M. Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A. V., Ph. D. Acute bronchitis in children icon

M. Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A. V., Ph. D. Acute bronchitis in children

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НазваM. Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A. V., Ph. D. Acute bronchitis in children
Дата19.09.2012
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M.Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A.V., Ph.D. ACUTE BRONCHITIS IN CHILDREN

  • Associate professor Masyuta D.I.


  • Respiratory problems are leading causes of death among children throughout the world. More than 4 million deaths each year in developing countries are due to acute respiratory tract infections. Respiratory physiology has been a challenging topic for most medical students.



Bronchitis is an inflammatory disease of bronchi of various etiology

  • Bronchitis is an inflammatory disease of bronchi of various etiology

    • infectious (mostly viral),
    • allergic,
    • physical and chemical (so called irritative bronchitis).
  • It may be

    • acute or
    • chronic.


There are the following main forms of bronchitis:

  • There are the following main forms of bronchitis:

    • acute simple bronchitis,
    • acute obstructive bronchitis,
    • bronchiolitis,
    • recurring bronchitis,
    • chronic bronchitis (primary and secondary).


Asthmatic bronchitis is a form of asthma that is often confused with acute bronchitis. With a variety of upper respiratory tract infections, some children have bronchial spasm and exudation similar to signs in older children with asthma.

  • Asthmatic bronchitis is a form of asthma that is often confused with acute bronchitis. With a variety of upper respiratory tract infections, some children have bronchial spasm and exudation similar to signs in older children with asthma.



Acute tracheobronchitis

  • It is commonly associated with an upper respiratory tract infection such as nasopharyngitis but is also associated with influenza, pertussis, measles, diphtheria, and scarlet fever.

  • An acute, primary, undifferentiated tracheobronchitis also occurs, most commonly in older children and adolescents.

  • It is likely that, except for the bacterial diseases mentioned, acute tracheobronchitis is of viral origin. Pneumococci, staphylococci, Haemophilus influenzae, and various hemolytic streptococci may be isolated from the sputum, but their presence does not imply a bacterial cause, and antibiotic therapy does not appreciably alter the course of the illness.



^ CLINICAL MANIFESTATIONS

  • Acute bronchitis is usually preceded by a viral upper respiratory infection. Secondary bacterial infection with Streptococcus pneumoniae, Moraxella catarrhalis, or H. influenzae may occur.

  • Typically, the child presents a frequent, dry, hacking, unproductive cough of relatively gradual onset, beginning 3–4 days after the appearance of rhinitis.

  • Symptoms of respiratory insufficiency are absent.

  • Low substernal discomfort or burning anterior chest pain is often present and may be aggravated by coughing.



As the illness progresses, the patient may be bothered by whistling sounds during respiration (probably rhonchi), soreness of the chest, and occasionally by shortness of breath.

  • As the illness progresses, the patient may be bothered by whistling sounds during respiration (probably rhonchi), soreness of the chest, and occasionally by shortness of breath.

  • Coughing paroxysms or gagging on secretions is associated occasionally with vomiting.

  • Within several days, the cough becomes productive, and the sputum changes from clear to purulent. Usually within 5–10 days, the mucus thins, and the cough gradually disappears.

  • The considerable malaise often associated with the illness may continue for 1 wk or more after acute symptoms have subsided.



Physical findings

  • They vary with the age of the patient and the stage of the disease.

  • Initially, the child is usually afebrile or has low-grade fever, and there are signs of nasopharyngitis, conjunctival infection, and rhinitis.

  • Later, auscultation reveals

    • roughening of breath sounds
    • coarse and fine moist bubbling rales which are heard on both sides of lungs, and
    • rhonchi which may be high pitched, resembling the wheezing of asthma.


The chest roentgenogram shows nothing significant except for the increased broncial markings in some of cases only.

  • The chest roentgenogram shows nothing significant except for the increased broncial markings in some of cases only.

