BRONCHIOLITIS !!! WHY ?
DR.FATMA AL-ZAHRANI
DR.BASMA AL-JABRI
TEAM C
BRONCHIOLITIS !!!WHY ? Bronchiolitis is the most common lower
respiratory tract infection in infants. Bronchiolitis associated hospitalizations have
been increased considerably since 1980. The diagnosis of bronchiolitis is generally
clinical,wheather diagnostic tests change the clinical course, management, or the prognosis of the disease is unclear.
BRONCHIOLITIS!!!WHY? Different treatment modalities have been in
practice for some years. some of these are specific to the causative agent, and the other are symptomatic.
The relative severity of the disease among vulnerable subpopulation suggests that some infants & children may benefit from prophylactic therapy..
BRONCHIOLITIS!!!WHY? systemic review of bronchiolitis management
in infants & children was presented by University of North Carolina Evidence-based practice center in 2006 …
OBJECTIVES
To clarify the existing knowledge base for bronchiolitis managements.
To offer directions for future research:
effectiveness of diagnostic tools,
pharmaceutical therapies
prophylactic therapy
cost effectiveness
SEARCH STRATIGIES Literatures review in 3 database:
1. MEDLINE
2. Health Economic Evaluation Data Base HEEDB
3. Cochrane Collaboration Library
SELECTIONCRITERIA
Diagnostic tools for bronchiolitis:• Prospective cohort studies.• Randomized control trials.
Intervention (therapy + prophylaxis):• Randomized control trials.
Cost effectiveness:• Economic analysis.
INCLUSION/EXCLUSIONCRITERIA
A clinically relevant outcomes & able to be abstracted.
Minimum sample size of 10 (small case series & single case report were excluded).
Studied in languages other than English were not reviewed.
744 abstracts were identified for possible inclusion, upon full review, total of 83 articles were retained.
Key question 1: effectiveness of diagnostic tools for diagnosing bronchiolitis 16 articles were reviewed Bronchilitis is clinical diagnosis, based on
typical history & findings on physical examination. characterised by initial signs & symptoms of URTI followed by cough, tachypnea, wheezing,fever,hypoxia, retraction.
No gold standard diagnostic test confirms the diagnosis of bronchilitis.
Key question 1:effectiveness of diagnostic tools for diagnosing bronchiolitisThe utility of complete blood count in bronchiolitis: 10 studies did CBC in all patients. Used only to demonstrate that treatment & control
groups were similar at baseline None of the studies demonstrated that CBC were
useful in either diagnosing bronchiolitis or guiding therapy.
correlate WBC with category of lung disease defined radiologically Saijo et al.
Key question 1: effectiveness of diagnostic tools of diagnosing bronchiolitisUtility of chest radiographs in bronchiolitis:
14 studies performed CXR on all patients. Large numbers of infants with bronchiolitis have
abnormalities on CXR. Shaw et al : patients with atelectasis were 2.7
time more likely to have severe disease than those without this X-ray finding.
Dawson et al: no correlation between X-ray finding & baseline disease severity.
Key question 1:effectiveness of diagnostic tools for diagnosing broncholitis These data suggest that:
in mild disease, CXR offer no information that is likely to affect the treatment, & that therefore should not be routinely performed.
Roosevelt et al: suggest such X-ray may lead to inappropriate use of antibiotics.
Key question 1: effectiveness of diagnostic tools for diagnosing bronchilitis Comparison of virology tests: 5 studies examined the accuracy of various
virologic tests for RSV & other causative agents:
1. Numerous tests for RSV exist.
2. Their tests characteristics vary,
3. Overall sensitivity of rapid antigen detection test to be in 80%- 90% range.
Identification of bronchiolitis etiology: 42 studies were performed RSVresting on all
subjects. 12 studies tested the patients for other viral
etiologies . RSV testing of patients with bronchiolitis is
justified in several situations:
1. Isolation of RSV as the etiology of fever in infants less than 3 months may support the clinician’s decision to add additional testing in the traditional rule out sepsis work up.
