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Acute lower respiratory tract infection causing obstruction of the small to medium conducting airways of the lung
GENERAL PREVENTION
The major means of preventing bronchiolitis is strict observance of infection control, with frequent handwashing,
avoidance of known ill contacts and crowded places, and limiting exposure to daycare and secondhand smoke.
EPIDEMIOLOGY
In the US, occurs from late fall through the winter and early spring. The Respiratory Syncytial Virus
(RSV) epidemic season begins earlier in the southeastern US, and in some areas (e.g. Florida,
Hawaii) can occur throughout the year. Parainfluenza 3 occurs throughout the year, as does
adenovirus. Influenza virus epidemics usually begin in late fall, peak in January/February, and wane
by April. Human metapneumovirus peaks slightly later in the year (March) than does RSV (January).
RSV infects most children within the 1st 2 years of life; 57% of those hospitalized are younger than 6
months. The infection rate is 68.8/100 in infants <1 year of age; by 2 years of age, 97% of children
have experienced an RSV infection.
RSV reinfection occurs in 5075% of children followed, and reinfection within the same RSV season is
possible.
Approximately 1/2 of all children experience an infection with parainfluenza 3 before 1 year of age.
RSV infection is the leading cause of hospitalization in infants <1 year old and causes >120,000
hospitalizations per year in children <5 years of age in the US. Hospitalization occurs in 2.8 of every
1,000 children with a parainfluenza lower respiratory tract infection.
Mortality associated with primary RSV infection in otherwise healthy children has been estimated to
be 3.1 deaths per 100,000 person-years in infants <1 year of age, and is ~13% among children with
underlying conditions. It is the most common viral cause of death in infants <1 year old.
Overproduction of IL-4
PATHOPHYSIOLOGY
RSV is the most common cause of this illness (5090% of those infants hospitalized).
Influenza virus and adenovirus are spread by small droplets that remain airborne and which are then
inhaled.
Viral shedding: Up to 21 days after infection, but can extend to several weeks or months in
immunocompromised patients
Virus proliferates in the nasal epithelium, resulting in coryza with profuse rhinorrhea.
Infected secretions are aspirated into the lower respiratory tract. From there, virus infects bronchiolar
epithelial cells of airways 75300 microns in diameter.
Infection causes necrosis and sloughing of cells into the airway lumen. There is goblet cell
proliferation and mucus hypersecretion. The airway lumen becomes filled with debris consisting of
dead cells and mucus resulting in plugging, which causes partial or complete airway obstruction,
increased airways resistance, hypoxemia, and decreased lung compliance.
Polymorphonuclear leukocytes are the predominant inflammatory cell type recovered from
bronchoalveolar lavage (BAL) fluid of infants with documented RSV bronchiolitis; a subset may also
have an elevated number of eosinophils in BAL fluid.
Mononuclear cells (lymphocytes and macrophages) infiltrate the peribronchial tissue, leading to
airway wall and interstitial edema.
RSV-induced changes in the bronchiolar epithelium can last beyond the acute infection. Regeneration
of bronchiolar epithelium takes weeks to months and lags behind clinical signs of recovery.
Diagnosis
History
Coughing? Initially hoarse cough for 35 days; progresses to deep wet cough of increased frequency
Low-grade fever? Characteristic of disease; not a reliable marker of severity of disease, but
contributes to increased insensible fluid loss
Apnea? Can be sole presenting sign in younger infants; if respiratory distress is present, suggests
impending respiratory failure
Physical Exam
General appearance:
1. Interactive versus ill-appearing
2. Paroxysmal cough (most common sign), not associated with a whoop
3. Poor oral intake
HEENT exam
1. Nasal flaring
2. Nasal congestion with copious secretions
Pulmonary examination
1. Pattern of breathing: Apnea or periodic breathing
Other findings:
1. Signs of dehydration
2. Low-grade fever
3. Tachycardia
4. Bradycardia associated with apnea
5. Possible cyanosis of nail beds and oral mucosa
6. Liver and spleen typically caudally displaced by hyperinflated lungs
TESTS
LABORATORY
Serum electrolytes: Sickest patients may have Syndrome of Inappropriate Anti-diuretic Hormone
release and hyponatremia; may also see abnormalities in those infants with significant dehydration;
not useful in the majority of infants with milder disease
RSV serology (acute and convalescent serum samples): No practical application for clinical use
Nasopharyngeal aspirate
Nasopharyngeal wash
Nasal swab
Tracheal aspirate
BAL fluid
Rapid tests:
1. Immunofluorescence assay (direct or indirect):
Results in 45 minutes
6090% sensitivity
7095% specificity
93.5100% sensitivity
63.9100% specificity
Viral culture:
1. Culture of nasopharynx
2. Considered gold standard. May take up to 14 days for results
3. Sensitivity and specificity highly dependent on quality of sample, handling of specimen, and
time to delivery to virology laboratory
IMAGING
Chest radiography findings include:
Peribronchial thickening
DIFFERENTIAL DIAGNOSIS
Asthma
CHF
Cystic fibrosis
Treatment
GENERAL MEASURES
OTHER
Supplemental oxygen:
1. Given to any patient with hypoxemia
2. Preferably warmed and humidified by nasal cannula, head box, or tent
Some (but not all) infants with bronchiolitis will improve clinically with
bronchodilator administration. A trial of an aerosolized -adrenergic agent with
critical assessment to see if there is any relief of symptoms is reasonable.
