This PowerPoint file is a supplement to the video presentation. Some of the educational content of this program is not available solely through the PowerPoint file. Participants should use all materials to enhance the value of this continuing education program. Pediatric Bronchiolitis Janie Robles, PharmD, AE-C Assistant Professor of Pharmacy Practice Pediatrics School of Pharmacy TTUHSC Lubbock, Texas EMS I 80116
Objectives 1. Recognize incidence, etiology, and pathophysiology of pediatric bronchiolitis. 2. Indicate pediatric bronchiolitis clinical manifestations and diagnosis. 3. Identify severity classifications and pharmacological management options. EMS I 80116 Immunodeficiencies Excluded Populations
Excluded Populations Underlying respiratory illnesses recurrent wheezing chronic neonatal lung disease neuromuscular disease Excluded Populations Underlying respiratory illnesses cystic fibrosis hemodynamically significant congenital heart disease
Presentation Goals Define the incidence and etiology of bronchiolitis. Discuss the pathophysiology of bronchiolitis. Describe the clinical manifestations and diagnosis of bronchiolitis. Differentiate between management options utilized in bronchiolitis. Patient Case Upon arrival to the patient s home you smell cigarette smoke and find Aaron, a 4-month-old boy, in severe distress. His mother informs the crew that last night he developed a fever and today has not been drinking as well with only 1 diaper. He has had rhinorrhea and tachypnea for the past 4 days.
Patient Case He has been coughing (taking medication for the last day) and his belly seems to suck in when he breathes. He does not have any sick contacts. Mom indicates he was premature when he was born and required oxygen for two weeks after birth. His immunizations are up to date, but he has not received his Synagis this month. Respiratory Illnesses Respiratory illnesses are common in pediatric patients Children have an increase in exposure due to contacts and setting Etiology includes bacterial or viral infections
Respiratory Illnesses Two common pediatric outpatient and inpatient viral illnesses croup bronchiolitis Background: Bronchiolitis Self-limiting acute inflammatory viral disease of the lower respiratory tract with an obstruction of small airways Highly contagious viral infection - spread by direct contact with respiratory secretions, reinfection can occur Usually managed in the home setting
Epidemiology Seasonal illness November - April: peak in January or February Slightly more common in boys Epidemiology Children <2 years (usually <1 year); smaller airways most common lower respiratory tract infection number 1 cause of hospitalizations more severe in infants, peaks at 3-6 months of age Almost all children will develop bronchiolitis by 2 years
Pathophysiology Acute inflammatory injury of the bronchioles with subsequent edema Pathophysiology Infects the respiratory epithelial cells of the small airways with necrosis, inflammation, edema, and increased mucous secretion - obstruction of the small airways occurs with subsequent hyperinflation, atelectasis, and wheezing Regrowth of epithelial cell layer occurs 2 weeks after infection with complete recovery in 8 weeks
Etiology - Viral Most common - respiratory syncytial virus (RSV) Etiology - Viral Others - viral parainfluenza 1, 2, or 3 influenza A or B human metapneumovirus rhinovirus adenoviruses
Risk Factors More severe course: prematurity, low birth weight, underlying cardiopulmonary disease, immunodeficiency, or <3 months Parental smoking Lower socioeconomic group Risk Factors Diseases chronic lung disease: bronchopulmonary dysplasia congenital or acquired neurologic disease congenital heart disease
Clinical Manifestations Incubation period is 2-5 days, viral shedding up to 3 weeks after symptoms Clinical Manifestations Predominately affects young infants, subtle progression of symptoms with some lasting up to 4 weeks first days, 3-6 days increase in fussiness (irritability) decreased feeding
Clinical Manifestations Predominately affects young infants, subtle progression of symptoms with some lasting up to 4 weeks first days, 3-6 days low-grade fever, <101.5 congestion/rhinitis Clinical Manifestations Predominately affects young infants, subtle progression of symptoms with some lasting up to 4 weeks increased work of breathing overall; rapid shallow respirations - tachypnea, wheezing, rales, use of accessory muscles, or nasal flaring
Clinical Manifestations Disease progresses from upper to the lower respiratory tract - cough (persistent), dyspnea, expiratory wheezing, inspiratory crackles Clinical Manifestations Severe symptoms of respiratory distress: varies due to obstruction severity poor feeding (<50% of the usual day intake in the last 24 hours) apnea, due to hypoxia respiratory rate >70 tachypnea
Clinical Manifestations Severe symptoms of respiratory distress: varies due to obstruction severity nasal flaring grunting lethargy drowsy Clinical Manifestations Severe symptoms of respiratory distress: varies due to obstruction severity confused diminished breath sounds inspiratory and expiratory wheezing
Clinical Manifestations Severe symptoms of respiratory distress: varies due to obstruction severity head bobbing (infant) retractions (subcostal, intercostal, substernal, supraclavicular) cyanosis Diagnosis Clinical diagnosis presentation respiratory - examples: tachypnea, retractions, nasal flaring, wheezing, shortness of breath, hypoxia
Diagnosis Clinical diagnosis presentation cough fever tachycardia Diagnosis Clinical diagnosis prior respiratory illness or contact exposure patient's age seasonal occurrence
Diagnosis Laboratory - respiratory direct viral panel, not recommended Chest radiograph not routine Patient Case Vital signs - weight, 7 kg; temperature, 101 F; pulse, 152 beats per minute; respiratory rate, 54 breaths per minute; blood pressure, 74/46 mm Hg; oxygen, 88% on room air
