BRONCHIOLITIS IN

CHILDREN
Ayu Setyorini MM
DEFINITION
Bronchiolitis is
inflammation of
bronchioles

No hyaline cartilage
rely on elastic fibre to
maintain the patency
obstruct easily

Diameter 0.3 5 mm
small obstruction
caused significant
symptoms

Spread until 16th

subdivision of
respiratory tract
 EPIDEMIOLOGY

2 8 12 24
m.o m.o m.o m.o

75% 25%

WHY ??
Smaller, more easily obstructed airways
Decreased ability to clear secretions
Insufficient collateral ventilation
 RISK FACTORS FOR SERIOUS
ILLNESS
Prematurity: Alveolarization occurs at ~36
weeks gestation, and mature surfactant
production by type II pneumocytes begins at
34-35 weeks. Premature infants are therefore
born with immature lungs that are unprepared
for normal gas exchange, and are at risk for
developing to more serious respiratory
infections
Congenital heart disease: significant CHDs that
have associated pulmonary overcirculation
pulmonary edema or pulmonary hypertension
more severe respiratory symptoms
 Airway abnormalities: Laryngomalacia,
tracheomalacia, and cleft lip or palate may
have difficulty managing increased upper
airway secretions
Down syndrome: due to CHD (present in
~50% of children with DS), pulmonary
hypertension (found in 10% who do not have
CHD), abnormal upper airway physiology
contributing to apnea and difficulty clearing
secretions, and immune response alterations
(abnormal thymus development and function,
low B and T cell numbers)
 PATHOPHYSIOLOGY
AGENT HOST ENVIRONMEN
T
RSV, RV, IV,
HMV, AV
INOCULATION OF
RESPIRATORY TRACT Acute
Prodo
cours
UPPER r-me
LOWER e LOWER
RESPIRATORY RESPIRATORY RESPIRATORY
TRACT (Nasal) 1-2 TRACT 1d TRACT
Copious rhinorhea d Cough, OBSTRUCTION
tachypneu, Peribronchial
lethargy, poor edema
feeding, Mononuclear
COMPLETE dehydration infiltrate
DYNAMIC
V:Q MISMATCH
AIRWAY Wheezing
AIRWAY
Hypoxemia
OBSTRUCTION Hypercarbia OBSTRUCTION
Atelectasis Tachypnea Hyperinflation,
wheezing, work
of breathing

RESOLUTION
(1-2 wk)
 CLINICAL
MANIFESTATION
Upper respiratory tract manifestation
day : rhinorea, coughing, subfebril
fever
1-2 days

Lower respiratory tract manifestation:

Tachypne, retraction, wheezing, coarse
rhales
More severe respiratory distress : nasal
flaring, head nodding, grunting, cyanosis
 DIAGNOSIS
Clinical basis: thorough history
taking and physical examination

Diagnostic testing is
controversial but is typically
used to exclude other diagnoses
(eg, bacterial pneumonia, sepsis,
or congestive heart failure) or if
developed tendency of
respiratory failure
 Commonly used tests in the evaluation of patients
with bronchiolitis include the following:
White blood cell count with differential
Pulse oximetry
Arterial blood gas analysis in severe respiratory distress
Reactive protein level & blood cultures in concomittant
sepsis
Urine analysis, specific gravity, and culture in
concomitant UTI
Rapid viral antigen or nucleic acid amplification testing of
nasopharyngeal secretions for respiratory syncytial virus
Cerebrospinal fluid analysis and culture in seizzure
Electrocardiography or echocardiography in arrhythmias
or cardiomegaly
 Imaging studies
Not routinely done
Indication :
Appear ill
Clinical deteriorating
High risk
 Atelectasis

Hyperaerated

Normal Bronchiolit
thorax is
 TREATMENT
Mainly supportive: hydration and
oxygenation
Hydration:
Intravenous fluids to correct & maintain hydration
Oral rehydration with Pedialyte, if the child want
to drink, caution in significant work of breathing
due to aspiration risk
Nasogastric feeding if necessary
Oxygen: maintain saturation >90-92%,
delivered by an appropriate method (ex.
nasal prongs, rebreathing or nonrebreathing
masks)
 Bronchodilators (salbutamol 0,1 mg/kgBW mixed with
NaCl3% @ 6 h)
Corticosteroids (dexamethason 0,33 mg/kgBW @ 8 h)
Antibacterial agents (ampicillin 25 mg/kgBW @ 6 h)
Chest physiotherapy
Nasal suction
Mucolytic

Are continue to be used, but none have demonstrated

significant impact on duration of illness, severity, or
subsequent clinical outcomes (e.g. postbronchiolitis
wheezing)
Some sources suggest a trial of these therapies, with
discontinuation in the absence of effect
 Predictable course of
bronchiolitis, the day of illness
can guide changes to supportive
care: a child on Day 4 who
continues to have intermittent
desaturation on pulse oximetry
may not require continued
oxygen therapy (as a child on
Day 2 with the same clinical
picture might)
 COMPLICATION

ARDS
Bronchiolitis obliterans
Congestive heart failure
Secondary infection
Myocarditis
Arrhythmias
Chronic lung disease
THANK YOU
 How to differentiate between
pneumonia and bronchiolitis?