1. Bronchiolitis in Children Prof. Dr. Saad S Al Ani Senior Pediatric Consultant Head of Pediatric Department Khorfakkan Hospital Sharjah, UAE Saad.alani@moh.gov.ae

2. Bronchiolitis is caused by a viral infection and is seasonal,peaking in the winter months. The most common cause is respiratory syncytial virus (RSV) which accounts for 80% of cases Other respiratory viruses that cause bronchiolitis: Rhinovirus Adenovirus Influenza virus Parainfluenza Bush A. Thomson AH..acute Bronchiolitis.BMJ2007,335(7628):1037-1041 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 2

3. Bronchiolitis is the most common disease of the lower respiratory tract during the first year of life Children present with : Cough Increased work of breathing Difficulty with feeding About 1 in 3 infants will develop bronchiolitis in the first year of life About 2% -3% of all infants will need admission to hospital Deshpande SA, Northern V.The clinical and health economic burden of respiratory syncytial virus disease among children under 2 years of age in a defined geographical area. Arch Dis Child2003,88(12):1065-9. 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 3

4. Young infants( especially those under 6 weeks) may present with apnea without other clinical signs) Apnea is considered a ‘ red flag’ symptoms that need emergency care in the hospital National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 4

5. Apnea (Observed or reported) The child look seriously unwell Severe respiratory distress:  Grunting  Marked chest recessions  Respiratory rate above 70 breaths per minute Central cyanosis Oxygen saturations persistently below 92% when breathing air Emergency consideration Scottish Intercollegiate Guidelines Network. Bronchiolitis in children: A national clinical guideline.2006. http://www.sign.ae.uk/pdf/sign91.pdf 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 5

6. Most children:  Will have mild disease that is self limiting  Can be managed at home Some children  Have more severe respiratory distress  Needing treatment Few children :  Will deteriorate rapidly  Develop severe life threatening bronchiolitis  Need urgent treatment National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 6

7. Clinical features that may be important predictors of deterioration include: Length of illness ( a deterioration is more likely in the early stages of the disease) Heart rate above 97 th centile Respiratory rate above 70 breaths per minute Fever Oxygen saturation below 92% Ability to feed Walsh P,et al.A validated clinical model to predict the need for admission and length of stay in children with acute bronchiolitis. Eur J Emerg Med2004;11(5):265-72 Corneli HM,et al. Bronchiolitis: clinical characteristics associated with hospitalization and length of stay. Pediatr Emerg care 2012;28(2):99-103 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 7

8. Referral indications to hospital If any of the followings is present in a child with bronchiolitis, referral to hospital is indicated: Respiratory rate > 60 breath per minute Difficulty with breastfeeding or inadequate oral intake Clinically dehydrated Chronic lung disease Congenital Heart disease Age under 3 months Premature birth(<32 weeks gestation) A neuromuscular disorder Immunodeficiency National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 8

9. Think of Bronchiolitis as a diagnosis if the child has a coryzal prodrome that lasts between 1-3 days and is followed by: A persistent cough AND Tachypnea or chest recession for both, AND Wheeze or crackles on auscultation for both National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 https://www.linkedin.com/pulse/who-do-you-think-pete-baker Diagnosis 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 9

10. Colourbox Do not perform a routine chest x ray Generally the diagnosis of bronchiolitis is Clinical and investigations are not considered helpful Chest x ray can’t discriminate between bronchiolitis and other lower respiratory tract infections Stephens D, Lalani A, Schuh S. Predictors of major intervention in infant with bronchiolitis. Pediatr Pulmonol2009;44(4):358-63 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 10

11. The treatment for bronchiolitis is Supportive No effective drug treatment Bronchiolitis is a viral and the rate of secondary bacterial infection is very rare Significant disadvantages associated with use of antibiotics: Adverse reactions Bacterial resistance Cost implications Luo Z, Fu Z, Liu E,et al. Nebulized hypertonic saline treatment in hospitalized children with moderate to severe viral bronchiolitis. Clin Microbiol Infect2011;17(12):1829-33 National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 11

12. Ineffective treatments All of the followings should not be used to treat children with bronchiolitis: Antibiotics Hypertonic saline Nebulized adrenaline Salbutamol Montelukast Ipratropium bromide Systemic or inhaled corticosteroids National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 12

13. When to give oxygen wiseGEEK Oxygen supplementation is needed if a child’s oxygen saturated is persistently < 92% in air No routine oxygen for all children with bronchiolitis National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 13

14. The following informations to parents caring for children with bronchiolitis at home: ‘Red flag’ symptoms:  Worsening of breathing work:  A reduced fluid intake  Apnea or cyanosis  Exhaustion Avoid smoking at home Follow up National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 14

15. Bronchiolitis versus Asthma 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 15

16. Clinical Features of Bronchiolitis Starts with upper respiratory tract symptoms:  Nasal obstruction  Cough Progresses over 3-4 days to involve the bronchioles:  Dyspnea  Poor feeding On auscultation: mixture of wheeze and crackles National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 16

17. Asthma It is less commonly under 1 year of age Recurrent respiratory symptoms:  Wheeze  Cough  Difficulty of breathing  Chest tightness Symptoms worse after exposure to triggers and at night Personal or family history of atopy or asthma On auscultation: widespread wheeze Improve lung function after adequate treatment Wu P, Hartert TV. Evidence for a causal relationship between respiratory syncytial virus infection and asthma. Expert Rev Anti Infect Ther2011;9(9):731-45 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 17

18. Post bronchiolitis syndrome Recovery takes between 5 – 7 days Persistent cough lasts >2 weeks occur in 50% Infants have increase frequency of subsequent wheeze Some children get chronic and relapsing episodic wheezing with subsequent viral infections Association between RSV and later on development of asthma is well documented Wu P, Hartert TV. Evidence for a causal relationship between respiratory syncytial virus infection and asthma. Expert Rev Anti Infect Ther2011;9(9):731-45. 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 18

19. References Bush A. Thomson AH..acute Bronchiolitis.BMJ2007,335(7628):1037-1041 Deshpande SA, Northern V.The clinical and health economic burden of respiratory syncytial virus disease among children under 2 years of age in a defined geographical area. Arch Dis Child2003,88(12):1065-9 National Institute for Health and Care Excellence. Bronchiolitis in children: diagnosis and management. NICE guidelines {NG9}.2015. https://www.nice.org.uk/guidance/ng9https://www.nice.org.uk/guidance/ng9 Scottish Intercollegiate Guidelines Network. Bronchiolitis in children: A national clinical guideline.2006. http://www.sign.ae.uk/pdf/sign91.pdf http://www.sign.ae.uk/pdf/sign91.pdf Walsh P,et al.A validated clinical model to predict the need for admission and length of stay in children with acute bronchiolitis. Eur J Emerg Med2004;11(5):265-72 Corneli HM,et al. Bronchiolitis: clinical characteristics associated with hospitalization and length of stay. Pediatr Emerg care 2012;28(2):99-103 Stephens D, Lalani A, Schuh S. Predictors of major intervention in infant with bronchiolitis. Pediatr Pulmonol2009;44(4):358- 63 Luo Z, Fu Z, Liu E,et al. Nebulized hypertonic saline treatment in hospitalized children with moderate to severe viral bronchiolitis. Clin Microbiol Infect2011;17(12):1829-33 Wu P, Hartert TV. Evidence for a causal relationship between respiratory syncytial virus infection and asthma. Expert Rev Anti Infect Ther2011;9(9):731-45 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 19

20. Dreamstime.com 25/09/2017 Bronchiolitis in children Prof. Dr. Saad S Al Ani 20