BRONCHIOLITIS !!! WHY ? DR.FATMA AL-ZAHRANI DR.BASMA AL-JABRI TEAM C

BRONCHIOLITIS !!! WHY ? Bronchiolitis is the most common lower respiratory tract infection in infants. Bronchiolitis associated hospitalizations have been increased considerably since The diagnosis of bronchiolitis is generally clinical,wheather diagnostic tests change the clinical course, management, or the prognosis of the disease is unclear.

BRONCHIOLITIS!!! WHY? Different treatment modalities have been in practice for some years. some of these are specific to the causative agent, and the other are symptomatic. The relative severity of the disease among vulnerable subpopulation suggests that some infants & children may benefit from prophylactic therapy..

BRONCHIOLITIS!!! WHY? systemic review of bronchiolitis management in infants & children was presented by University of North Carolina Evidence-based practice center in 2006 …

OBJECTIVES To clarify the existing knowledge base for bronchiolitis managements. To offer directions for future research: effectiveness of diagnostic tools, pharmaceutical therapies prophylactic therapy cost effectiveness

SEARCH STRATIGIES Literatures review in 3 database: 1. MEDLINE 2. Health Economic Evaluation Data Base HEEDB 3. Cochrane Collaboration Library

SELECTION CRITERIA Diagnostic tools for bronchiolitis: Prospective cohort studies. Randomized control trials. Intervention (therapy + prophylaxis): Randomized control trials. Cost effectiveness: Economic analysis.

INCLUSION/EXCLUSION CRITERIA A clinically relevant outcomes & able to be abstracted. Minimum sample size of 10 (small case series & single case report were excluded). Studied in languages other than English were not reviewed. 744 abstracts were identified for possible inclusion, upon full review, total of 83 articles were retained.

Key question 1: effectiveness of diagnostic tools for diagnosing bronchiolitis 16 articles were reviewed Bronchilitis is clinical diagnosis, based on typical history & findings on physical examination. characterised by initial signs & symptoms of URTI followed by cough, tachypnea, wheezing,fever,hypoxia, retraction. No gold standard diagnostic test confirms the diagnosis of bronchilitis.

Key question 1:effectiveness of diagnostic tools for diagnosing bronchiolitis The utility of complete blood count in bronchiolitis: 10 studies did CBC in all patients. Used only to demonstrate that treatment & control groups were similar at baseline None of the studies demonstrated that CBC were useful in either diagnosing bronchiolitis or guiding therapy. correlate WBC with category of lung disease defined radiologically Saijo et al.

Key question 1: effectiveness of diagnostic tools of diagnosing bronchiolitis Utility of chest radiographs in bronchiolitis:  14 studies performed CXR on all patients.  Large numbers of infants with bronchiolitis have abnormalities on CXR.  Shaw et al : patients with atelectasis were 2.7 time more likely to have severe disease than those without this X-ray finding.  Dawson et al: no correlation between X-ray finding & baseline disease severity.

Key question 1:effectiveness of diagnostic tools for diagnosing broncholitis These data suggest that: in mild disease, CXR offer no information that is likely to affect the treatment, & that therefore should not be routinely performed. Roosevelt et al: suggest such X-ray may lead to inappropriate use of antibiotics.

Key question 1: effectiveness of diagnostic tools for diagnosing bronchilitis Comparison of virology tests: 5 studies examined the accuracy of various virologic tests for RSV & other causative agents: 1. Numerous tests for RSV exist. 2. Their tests characteristics vary, 3. Overall sensitivity of rapid antigen detection test to be in 80%- 90% range.

