Helmi M Lubis, Dr, Sp.

A(K)
Ridwan M Daulay, Dr, SpA(K)
Wisman Dr, Sp.A

Bronchiolitis
Bronchioles inflammation
Clinical syndromes:

fast breathing, breathing difficulties,

retractions, wheezing, poor feeding, ,
cough, irritability, (very young) apnoe.
Predominantly < 2 years of age
(2 6 months)
Difficult to differentiate with pneumonia

 Pathology

Bronchiolitis

Necrosis of the resp. epithelium

Destruction of ciliated epithelial cells
Peribronchial infiltration with lymphocites &

neutrophils
Sub mucosal edematous
No destruction of collagen, muscle, or elastic
tissue

Pathophysiology
Edema + accumulation of mucous & cellular
debris narrow of peripheral airway partially /
totally occluded over distention / atelectasis

Bronchiolitis

Etiology
Predominantly RSV (Respiratory Syncytial

Virus)
Other viruses : rhinovirus, adenovirus,
influenza virus, parainfluenza virus, entero
virus, etc.

Severity

Prematurity
OR 1.84
Underlying medical condition
OR 2.84
Group A RSV strain
OR 3.26
Age < 3 mo
OR 4.39

Bronchiolitis

Diagnosis
Etiological diagnosis

Microbiologic examination

Clinical diagnosis
Signs and symptoms
Age
Resource of infection epidemic of RSV

Laboratory finding
Radiological examination

Bronchiolitis
Clinical Manifestations : mild rhinorrhea,

cough, cold, low-grade fever

1-2 d fast breathing, chest
retraction, wheezing, irritable, vomitus,
poor intake
Physical Examinations

tachypnea, tachycardia, retraction,

prolonged expiration, wheezing,
fever,pharyngitis, conjunctivitis, otitis
media, dehydration

Bronchiolitis

Radiologic examination
diffuse hyperinflation
flat diaphragm,
Intercostal space >
retrosternal space >

peribronchial infiltrates / thickening

patchy atelectasis segmental collapse
pleural effusion (rare)
Laboratory finding
Respiratory rate : Arterial saturation

pCO2

Bronchiolitis

Laboratory finding
Microbiologic examination
WBC : 5000 24.000 cells/mm3,

predominantly PMN & bands

Blood Gas Analysis
Arterial saturation
pCO2
Mild respiratory alkalosis
Metabolic acidosis
Acute respiratory acidosis

Differential Diagnosis

Asthma
Pneumonia
Acute Bronchitis
Congestive Heart Failure
Pulmonary Edema
Obstruction in the lower respiratory

tract

Bronchiolitis
Management
Mild treated at home
Moderate / severe disease hospitalization

support :

oxygen
intra venous fluid drip
(antibiotics)
detect & treat possible complication
prevent the spread of inf.
Controversial :
bronchodilator
corticosteroid
antiviral
antibiotic

2 Agonist
Flores and Horwitz, 1997
Meta-analysis of RCT inhaled 2 Agonist
Sample : 3 inpatient & 5 outpatient
studies
Treatment : nebulized albuterol
Outcome : clinical score, satO2, LOS
Result : unavailable evidence of 2
Agonist efficacy

Corticosteroid
Garrison et al, 2000

Databases (Medline, Embase,

Cochrane)
Treatment : Prednison equivalent 0,66,3 mg/kg. Total : 3,0 18,9 mg/kg
Outcome : LOS, duration of
symptoms (DOS), clinical scores
Result : LOS and DOS
clinical score

Corticosteroid
Clinical score :
Wheezing
SatO2
Accessory muscle use
RR
Conclusion :
Benefits depend on severity and
initiation of treatment

Bronchiolitis
Natural history & complications
Regeneration of bronchiolar epithelium

after 3 or 4 d
Cilia after 3 or 4 d
Improved clinical findings : in 3-4 days
Improved radiological features: in 9 days

Persistent respiratory obstruction :

20%
Respiratory failure : 25 %
Lung collaps (rare)

Prognosis
23% infant asthma at 3 years,

Control 1% asthma
OR : 28; 90% CI 4-1235
(Garrison et al. 2000 after Sigurs et
al. 1995)

Bronchiolitis

Correlation with Asthma

30 % - 50 % becomes asthmatic patients
Similarity in :
- pathogenic

mechanisms
- pathologic disorders