the common cold.

Palivizumab, sold under the brand name Synagis, is a monoclonal antibody produced by recombinant DNA technology used to prevent severe disease caused by respiratory syncytial virus (RSV) infections. It is recommended for infants at high-risk for RSV due to conditions such as prematurity or other medical problems including heart or lung diseases.

<span class="mw-page-title-main">Bronchitis</span> Inflammation of the large airways in the lungs

Bronchitis is inflammation of the bronchi in the lungs that causes coughing. Bronchitis usually begins as an infection in the nose, ears, throat, or sinuses. The infection then makes its way down to the bronchi. Symptoms include coughing up sputum, wheezing, shortness of breath, and chest pain. Bronchitis can be acute or chronic.

<span class="mw-page-title-main">Acute exacerbation of chronic obstructive pulmonary disease</span> Medical condition

An acute exacerbation of chronic obstructive pulmonary disease, or acute exacerbations of chronic bronchitis (AECB), is a sudden worsening of chronic obstructive pulmonary disease (COPD) symptoms including shortness of breath, quantity and color of phlegm that typically lasts for several days.

<span class="mw-page-title-main">Chronic obstructive pulmonary disease</span> Lung disease involving long-term poor airflow

Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. GOLD 2024 defined COPD as a heterogeneous lung condition characterized by chronic respiratory symptoms due to abnormalities of the airways and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction.

<i>Orthopneumovirus</i> Genus of viruses

The genus Orthopneumovirus consists of pathogens that target the upper respiratory tract within their specific hosts. Every orthopneumovirus is characterized as host-specific, and has a range of diseases involved with respiratory illness. Orthopneumoviruses can cause diseases that range from a less-severe upper-respiratory illness to severe bronchiolitis or pneumonia. Orthopneumoviruses are found among sheep, cows, and most importantly humans. In humans, the orthopneumovirus that specifically impacts infants and small children is known as human respiratory syncytial virus.

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