ppt

1. Evidence based guideline for
the management of
bronchiolitis
Turner T, Wilkinson F, Harris C, Mazza D
On behalf of the Health for Kids Guideline Development Group
Islammiyah Dewi Yunianti
Rio Santy Anjarwati
Pembimbing:
Prof. dr. M. Sidhartani Zain, MSc, SpA(K)
dr. Dwi Wastoro Dadiyanto, Sp.A(K)
dr. MS Anam, MSi Med, SpA

2. Bronchhiolitis
• Viral infection of the respiratory tract commonly
caused by RSV
• Also caused by parainfluenza, adenovirus and
influenza
• Occur during autumn and winter (most cases)
• Some types of parainfluenza virus are present
during other months can be seen troughout the
year

3. Characteristic of bronchiolitis
• Acute inflamation, oedema, necrosis of epithelial
cells lining the bronchioles
• Increased mucos production
• Bronchospasm
• Obstruction of the small airways

4. Infant and children with bronchiolitis featured by both
upper and lower respiratory

5. Duration of illness
• Approximatelt 2 weeks
• 20% having sympptoms longer than 3 weeks

6. Why was this guideline developed?
• Bronchiolitis is the most common lower respiratory
tract infection in infants
• In Australasia, Europe and north America up to
3% of all children are hospitalised in their first year
of life
• Most of them mild bronchiolitis  outpatient basis
• In Australia, 13.500 children are admitted to
hospital with bronchiolitis each year (80% < 1 year
of age)

7. The scope of this guideline
• Refers to a child
presenting to either a
hospital emergency or
general practice with
bronchiolitis
Not apply to :
•Children over 18 months of
age
•Infants or children with pre-existing
airway abnormalities
(cystic fibrosis)
•Cyanotic cardia anomalies
•Admitted to ICU

8. Extra caution and consult with appropriate specialist
clinicians when caring for
Speciql care to
exclude other
diagnoses in
presenting with
recurrent
wheezing

9. Recommendations
• Diagnosis clinical-no diagnostic test confirms the
disease
An infant or child < 18 months of age presenting with initial
symptoms and signs of upper respiratory tract infection
followed by cough, tachypnoea, inspiratory crepitations and
wheeze  bronchiolitis
• Fever, hypoxia and accessory muscle may be
present
• Chest examination may be clear, prolonged
expiratory phase with wheeze, rhonchi, and
crepitation may be found
• Dehydration : combination of difficulty feeding and
increase IWL due to tacyhpnoea

10. Differential diagnoses
• Asthma
• Pneumonia
• Whooping cough
• Cystic fibrosid
• CHF
• Inhaled foreign body

11. Differential diagnoses
• Consider other diagnosis in infants or children with
recurrent-bouts of bronchiolitis-like symptoms (D)
• An infant or child with bronchiolitis-like symptoms
who responds to treatment with a bronchodilator
should be treated according to asthma
management guidelines (D)

12. Investigation

13. Investigation
• Urine culture
Should not be routinely performed in infants or children with
bronchiolitis(D)
• Blood gas analysis
should not be routinely performed in infants or
children with bronchiolitis(D)
Should be performed in infants or children with
life threatening or severe disease(D)
Consider blood gas analysis in infants or children
with moderate disease(D)

16. Assessment of bronchiolitis
Focused on classification of severity of disease :
• mild
• moderate
• severe, or
• life threatening

17. • Seven studies →examined the relationship between
severity of bronchiolitis and clinical indicators.
• These included:
- oxygen saturation and the need for:
- oxygen supplementation
-mechanical ventilation
-hospital admission
-intensive care unit admission.

18. Classification of severity

19. Patients at high risk of more
severe
• Infants < 3 months of age / born at < 36 weeks
gestation
• infants or children →
• cardiorespiratory disease

20. Nonpharmacological
management
• Oxygen
It is a mainstay of therapy in the hospital setting.
• Feeding and hydration
bronchiolitis →dehydrated as a result →poor oral
intake & water loss →↑ RR and work of breathing.

21. the GDG made the following consensus
recommendations:
• Infants/children with mild/moderate
bronchiolitis→continue oral feeding→≠ , iv or NGT.
(D)

22. • Chest physiotherapy
Chest physiotherapy →not be routinely used (A)
• Mist, steam or nebulised saline
Should not be routinely used →bronchiolitis(D)

23. • Saline drops
Saline nasal drops should be trialled in infants with
bronchiolitis→ nasal congestion, particularly before
feeds(D)
• Suctioning
Nasal suctioning may be trialled(D)

24. • Apnoea management
Bronchiolitis → increased risk → age < 3 months,
premature birth or previous apnoea(D)
• Positioning
Infants allowed to adopt the position they find most
comfortable(D)

25. Pharmacological management
• Nebulised adrenaline
Adrenaline should not be routinely used for the
treatment of bronchiolitis (A)
• β2 agonist bronchodilators
β2 agonist bronchodilators should not be routinely (A)
Consider a trial of a single dose of β2 agonist
bronchodilators in patients over 9 months of age,
particularly those with recurrent wheezing(D)

26. β2 agonist bronchodilators should not be continued if an
infant or child does not respond to an initial trial(D)
• Ipratropium bromide
Should not be routinely used for the treatment of
bronchiolitis(A)
• Antibiotics
Should not be routinely used for the treatment of
bronchiolitis(A)
Consider antibiotics → a secondary bacterial infection(D)

27. • Corticosteroids
Should not be routinely used for the treatment of
bronchiolitis(A)
• Ribavirin
Should not be routinely used for the treatment of
bronchiolitis(A)
• Immunoglobulin
Should not be routinely used for the treatment of
bronchiolitis(A)

28. • Analgesics and antipyretics
Bronchiolitis and fever →paracetamol / ibuprofen to bring
their temperature down and reduce irritability(D)
• Oral antitussives, expectorants or decongestants
Should not be routinely used for the treatment of
bronchiolitis(D)

29. • Level of care
May be managed by a GP and sent home for
observation if the GP (D)
Moderate bronchiolitis ≠require oxygen or fluid therapy
→GP,
Otherwise the infant or child should be sent to a
hospital(D)
If a GP is not available→ taken to a hospital emergency
department

30. • When should an ambulance be called?
Severe or life threatening bronchiolitis sent by
ambulance to a hospital emergency department

31. Summary of important points
• infant <18 months of age → initial signs and
symptoms of an upper respiratory tract infection
→(cough, tachypnoea, inspiratory crepitations, and
wheeze)
• no diagnostic test confirms the disease.
• Chest X-rays should not be used to diagnose
bronchiolitis

32. • Differentiating between bronchiolitis and viral
pneumonia is difficult→ supportive
• a trial of a single dose of β2 agonist bronchodilators
in > 9 months of age→with recurrent wheezing
• Responds to treatment with a bronchodilator, such
as salbutamol→treated according to asthma
management guidelines.

33. • duration of illness is 2 weeks, approximately 20% of
patients have symptoms > 3 weeks
• mild or moderate cases tolerating feeds and not
requiring oxyen:
– suggest small, frequent feeds
– provide parent information
– offer review.

34. • In moderate cases not tolerating feeds and/or
requiring oxygen:
– provide parent information
– send to hospital.
• In severe or life threatening cases:
– give oxygen
– call an ambulance.