Identification of bronchiolitis etiology: 42 studies were performed RSVresting on all subjects. 12 studies tested the patients for other viral etiologies. RSV testing of patients with bronchiolitis is justified in several situations:

1. Isolation of RSV as the etiology of fever in infants less than 3 months may support the clinician’s decision to add additional testing in the traditional rule out sepsis work up. 2. RSV testing may helpful in clinical situations where the diagnosis of bronchiolitis is unclear. 3. Is an important tool for surveillance of LRTI in infants. 4. Will be essential in research sitting, where RSV specific therapies are being evaluated for effectiveness…

Key question 1: effectiveness of diagnostic tools for diagnosing bronchiolitis Comparisons of virological tests: Ahluwalia et al : Compared two methods of specimens collection & demonstrated that viral culture, EIA, IFA all yield positive results more often when performed on nasopharyngeal aspirate than when performed on nasopharyngeal swabs.

Key question 2: effectiveness of pharmaceutical therapies for bronchiolitis treatment Nebulised epinephrine vs. nebulised placebo: Doubled blinded, placebo controlled, RCT 29 infants & children without co morbidities. Outcomes: Kristjansson et al. Statistically significant improvement in 02 saturation & in the clinical scores at 15 min.interval till one hour …

Nebulised epinephrine vs. nebulised bronchodilators: 4 studies were reviewed subjects. outcomes: duration of hospitalization, changes in clinical scores Menon et al: Statistically significant improvement in 02 saturation 60 min after treatment in epinephrine group than salbutamol group

Nebulised bronchodilators vs. oral bronchodilators, nebulised ipratropium bromide: 11 studies. 158 subjects. Ages: up to 24 months Outcomes : hospitalization rate clinical scores

All statistically significant outcomes were in the 1 st hour after the treatment was given. Can et al: respiratory distress score was significantly better for neb. Salbutamol compared to neb. saline. Klassen et al: 30 min. & 60 min Schwein et al: neb. Albuterol vs. saline placebo.

Nebulised bronchodilators + nebulised ipratropium bromide vs. bronchodilators or ipratropium bromide alone: 4 studies Outcomes Wang et al: statistically significant improvement of 02 saturation in salbutamol+ ipratropium bromide & decrease in hospital stay

Oral corticosteroid vs. placebo with or without bronchodilators: 5 studies subjects. 2 yrs of age.( van woensel et al admitted infants with severe disease & comorbidities: ventilators, BPD outcome

Goebel et al: statistically significant difference in clinical scores between day 0, 2 in the group who received predinsolone+ albuterol more than placebo or albuterol groups. Schuh et al: significant lower rate of hospitalization 19% vs. 44% & improved clinical scores at 240 min post treatment & less need for steroid after discharge in dexamethasone + neb. Albuterol compared to placebo, albuterol groups

Van woensel et al: Significantly greater mean decline in symptoms score among 39 non ventilated patients Shorter duration of hospitalization among 14 ventilated patients 5 yrs follow up didn’t demonstrated any significant differences in long term outcomes such as wheezing in 1 st yr of life or persistent or late onset wheezing

Key question 3: role of prophylaxis in prevention of bronchiolitis Palivizumab or RSV IG IV on monthly basis is effective prophylaxis in high risk group Palivizumab has supplanted RSV IG IV because the ease of administration Studies of immunization with purified F protein vaccines didn’t demonstrate benefits. Only one study Piedra et al did seem to obtain benefits from the vaccine for older children with cystic fibrosis.

Conclusion recommendations Diagnosis: No specific literature were found regarding the diagnosis of bronchiolitis The disease is clinically diagnosed Encourage the

Conclusion recommendations Treatments: There was no specific treatment with strong & convincing evidence of effectiveness. Several interventions that show some potential for being efficacious & should be subjected to strongly designed, adequately sized trials: neb. Epinephrine, neb. salbutamol+ ipratropium bromide, neb. Ipratropium bromide, oral, inhaled & parentral steroids

Conclusion recommendations 2 interventions applicable for most severely ill children: inhaled helium 02 & surfactant for ventilated patients No single agent or antimicrobial drug is the most effective in improving the symptoms of bronchiolitis Most of outcomes studied in short term,

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