  • Laboratory tests show

    • normal leucocyte count or leucopenia,
    • Lymphocytosis,
    • ESR is not increased.


Obstructive bronchitis

  • It is a variant of acute bronchitis which proceeds with respiratory tract obstruction because of

    • bronchospasm,
    • mucous edema, and
    • hypersecretion.
  • Sign of respiratory tract obstruction:

    • persistant "spastic" cough,
    • expiratory dyspnea,
    • oral crepitations, dry and
    • various bubbling rales.


TREATMENT

  • There is no specific therapy; most patients recover uneventfully without any treatment.

  • In small infants, pulmonary drainage is facilitated by frequent shifts in position.

  • Older children are more comfortable in high humidity, but there is no evidence that this shortens the duration of illness.



TREATMENT

  • Antihistamines, which dry secretions, should not be used.

  • Expectorants may be helpful.

  • Antibiotics do not shorten the duration of the viral illness or decrease the incidence of bacterial complications, although the fact that patients with recurrent episodes may occasionally improve with such treatment suggests that some secondary bacterial infection is present.



^ RECURRING BRONCHITIS

  • respiratory tract anomalies,

  • foreign bodies,

  • bronchiectasis,

  • immune deficiency,

  • tuberculosis,



BRONCHIOLITIS

  • Acute bronchiolitis, a common disease of the lower respiratory tract of infants, results from inflammatory obstruction of the small airways (the bronchioles).

  • It occurs during the first 2 yr of life, with a peak incidence at approximately 6 mo of age.

  • The incidence is highest during the winter and early spring.



ETIOLOGY

  • Acute bronchiolitis is predominantly a viral illness.

    • The respiratory syncytial virus (RSV) is the causative agent in more than 50% of cases.
    • Parainfluenza 3 virus, mycoplasma, some adenoviruses, and occasionally other viruses produce most of the remaining cases.
    • Adenovirus may be associated with long-term complications, including bronchiolitis obliterans.
  • There is no firm evidence that bacteria cause bronchiolitis.



EPIDEMIOLOGY

  • Bronchiolitis occurs most commonly in male infants between 3 and 6 mo of age who have not been breast-fed and who live in crowded conditions.

  • The source of the viral infection is usually a family member with minor respiratory illness.

  • Older children and adults tolerate bronchiolar edema better than infants and do not develop the clinical picture of bronchiolitis even when the smaller airways of their respiratory tract are infected by a virus.



EPIDEMIOLOGY

  • Infants whose mothers smoke cigarettes are more likely to develop bronchiolitis than infants of nonsmoking mothers.

  • Despite the known risks of respiratory infections from child care, infants who stay home with mothers who are heavy smokers are more likely to develop bronchiolitis than infants who attend day care centers.



PATHOPHYSIOLOGY

  • Acute bronchiolitis is characterized

  • by bronchiolar obstruction due to

    • edema and
    • accumulation of mucus and cellular debris and
  • by invasion of the smaller bronchial radicles by virus.





PATHOPHYSIOLOGY

  • Because resistance to airflow in a tube is inversely related to the fourth power of the radius, even minor thickening of the bronchiolar wall in infants may profoundly affect airflow.

  • Resistance in the small air passages is increased during the inspiratory and expiratory phases, but because the radius of an airway is smaller during expiration, the resultant ball valve respiratory obstruction leads to early air trapping and overinflation.

  • Atelectasis may occur when an obstruction becomes complete and trapped air is absorbed.



PATHOPHYSIOLOGY

  • The pathologic process impairs the normal

  • exchange of gases in the lung.

  • Ventilation perfusion mismatch results in hypoxemia, which occurs early in the course.

  • Carbon dioxide retention (i.e., hypercapnia) does not usually occur except in severely affected patients.

  • The higher the respiratory rate, the lower is the arterial oxygen tension. Hypercapnia usually does not occur until respirations exceed 60/min; it then increases in proportion to the tachypnea.