2. RSV testing may helpful in clinical situations where the diagnosis of bronchiolitis is unclear.
3. Is an important tool for surveillance of LRTI in infants.
4. Will be essential in research sitting, where RSV specific therapies are being evaluated for effectiveness…
Key question 1: effectiveness of diagnostic tools for diagnosing bronchiolitis Comparisons of virological tests:
Ahluwalia et al :
Compared two methods of specimens collection & demonstrated that viral culture, EIA, IFA all yield positive results more often when performed on nasopharyngeal aspirate than when performed on nasopharyngeal swabs.
Key question 2: effectiveness of pharmaceutical therapies for bronchiolitis treatment Nebulised epinephrine vs. nebulised placebo: Doubled blinded , placebo controlled, RCT 29 infants & children without co morbidities. Outcomes: Kristjansson et al. Statistically significant improvement in 02
saturation & in the clinical scores at 15 min.interval till one hour …
Nebulised epinephrine vs. nebulised bronchodilators:
4 studies were reviewed. 33- 100 subjects. outcomes: duration of hospitalization, changes in
clinical scores Menon et al:
Statistically significant improvement in 02 saturation 60 min after treatment in epinephrine group than salbutamol group
Nebulised bronchodilators vs. oral bronchodilators, nebulised ipratropium bromide:
11 studies. 158 subjects. Ages: up to 24 months Outcomes : hospitalization rate
clinical scores
All statistically significant outcomes were in the 1st hour after the treatment was given.
Can et al: respiratory distress score was significantly
better for neb. Salbutamol compared to neb. saline.
Klassen et al: 30 min. & 60 min Schwein et al: neb. Albuterol vs. saline
placebo.
Nebulised bronchodilators + nebulised ipratropium bromide vs. bronchodilators or ipratropium bromide alone:
4 studies Outcomes Wang et al: statistically significant
improvement of 02 saturation in salbutamol+ ipratropium bromide & decrease in hospital stay
Oral corticosteroid vs. placebo with or without bronchodilators:
5 studies. 51-72 subjects. 2 yrs of age.( van woensel et al admitted
infants with severe disease & comorbidities: ventilators, BPD
outcome
Goebel et al: statistically significant difference in clinical scores between day 0, 2 in the group who received predinsolone+ albuterol more than placebo or albuterol groups.
Schuh et al: significant lower rate of hospitalization 19% vs. 44% & improved clinical scores at 240 min post treatment & less need for steroid after discharge in dexamethasone + neb. Albuterol compared to placebo, albuterol groups
Van woensel et al:Significantly greater mean decline in
symptoms score among 39 non ventilated patients
Shorter duration of hospitalization among 14 ventilated patients
5 yrs follow up didn’t demonstrated any significant differences in long term outcomes such as wheezing in 1st yr of life or persistent or late onset wheezing
Key question 3: role of prophylaxis in prevention of bronchiolitis Palivizumab or RSV IG IV on monthly basis is
effective prophylaxis in high risk group Palivizumab has supplanted RSV IG IV
because the ease of administration Studies of immunization with purified F
protein vaccines didn’t demonstrate benefits. Only one study Piedra et al did seem to
obtain benefits from the vaccine for older children with cystic fibrosis.
Conclusion recommendations
Diagnosis: No specific literature were found regarding
the diagnosis of bronchiolitis The disease is clinically diagnosed Encourage the
Conclusionrecommendations
Treatments: There was no specific treatment with strong &
convincing evidence of effectiveness. Several interventions that show some
potential for being efficacious & should be subjected to strongly designed, adequately sized trials: neb. Epinephrine, neb. salbutamol+ ipratropium bromide, neb. Ipratropium bromide, oral, inhaled & parentral steroids
Conclusionrecommendations
2 interventions applicable for most severely ill children: inhaled helium 02 & surfactant for ventilated patients
No single agent or antimicrobial drug is the most effective in improving the symptoms of bronchiolitis
Most of outcomes studied in short term,
Thank
you