Bronchiolitis | Case Study

1. Bronchiolitis
MOHAMMAD MATOUQ ALGHAMDI –
PHARM.D INTERNSHIP
PEDIATRIC ROTATION

2. Bronchiolitis
Bronchiolitis is an acute viral infection of the lower respiratory
tract of infants that affects ~50% of children during the first year
of life and 100% by 3 years.
Respiratory syncytial virus is the most common cause of
bronchiolitis, accounting for up to 75% of all cases.
Parainfluenza viruses are the second most common cause.
Bacteria serve as secondary pathogens in only a small minority
of cases.

3. Clinical Presentation

5. Treatment
• Bronchiolitis is a self-limiting illness and usually requires
no therapy (other than reassurance, antipyretics, and
adequate fluid intake) unless the infant is hypoxic or
dehydrated. Otherwise healthy infants can be treated for
fever, provided generous amounts of oral fluids, and
observed closely.
• In severely affected children, the mainstays of therapy for
bronchiolitis are oxygen therapy and intravenous (IV) fluids.

6. Treatment
• Aerosolized β-adrenergic therapy appears to offer little benefit for
the majority of patients but may be useful in the child with a
predisposition toward bronchospasm.
• Because bacteria do not represent primary pathogens in the
etiology of bronchiolitis, antibiotics should not be routinely
administered. However, many clinicians frequently administer
antibiotics initially while awaiting culture results because the clinical
and radiographic findings in bronchiolitis are often suggestive of a
possible bacterial pneumonia.

7. Treatment
• Ribavirin may be considered for bronchiolitis caused by respiratory
syncytial virus in a subset of patients (severely ill patients, especially
those with chronic lung disease, congenital heart disease,
prematurity, and immunodeficiency (especially severe combined
immunodeficiency and human immunodeficiency virus [HIV]
infection).). Use of the drug requires special equipment (small-
particle aerosol generator) and specifically trained personnel for
administration via oxygen hood or mist tent.

8. INDICATIONS FOR HOSPITALIZATION
Toxic appearance, poor feeding, lethargy, or dehydration
Moderate to severe respiratory distress, manifested by one or more of the
following signs: nasal flaring; intercostal, subcostal, or suprasternal retractions;
respiratory rate >70 breaths per minute; dyspnea; or cyanosis
Apnea
Hypoxemia with or without hypercapnia

9. Clinical Case

10. Demographic and Administrative Information
Age 5 Month
Gender Female
Nationality Saudi
Date of Administration 17 – 2 - 1438
Date of Discharge 22 – 2 - 1438
Weight 6.5 KG

11. Laboratory Data
Date Result
WBCs 13.6
RBCs 5.60
HGB 13.9
HCT 41
MCV 73.2
MCH 33.9
MCHC 33.9
PLT 428

12. Chief Complaint
Fever and Cough for tow day ago

13. Acute Medical Therapy :
 Cefotaxime
Dexamethasone
Paracetamol
Bromhexine
Normal Saline
Ventolin

14. Vital Signs
Date 17 18 19 20 21 22
Temp 37.4 36.5 36.7 36.5 36.9 37.1
Oxygen 96% 88% 91% 90% 96% 96%
Pulse 155 140 146 130 124 129
R.R 30 34 32 33 32 30
Normal Vital Signs

15. Current Drug Therapy
Drug name / Dose / Strength / Rout / Freq . Indication Strat Stop Discharged ( Y
/ N )
Cefotaxime 125 m / I.V / Q6H LRTI 17 - 2 - Y
Dexamethasone 0.25 ml / I.V / BID Anti inflammatory 17 - 2 - Y
Paracetamol 2.3 ml / P.O / S.O.S Fever 17 - 2 20 -2 N
Normal Saline 150 ml / I.V / Q8H Fluid 17 - 2 - Y
NEB . Ventolin 0.125 mg / Q4H bronchodilators 20 - 2 22 – 2 N

16. Drug Interaction
Drug interaction assessment worksheet
Potential interactionseverityDrug 2Drug 1
Corticosteroids may enhance the
hypokalemic effect of Beta2-Agonists.
[B] No Action
Needed
Dexamethaso
ne
Albuterol

17. Pharmacist’s care plan
Fluid management
The fluid intake and output of infants and children with bronchiolitis
should be assessed regularly. Children with bronchiolitis may have
difficulty maintaining adequate hydration because of increased
needs (related to fever and tachypnea) and decreased intake (related
to tachypnea and respiratory distress).

18. Supplemental oxygen
Supplemental oxygen should be provided by nasal cannula,
face mask, or head box to maintain SpO2 above 90 to 92
percent

19. Nasal suctioning
For children hospitalized with
bronchiolitis, we suggest mechanical
aspiration of the nares as necessary to
relieve nasal obstruction. Saline nose
drops and mechanical aspiration of nares
may help to relieve partial upper airway
obstruction in infants and young children
with respiratory distress or feeding
difficulties.

20. HFNC and CPAP
Heated humidified high-flow nasal cannula (HFNC) therapy
and/or continuous positive airway pressure (CPAP) are used to
reduce the work of breathing, improve gas exchange, and avoid
the need for endotracheal intubation in children with
bronchiolitis who are at risk for progression to respiratory failure

21. Monitoring clinical status
Respiratory status – Repeated clinical assessment of the respiratory
system (eg, respiratory rate; nasal flaring; retractions; grunting) is
necessary to identify deteriorating respiratory status .
Fluid status – The fluid intake and output of infants and children
with bronchiolitis should be assessed regularly. It is also important to
monitor urine output. Plasma antidiuretic hormone levels rarely may
be elevated, leading to fluid retention and hyponatremia

22. INTERVENTIONS THAT ARE NOT
ROUTINELY RECOMMENDED
Bronchodilators
Inhaled bronchodilators – We do not suggest routine administration
of inhaled bronchodilators for children with bronchiolitis. Meta-
analyses of randomized trials and systematic reviews suggest that
bronchodilators may provide modest short-term clinical
improvement but do not affect overall outcome, may have adverse
effects, and increase the cost of care

23. INTERVENTIONS THAT ARE NOT
ROUTINELY RECOMMENDED
Bronchodilators
Oral bronchodilators – We recommend against the use of oral
bronchodilators in the management of bronchiolitis. In randomized
trials, oral bronchodilators have neither shortened clinical illness nor
improved clinical parameters, but were associated with adverse
effects (eg, increased heart rate)

24. INTERVENTIONS THAT ARE NOT
ROUTINELY RECOMMENDED
Glucocorticoids
Systemic glucocorticoids – For healthy infants and young children
with a first episode of bronchiolitis, we recommend not using
systemic glucocorticoids
The anti-inflammatory effects of glucocorticoids theoretically reduce
airway obstruction by decreasing bronchiolar swelling, most studies
show little effect in bronchiolitis

25. INTERVENTIONS THAT ARE NOT
ROUTINELY RECOMMENDED
Nebulized hypertonic saline — For infants and children with severe
bronchiolitis who are treated in the emergency department, we
suggest not routinely treating with nebulized hypertonic saline (of
any concentration). In 2015 systematic reviews of randomized trials
evaluating administration of hypertonic saline in the emergency
department, hypertonic saline reduced the rate of hospitalization
among children with bronchiolitis, but the evidence was not high
quality

26. INTERVENTIONS THAT ARE NOT
ROUTINELY RECOMMENDED
Antibiotics – Antibiotics should not be used routinely in the
treatment of bronchiolitis, which is almost always caused by viruses
Bronchiolitis does not increase the risk for serious bacterial infection

28. Thank You