^ CLINICAL MANIFESTATIONS

  • Most affected infants have a history of exposure to older children or adults with minor respiratory diseases within the week preceding the onset of illness.

  • The infant first has a mild upper respiratory tract infection with serous nasal discharge and sneezing.

  • These symptoms usually last several days and may be accompanied by diminished appetite and fever of 38.5-39C (101–102F), although the temperature may range from subnormal to markedly elevated.



^ CLINICAL MANIFESTATIONS

  • The gradual development of respiratory distress is characterized by paroxysmal wheezy cough, dyspnea (rapid shallow breathing), and irritability.

  • There is expiratory wheesing or grunting.

  • Breast- or bottle-feeding may be particularly difficult, because the rapid respiratory rate may not permit time for sucking and swallowing.

  • In mild cases, symptoms disappear in 1–3 days. In the more severely affected patients, symptoms may develop within several hours, and the course is protracted.

  • Other systemic manifestations, such as vomiting and diarrhea, are usually absent.







BRONCHIOLITIS

  • The characteristic findings on examination are:

  • sharp, dry cough

  • tachypnoea

  • subcostal and intercostal recession

  • hyperinflation of the chest

    • sternum prominent
    • liver displaced downwards
  • fine end-inspiratory crackles

  • high-pitched wheezes - expiratory > inspiratory

  • tachycardia

  • cyanosis or pallor.









^ CLINICAL MANIFESTATIONS

  • An examination reveals a tachypneic infant, often in extreme distress. Respirations range from 60–80/min.

  • Severe air hunger and cyanosis may occur.

  • The alae nasi flare, and use of the accessory muscles of respiration results in intercostal and subcostal retractions, which are shallow because of the persistent distention of the lungs by the trapped air.

  • The depression of the liver and spleen by the overinflated lungs may result in their being palpable below the costal margin.



^ CLINICAL MANIFESTATIONS

  • Percussion note is hyper-resonant. This is because of emphysema.

  • Widespread fine crackles or crepitations may be heard at the end of inspiration and in early expiration.

  • The expiratory phase of breathing is prolonged, and expiratory wheezes are usually audible.

  • In the most severe cases, breath sounds are barely audible when bronchiolar obstruction is almost complete.



Roentgenography

  • Roentgenographic examination reveals hyperinflation of the lungs and an increased anteroposterior diameter on lateral view.

  • Intercostal spases are wide.

  • Diaphragm pushed down.

  • Scattered areas of consolidation are found in about 30% of patients and are caused by atelectasis secondary to obstruction or by inflammation of the alveoli.

  • There are increased broncho-vascular markings.

  • Early bacterial pneumonia cannot be excluded on radiographic grounds alone.



Laboratory data

  • The white blood cell and differential cell counts are usually within normal limits.

  • Leukopenia, commonly associated with many viral illnesses, is usually not found.

  • ESR is normal or slightly increased.

  • Nasopharyngeal cultures reveal normal bacterial flora.

  • Virus may be demonstrated in nasopharyngeal secretions by antigen detection (e.g., enzyme immunoassay) or by culture.



^ DIFFERENTIAL DIAGNOSIS

  • The condition most commonly confused with acute bronchiolitis is asthma. One or more of the following favors the diagnosis of asthma:

    • a family history of asthma,
    • repeated episodes in the same infant,
    • sudden onset without preceding infection,
    • markedly prolonged expiration,
    • eosinophilia, and
    • an immediate favorable response to the administration of a single dose of aerosolized albuterol.


^ DIFFERENTIAL DIAGNOSIS

  • Repeated attacks represent an important differential point: fewer than 5% of recurrent attacks of clinical bronchiolitis have viral infections as a cause.

  • Other entities that may be confused with acute bronchiolitis are

    • congestive heart failure,
    • a foreign body in the trachea,
    • pertussis,
    • organophosphate poisoning,
    • cystic fibrosis, and
    • bacterial bronchopneumonias associated with generalized obstructive pulmonary overinflation.