Patient Case Physical exam - tachypneic with respiratory distress, rhinorrhea, dry mucous membranes, wheezing, moderate subcostal and intercostal retractions, nasal flaring Treatments Nonpharmacological supplemental oxygen if oxyhemoglobin saturation <90% no chest physiotherapy hydration - nasogastric or intravenous suctioning
Treatments Pharmacologic bronchodilators: albuterol, epinephrine antibiotics hypertonic saline corticosteroids cough and cold products Albuterol Not recommended Beta2 receptor agonist; causes bronchodilation by decreasing muscle tone adverse drug reaction (ADR): tachycardia, severe - induced arrhythmias Risk outweighs benefit in routine situations
Racemic Epinephrine Not recommended Stimulates alpha-adrenergic, beta1-adrenergic, and beta2-adrenergic receptor; causes bronchodilation by decreasing muscle tone ADR: tachycardia Transient effects require a long-term monitored setting Hypertonic Saline Not routinely recommended, does not change length of stay Recommended only in the hospitalized setting in mild to moderate severity Concerns of bronchospasm if patient has underlying undiagnosed asthma
Hypertonic Saline Aids in mucociliary clearance Dose: 3% hypertonic saline inhaled ADR: possible bronchospasm in older children Corticosteroids Not recommended, does not change length of stay - may prolong viral shedding Blocks release of inflammatory mediators Drug: prednisone, dexamethasone, budesonide ADR: increases in glucose with systemic formulations, potential gastrointestinal upset
Antibiotics Not routinely recommended - side effects, cost, and resistance Patients that may benefit include those with an underlying secondary bacterial infection or toxic appearance Therapy is dependent on the type of infection and severity of patient Over-the-counter (OTC) and/or Prescription (RX) Antihistamines, cough suppressants, decongestants NOT recommended - evidence does not support use in pediatric patients
Over-the-counter (OTC) and/or Prescription (RX) Antipyretics are the only OTC products recommended acetaminophen ibuprofen, not for <6 months Prevention = Reduction Prevention is key! handwashing - contact isolation, important for healthcare professionals breastfeeding eliminate sick contacts and setting exposure eliminate tobacco exposure palivizumab in those at high risk, if meet criteria
Palivizumab (Synagis ) Monoclonal antibody Prophylaxis - patients that may benefit include those with a high risk of RSV, must meet qualifications Neutralizes and inhibits fusion activity of RSV Palivizumab (Synagis ) Dose: administered intramuscularly once a month for 5 months, expensive ~ $5,000 for course ADR: minimal, low hypersensitivity concerns
Prevention Palivizumab: High Risk Population Start of RSV season patient age <29weeks, 5 doses patient 12 months - hemodynamically significant heart disease or chronic lung disease of prematurity (<32 weeks + 21% oxygen for 1st 28 days) Prevention Palivizumab: High Risk Population Start of RSV season patient 12-24 months - chronic lung disease + oxygen therapy, chronic corticosteroids, or diuretic therapy within six months of RSV season
Prevention Palivizumab: High Risk Population Insufficient data - Down syndrome, cystic fibrosis, pulmonary abnormality, neuromuscular disease, or immune compromise Patient Education Prevention RSV prophylaxis for high-risk patients avoid RSV exposure handwashing Seek medical attention - respiratory distress
Management Emergency Setting Mainstay - supportive therapy, younger patients or those with risk factors are more likely to have a severe presentation Monitor patient for signs and symptoms and maintain respiratory status, sometimes confused with asthma, rule out if possible Management Emergency Setting Treatment nonpharmacological pharmacological
Management Emergency Setting Nonpharmacological most important - supplemental oxygen with nasal canula or facemask; maintain >90% hydration; bolus and/or replacement fluids nasal suctioning with saline for nasal blockage not recommended: chest physiotherapy Management Emergency Setting Pharmacological - generally no recommendations BUT doses of hypertonic saline could be administered in the hospital setting
Patient Case Treatment oxygen supplementation for oxygen at 88% fluid bolus due to dry mucous membranes and decrease in diapers Patient Case - Revisit Upon arrival to the patient s home you smell cigarette smoke and find Aaron, a 4-month-old boy in severe distress. His mother informs the crew that last night he developed a fever and today has not been drinking as well with only 1 diaper. He has had rhinorrhea and tachypnea for the past 4 days.
Patient Case - Revisit He has been coughing (taking medication for the last day) and his belly seems to suck in when he breathes. He does not have any sick contacts. Mom indicates he was premature when he was born and required oxygen for two weeks after birth. His immunizations are up to date, but he has not received his Synagis this month. Summary Respiratory viral illness that is easily transmittable with secretions Gradual progression of symptoms with resolution generally within one week, some symptoms continue for ~ 1 month
Summary Supportive treatment is priority, oxygenation Pharmacological treatments are not recommended References Hasegawa K, Tsugawa Y, Brown DF, Mansbach JM, Camargo CA. Trends in bronchiolitis hospitalizations in the United States, 2000-2009. Pediatrics 2013; 132: 28-36.
References Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S, Hernandez-Cancio S. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 2014; 134: e1474-e1502 Pediatric Bronchiolitis If you have any questions about the program you have just watched, you may call us at: (800) 424-4888 or fax (806) 743-2233. Direct your inquiries to Customer Service. Be sure to include the program number, title, and speaker. EMS I 80116
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