BRONSIOLITA ACUTAMihai CraiuSef de Lucrari UMFMedic primar pediatruMedic specialist pneumologie pediatricaClinica II IOMC

BRONSIOLITA ACUTA DEFINITIEAfectiune acuta la copiii cu varsta < 2 ani cu

afectarea cailor aeriene mici & mijlocii la acest nivel apare obstructie bronsica prin :Edem si necroza de mucoasa bronsicaSecretii bronsice abundente+/- bronhospasm

BRONSIOLITA ACUTAFrecventa11,4 din 100 copii (SUA) dezvolta bronsiolita in primul an de viataFrecventa maxima intre 2 6 luni

BRONSIOLITA ACUTAAcute respiratory tract infections among a birth cohort of children from Cali, Colombia, who were studied through 17 months of age. Borrero I, Fajardo L, Bedoya A, Zea A, Carmona F, de Borrero MF -Rev Infect Dis. 1990 Nov-Dec;12 Suppl 8:S950-6. Incidenta IACR a fost 6.6 cazuri pe copil-an. Incidenta IACRS a fost 4.9 cazuri pe copil-an si cea a Inf joase a fost 1.7 cazuri pe copil-an. VSR a fost agentul viral cel mai frecvent izolat in culturi de aspirat nazofaringian la copiii cu Inf joase la varste < 18 luni

BRONSIOLITA ACUTA

Etiologie VIRALA (1)VSR (~ 70-90% din cazuri)Rhinovirusuri (29% din cazuri forme severe !)Virusuri paragripaleVirusuri gripale A & BMetapneumovirusul uman *AdenovirusuriEnterovirusuri (herpangina & BDA VARA !)Asocieri virale (19,5% cel mai des VSR si rhinov)

BRONSIOLITA ACUTA

Etiologie VIRALA (2)Metapneumovirusul uman

2,3% din viroze 2000-01 (Canada); 6,2% copii cu ARI in Massachusetts, 2004; 21% din copii spitaliz Norvegia in 2004

BRONSIOLITA ACUTA

Etiologie BACTERIANA RARISIMA !Mycoplasma pneumoniaeUreaplasma urealiticumChlamydia pneumoniae

BRONSIOLITA ACUTAEpidemiologie Afectiune acuta aparuta iarna si la inceputul primaveriiProdrom de tip viral cu durata 1-3 zileTuseCorizaStranutFebra +/-

BRONSIOLITA ACUTASimptome (1)Tahipnee Apnee, mai > la sugarii mici (varsta < 44 sapt Post-Conceptual)

BRONSIOLITA ACUTAAcute lower respiratory infection in Argentinian children: a 40 month clinical and epidemiological study. Murtagh P, Cerqueiro C, Halac A, Avila M, Salomon H, Weissenbacher M. Pediatr Pulmonol. 1993 Jul;16(1):1-8. FR > 50/min. (numaratoare pe 60 secunde !) Mai crescuta la pacienti < 1 an si la pac cu bronsiolita. Tirajul (Retractions) a avut o mult mai mica dependenta de varsta, fiind prezent in cazurile severe, indiferent de dg clinic. Tirajul, singur sau asociat cu cianoza, a fost indicatorul cel mai bun de severitate in IACR.

BRONSIOLITA ACUTASimptome (2)E:\tiraj amplu2.aviE:\tiraj costal.AVIE:\tiraj sc.AVI

BRONSIOLITA ACUTASimptome (3)Sindrom bronho-obstructivExpir prelungit + WheezingTorace cu diam >>Hipersonor la percutie Ficat & splina coborate

BRONSIOLITA ACUTAInvestigatiiPulsoximetrie & ASTRUPRxCBC utila pt dg difELISA pt VSR

BRONSIOLITA ACUTAClinical findings and severity of acute bronchiolitis. Mulholland EK, Olinsky A, Shann FA. -Lancet. 1990 May 26;335(8700):1259-61.

The best method for initial assessment of bronchiolitis was pulse-oximetry.

Subcrepitantele si cianoza se coreleaza cu nevoile crescute de oxigen, la cei spitalizati.

BRONSIOLITA ACUTARadiologieHiperinflatie difuza (TIPIC)Tulburari de ventilatie (~ 20% din pac int)

BRONSIOLITA ACUTADg diferentialAfectiune acuta resp de CRIAstm bronsicAspiratie de CSF/CRGEMCC cu sunt sistemico-pulmMalform Cai aeriene

BRONSIOLITA ACUTADg diferential (2)Malform Cai aerieneE:\tiraj amplu.AVI

BRONSIOLITA ACUTATratament (1)Mentinerea oxigenarii (Ox flux liber, masca, VM)Umidifiere secr (SF sau NaCl M)BronhodilatatieAdrenalina 0,15 0,5 mg/kg/doza Sugari max 2,5 mg, prescolari max 5 mgRibavirina (Viratek-SPAG)

BRONSIOLITA ACUTATratament (2)Tratamentul cu ANTIBIOTICE este : INUTILPOTENTIAL PERICULOSMacrolidele noi favorizeaza selectia DRSPCefalosporinele gen II-III selecteaza gram neg ESBLlactami + inhib de -lactamaza selecteaza MRSANU MODIFICA EVOLUTIA BOLII

BRONSIOLITA ACUTATratament (3)Tratamentul cu CORTICOSTEROIZI este : CONTROVERSAT

BRONSIOLITA ACUTATratament (4)Tratamentul cu CORTICOSTEROIZI este : INEFICIENT Cochrane Database Syst Rev. 2004;(3):CD004878 Glucocorticoids for acute viral bronchiolitis in infants and young children. A total of 1,198 children aged 0 to 30 months were treated with the equivalent of 0.5 to 10 mg/kg of systemic prednisone for two to seven days. LOS unchanged by Glucocorticoid treatment!