COURSE

  • The most critical phase of illness occurs during the first 48–72 hr after the onset of cough and dyspnea. During this period, the infant appears desperately ill, apneic spells occur in the very young infant, and respiratory acidosis is likely to be noticed.

  • After the critical period, improvement occurs rapidly and often dramatically.

  • Recovery is complete in a few days.



PROGNOSIS

  • The case fatality rate is below 1%;

  • death may result from

    • prolonged apneic spells,
    • severe uncompensated respiratory acidosis,
    • or profound dehydration secondary to the loss of water vapor from tachypnea and the inability to drink fluids.
  • Infants with conditions such as congenital heart disease, bronchopulmonary dysplasia, immunodeficiency diseases, or cystic fibrosis have a greater morbidity rate and have a slightly increased mortality rate.

  • Cardiac failure during bronchiolitis is rare, except in children with underlying heart disease.



PROGNOSIS

  • A significant proportion of infants with bronchiolitis have hyper-reactive airways during later childhood, but the relation of these two entities, if any, is not understood.

  • The infants with bronchiolitis who develop reactive airways are more likely to have a family history of asthma and allergy, a prolonged acute episode of bronchiolitis, and exposure to cigarette smoke.



TREATMENT

  • Infants with respiratory distress should be hospitalized, but only supportive treatment is indicated.

  • The patient is commonly placed in an atmosphere of cool, humidified oxygen to relieve hypoxemia and reduce insensible water loss from tachypnea; this treatment relieves the dyspnea and cyanosis and allays anxiety and restlessness.

  • The infant is usually more comfortable sitting at a 30 to 40 degree angle or with the head and chest slightly elevated so that the neck is somewhat extended.



TREATMENT

  • Small feeds are necessary while awake - to avoid overloading.

  • Oral intake must often be supplemented or replaced by parenteral fluids to offset the dehydrating effect of tachypnea.

  • Electrolyte balance and pH should be adjusted by suitable intravenous solutions.



TREATMENT

  • Antiviral agents have been available for the treatment of viral infection.

  • Since exact etiologic diagnosis is practically impossible in clinical practise, antibiotics are recommended in severe cases with superadded bacterial infection. In these cases children may be initially afebrile later develop fever.

  • Corticosteroids are not beneficial and may be harmful under certain conditions but hopefully given most of the time. Steroids are longer recommended.



TREATMENT

  • Bronchodilating aerosolized drugs (e.g., albuterol) are frequently used empirically; studies are divided between those that demonstrate benefit and those that demonstrate no benefit or even harm.

  • Epinephrine or other adrenergic agents have a theoretical basis for use, and in two studies, aerosolized epinephrine provided some benefit to infants with bronchiolitis.

  • Some patients may progress rapidly to respiratory failure, requiring ventilatory assistance.









Infectious Upper Airway Obstruction

  • Croup (Laryngotracheobronchitis), the most common form of acute upper airway obstruction, is caused primarily by viruses.



ETIOLOGY

  • The parainfluenza viruses account for approximately 75% of cases.

  • Adenoviruses, respiratory syncytial, influenza, and measles viruses cause the remaining viral cases.

  • In one study, Mycoplasma pneumoniae was recovered from 3.6% of patients who had acute upper airway obstruction.

  • Secondary bacterial infection is rare.



Sites of infection in the upper respiratory tract



EPIDEMIOLOGY

  • Most patients who have viral croup are between the ages of 3 mo and 5 yr, but disease due to H. influenzae is more common from 3–7 yr of age.

  • Croup occurs most commonly during the cold season of the year.

  • Approximately 15% of patients have a strong family history of croup, and laryngitis tends to recur in the same child.



Pathogenesis

  • The primary findings appear to be

    • inflammatory edema,
    • destruction of ciliated epithelium, and
    • exudate.




^ CLINICAL MANIFESTATIONS

  • Most patients have an upper respiratory tract infection for several days before cough becomes apparent.

