Akutni virusni bronhiolitis Prof. dr Branimir Nestorović

Definicija Virusna infekcija donjih disajnih puteva, sa akutnim zapaljenjem, edemom, nekrozom epitela malih disajnih puteva, sa povećanim lučenjem mukusa, broinhoopstrukcijom AHRQ Evidence Report

} Virusi Respiratorni sincitcijalni virus (RSV): 70% Metapneumovirus 10-20% Parainfluenza Influenza 10-20% Adenovirus Bocavirus ? }

Epidemiologija Statistika 90% dece 0-2 godine inficirano sa RSV 20% ima infekciju donjih delova respiratornog trakta 3% hospitalizovano 0.002% mortalitet Vreme pojave Vrhunac sa 2-5 meseci Redak pre drugog meseca života

Seasonality Bronchiolitis RSV Isolates Year Hall, NEJM 2001

Klinički tok Inkubacija: 2-8 dana Rinoreja: 1-3 dana Pogoršavanje opstrukcije 3-5 dana Pun oporavak: 2-8 nedelje Percent Dani Swingler et al. 2000

Risk faktori za hospitalizaciju Više rizik faktora Prematuritet Hronične bolesti < 6 nedelja života

Difuzno pojačan intersticijalni crtež Rendgen Difuzno pojačan intersticijalni crtež Hiperinflacija > 50% Peribronhialno zadebljanje Lobarna ili segmenta konsolidacija 2050%; najčešće gornji desni ili sredni režanj desno

Apneja Apnea – u 20% hospitalizovane dece Rizik faktori < 2-3 meseci uzrasta Prematuritet Rekurentna u oko 50% Mortalitet < 2% Levine et al. 2004

Otitis media Otitis media 62% (potvrdjen timpanocentezom) 24% sa efuzijom Andrade et al. 1998

Astma 40-50% hospitalizovane dece će imati kasnije wheezing Povećan rizik > 12 meseci života, atopija, eozinofilija Reijonen 1997 Ehlenfield 2000

AAP preporuke 2014 Nema potrebe za etiološkom dijagnozom infekcije

Dijagnoza se zasniva na anamnezi i fizikalnom pregledu. Rutinsko snimanje pluća se ne preporučuje. Procena rizik faktora

Deca na koje se preporuke ne odnose

Nije neophodno da se pokuša sa primenom bronhodilatatora Indikovana je samo potporna terapija (kiseonik, hidracija). Zdrava deca sa gestacionom starošću preko 29 nedelja ne zahtevaju prevenciju palivizumabom.

Preporuke za profilaksu RSV infekcije ≤28 nedelja GS Palivizumab ≤12 meseci Na početku sezone RSV Prematurusi, bez CLD, bez USM 29-32 nedelja GS Palivizumab ≤6 meseci na početku sezone RSV 32-35 nedelja GS Palivizumab ≤6 meseci na početku sezone, ako imaju dva faktora rizika American Academy of Pediatrics (AAP) Guidelines 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. 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. Hemodinamski značajna USM Palivizumab ≤2 godine na početku sezone RSV Chronic Lung Disease* (CLD) *Receiving medical therapy for CLD within 6 months

Nije potrebna primena adrenalina ili fizioterapije. Hipertoni NaCl se može dati deci koja su hospitalizovana.

Nije neophodno praćenje pulsnim oksimetrom, ako je opšte stanje deteta dobro. Nije indikovano davanje antibiotika. Može se davati tečnost na nazogastričnu sondu ili u infuziji.

Bronhiolitis nije astma – ne lečiti kao astmu

Nozokomijalna infekcija

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