Infants with a prior history of wheezing or familial history of asthma or atopy are
more likely to respond to bronchodilators.
2. Nebulized epinephrine:
Both racemic epinephrine (0.1 mL/kg of 2.25% solution) and L-epinephrine have
been studied separately and showed beneficial results compared with agonists.
3. Anticholinergic agents: Ipratropium bromide has not been shown to be effective in the
treatment of bronchiolitis.
4. Corticosteroids:
5. Leukotriene modifiers:
Infants who develop wheezing with RSV infection have high concentrations of
cysteinyl leukotrienes and histamine in respiratory secretions.
No studies have evaluated the use of leukotriene modifiers during the acute
phase of bronchiolitis.
6. Mucolytics:
Recombinant human DNase and N-acetyl cysteine are not effective in shortening
the duration of symptoms in infants with bronchiolitis.
7. Surfactant:
The gas does not alter the course of the underlying illness, but because helium is
less dense than nitrogen, resistance in areas of turbulent flow is decreased.
This in turn can decrease breathing effort, respiratory rate, and heart rate.
8. Heliox:
9. Antibiotics:
Other than otitis media, the incidence of concurrent serious bacterial infection
(pneumonia, meningitis, sepsis) is <2% in healthy infants with no underlying
disease who have RSV bronchiolitis.
OTHER
Presence of apnea, tachypnea (respiratory rate >70/min), retractions, poor feeding, pallor, lethargy, or
agitation (signs of impending respiratory failure)
Follow-up Recommendations
EXPECTED COURSE/PROGNOSIS
Premature infants of 3235 weeks gestation hospitalized for bronchiolitis have been shown to have
an increased number of subsequent hospitalizations for respiratory problems, a greater number of
outpatient visits, and an increased risk of sudden death compared with those who were not
hospitalized for bronchiolitis.
Mortality associated with primary RSV infection in otherwise healthy infants is 0.0050.02%.
Morbidity and mortality are considerable in patients with an underlying chronic disease.
Up to 50% of infants with bronchiolitis develop subsequent episodes of recurrent wheezing until 11
years of age.
POSSIBLE COMPLICATIONS
Common complications:
1. Otitis media
2. Pneumonia
3. Aspiration syndrome
4. Respiratory failure requiring mechanical ventilation
Sepsislike syndrome
PATIENT MONITORING
Most infants with no underlying disease improve within 35 days. In some, nasal congestion and
cough may continue for 13 weeks. Premature infants and those with underlying cardiopulmonary
disease typically experience a protracted illness.
Those who need mechanical ventilation may have difficulties with extubation due to excessive
secretions and atelectasis.
As many as 50% of infants will have recurrent wheezing through the 1st decade of life.
OTHER
Fatigue may occur in infants who have prolonged and extensive disease.
CLINICAL:
Be aware of apnea.
A: RSV bronchiolitis is a common, seasonal, lower respiratory tract infection that is easily
transmissible.
A: Children can become reinfected with RSV bronchiolitis, and infection can occur more than once
during the same respiratory season.
A: RSV-positive patients need to be isolated with other RSV-positive patients and from uninfected
patients. Patients receiving ribavirin should be kept in isolation.
A: Recurrent wheezing has been described in up to 50% of infants with RSV bronchiolitis. However,
most data are retrospective and observational. Whether RSV per se can contribute to the
development of asthma and allergic sensitization remains unclear.