  • With progressive compromise of the upper airway, a characteristic sequence of symptoms and signs occurs. At first, there is only a mild, brassy cough with intermittent inspiratory stridor.

  • As obstruction increases, stridor becomes continuous and is associated with worsening cough, nasal flaring and suprasternal, infrasternal, and intercostal retractions.



^ CLINICAL MANIFESTATIONS

  • As inflammation extends to the bronchi and bronchioles, respiratory difficulty increases, and the expiratory phase of respiration also becomes labored and prolonged.

  • Various degrees of lower respiratory involvement occur.

  • The temperature may be only slightly elevated. It rarely reaches 39–40C (102–104F).

  • Symptoms are characteristically worse at night and often recur with decreasing intensity for several days.



^ CLINICAL MANIFESTATIONS

  • There may be bilaterally diminished breath sounds, rhonchi, and scattered crackles.

  • With further compromise of the airway, air hunger and restlessness occur and are then superseded by severe hypoxemia, hypercapnia, and weakness, accompanied by decreased air exchange and stridor, tachycardia, and eventual death from hypoventilation.



^ CLINICAL MANIFESTATIONS

  • In the hypoxemic child who may be cyanotic, pale, or obtunded, any manipulation of the pharynx, including use of a tongue depressor, may result in sudden cardiorespiratory arrest.

  • This examination therefore should be deferred, and oxygen should be administered until the patient is transferred to a place in the hospital where optimal management of the airway and shock is possible.







Substernal recession



^ CLINICAL MANIFESTATIONS

  • Agitation and crying greatly aggravate the symptoms and signs, and the child prefers to sit up in bed or be held upright.

  • Older children are usually not seriously ill.

  • Other family members may have mild respiratory illness.



^ CLINICAL MANIFESTATIONS

  • Roentgenographic examination of the nasopharynx and upper airway reveals sub-glottic narrowing.

  • The white cell count is generally nonsignificant.







COURSE

  • The duration of illness ranges from several days to, rarely, several weeks.

  • Recurrences are frequent from 3–6 yr of age, decreasing with growth of the airway.

  • Most patients with croup progress only as far as stridor and slight dyspnea before they start to recover.

  • In some, there is worse obstruction.



PROGNOSIS

  • In general, the length of hospitalization and the mortality rate for cases of acute infectious upper airway obstruction increase as the infection extends to involve a greater portion of the respiratory tract.

  • Most deaths from croup are caused by a laryngeal obstruction or by the complications of tracheotomy.

  • The outcome of acute laryngotracheobronchitis is excellent.

  • As a group, children who need to be hospitalized for croup have somewhat increased bronchial reactivity compared with normal children when tested several years later.



TREATMENT

  • Therapy for infectious croup consists primarily of maintaining or providing for adequate respiratory exchange and depends in part on the primary location of the disease and its cause.





Most afebrile children with acute spasmodic croup or febrile patients with mild laryngotracheobronchitis can usually be safely and effectively managed at home.

  • Most afebrile children with acute spasmodic croup or febrile patients with mild laryngotracheobronchitis can usually be safely and effectively managed at home.

  • The use of steam from a shower or bath in a closed bathroom, steam from a vaporizer, or "cold steam" from a nebulizer (which has a safety and perhaps efficacy advantage) often terminates acute laryngeal spasm and respiratory distress within minutes.

  • The same effect has been observed by many parents as they take their child out into the cold night air on the way to the physician's office.

    • This long-recognized phenomenon may be explained by the upper airway's serving as a heat- and humidity-exchange organ; inspired air that is cooler than body temperature and less than 100% saturated with water vapor results in mucosal cooling, leading to vasoconstriction and lessened edema.


TREATMENT

  • actual or suspected epiglottitis,

  • progressive stridor,

  • severe stridor at rest,

  • respiratory distress,

  • hypoxemia,



TREATMENT

  • In all cases, the decision for hospitalization is made because of the need for reliable observation and relatively safe tracheotomy or more often nasotracheal intubation, if either of these becomes necessary.

  • At home or in the hospital, the patient with croup should be watched carefully for intensification of symptoms of respiratory obstruction.



Basic management of acute upper airways obstruction:

  • Don't examine the throat!

  • Reduce anxiety by staff being calm, confident and well organised.

  • Observe carefully for signs of hypoxia or deterioration.

  • If in doubt, administer nebulised epinephrine (adrenaline).

  • If respiratory failure develops from increasing airways obstruction, exhaustion or secretions blocking the airway, urgent tracheal intubation is required.



TREATMENT

  • The hospitalized child is usually placed in an atmosphere of cool humidity to lessen irritation and drying of secretions and perhaps to lessen edema.

  • Frequent or continuous monitoring of the respiratory rate is essential, because increasing tachypnea may be the first sign of hypoxemia and approaching total respiratory obstruction.

  • The patient should be disturbed as little as possible.

  • The child should sit in a comfortable upright position.



TREATMENT

  • In cases of moderate to severe respiratory distress, parenteral fluids should be given to make up for insensible and respiratory water loss and decrease the risk of vomiting, with its potential for aspiration.

  • Sedatives are usually contraindicated because restlessness is used as one of the principal clinical indices of the severity of obstruction and the need for tracheotomy or nasotracheal intubation.

  • Oxygen should be used to alleviate hypoxemia and apprehension, but because the oxygen reduces cyanosis, which is an indication for tracheotomy or nasotracheal intubation, these patients must be observed particularly closely.



TREATMENT

  • Laryngotracheobronchitis and spasmodic croup do not respond to antibiotics. But antibiotics may be necessary to combat secondary infection. In the bacterial forms, antibiotic therapy is important.

  • Nonurgent tests should be delayed to prevent increased symptoms associated with agitation and anxiety.



Racemic epinephrine by aerosol often results in transient relief of symptoms; close observation and repeated treatments usually are necessary.

  • Racemic epinephrine by aerosol often results in transient relief of symptoms; close observation and repeated treatments usually are necessary.

    • A child sick enough for hospitalization before administering an aerosol should be hospitalized even if there is a dramatic response to the aerosol, because the obstruction is likely to return after the aerosol's effects have waned.
  • Racemic epinephrine does not cause rebound worsening of obstruction.

    • However, if the aerosol is administered during the worsening phase of the natural history of the child's illness, the obstruction may be worse after the effects have worn off.
    • If the aerosol is administered at what would have been the peak of the obstruction, the child will be better after the aerosol effects have waned.
  • Frequent treatments help all but the sickest children through this illness.



TREATMENT

  • The use of corticosteroids is probably indicated for the hospitalized child with croup.

  • The theoretical basis for corticosteroid treatment in laryngotracheobronchitis is to reduce inflammatory edema and prevent destruction of ciliated epithelium.

  • There is no substantial evidence suggesting any adverse effect of corticosteroid treatment.

  • Topical, nonabsorbed, inhaled steroids have benefit in treating children with croup.



TREATMENT

  • Rarely, there is sufficient obstruction to warrant nasotracheal intubation or tracheotomy.

  • In the very ill child in the intensive care unit, breathing a helium-oxygen mixture, with its lower density and the resultant improved turbulent airflow, may decrease the work of breathing.



Acute epiglottitis

  • Acute epiglottitis is a life-threatening emergency due to respiratory obstruction. It is caused by H. influenzae type b.

  • The onset of epiglottitis is often very acute with:

  • high fever in an ill, toxic-looking child

  • an intensely painful throat that prevents the child from speaking or swallowing; saliva drools down the chin

  • soft inspiratory stridor and rapidly increasing respiratory difficulty over hours

  • the child sits immobile, upright, with an open mouth to optimise the airway.



Acute epiglottitis















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