BRONSIOLITA ACUTATratament (5)Tratamentul cu CORTICOSTEROIZI este eficient la acei pacienti care raspund la 2-agonisti cu durata scurta de actiune (ventolin) viitori pacienti cu ASTM ??

BRONSIOLITA ACUTAProfilaxie (1)Afectiune foarte contagioasaUn pacient care stranuta elibereaza VSR in picaturile Pflugge pe o raza de aprox 2 metriSpalat pe mainiVSR persista circa ora pe mainile nespalatePe jucarii si alte suprafete VSR persista viabil mai multe ore

BRONSIOLITA ACUTAProfilaxie (2)Ig-specifice VSRCopii < 2 ani cu Oxigen la domiciliuPac cu displazie bronho-pulmonara (BDP)Fosti prematuri < 32 s VG si varsta actuala < 6 L, in anotimpul rece (iarna)Sugari cu MCC

BRONSIOLITA ACUTAProfilaxie (3)Un anticorp monoclonal VSR-specific (Palivizumab) a fost dezvoltat pt profilaxie.Impact of respiratory syncytial virus infection as a cause of lower respiratory tract infection in children younger than 3 years of age in Japan. Kaneko M, Watanabe J, Kuwahara M, Ueno E, Hida M, Kinoshita A, Sone T. - Infect. 2002 May;44(4):240-3. Meissner HC, Long SS; American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and Newborn. Revised indications for the use of palivizumab and respiratory syncytial virus immune globulin intravenous for the prevention of respiratory syncytial virus infections. Pediatrics. 2003 Dec;112(6 Pt 1):1447-52.

BRONSIOLITA ACUTACriterii de InternareDetresa respiratorieFR > 50/minTiraj (Retractions)Cianoza sau hipoxemie documentataImposibilitate supt/bautMaladie asociata (MCC, neuro, b pulm cr)Varsta < 3 luniFebra > 39 C

BRONSIOLITA ACUTAPrognostic in faza acuta (1)Hipoxemia la internare este cel mai bun predictor de evolutie grava**Hypoxaemia in young Kenyan children with acute lower respiratory infection. Onyango FE, Steinhoff MC, Wafula EM, Wariua S, Musia J, Kitonyi J.- BMJ. 1993 Mar 6;306(6878):612-5. 59% din copii internati erau hipoxemici. 10% din cei internati au decedat. 90.4% din cei decedati aveau saturatii in oxigen intre 40-88%. Copii cu hipoxemie au avut un risc de deces, in primele 5 zile de spitalizare, de 4.3 ori mai mare decat cei fara hipoxemie

BRONSIOLITA ACUTAPrognostic in faza acuta (2)Scoruri clinice in bronsiolita ** Clinical score and arterial oxygen saturation in children with wheezing associated respiratory illness (WARI). Sritippayawan S, Deerojanawong J, Prapphal N. - J Med Assoc Thai. 2000 Oct;83(10):1215-22. Scopul studiului - determinarea corelatiei intre scorul clinic (bazat pe FR, tiraj (retractions), intrarea aerului, wheezing, stare de constienta) si SaO2 masurata cu puls-oximetrul. Stabilirea unui scor total, cu caracter predictiv pt hipoxemie (SaO2 < sau = 94%) la copiii cu WARI (wheezing associated respiratory illness).Un scor >/= 4 este strans corelat cu hipoxemia

BRONSIOLITA ACUTAPrognostic in faza acuta (3)Boala autolimitata < 10 zile (7 14 zile)Tusea poate persista ~ 3 saptRiscul de suprainfectie bacteriana este extrem de redus* ** ***

* Sepsis evaluations in hospitalized infants with bronchiolitis. Antonow JA, Hansen K, McKinstry CA, Byington CL - Pediatr Infect Dis J. 1998 Mar;17(3):231-6.

** Low risk of bacteremia in febrile children with recognizable viral syndromes. Greenes DS, Harper MB, Pediatric Infectious Disease Journal. 18(3):258-261, 1999.

*** Prevalence of Serious Bacterial Infections in Febrile Infants With Respiratory Syncytial Virus Infection M. Olivia Titus, Seth W. Wright PEDIATRICS Vol. 112 No. 2 August 2003, pp. 282-284

BRONSIOLITA ACUTAIntrebari

Are risc de a avea o boala bacteriana un sugar cu tablou clinic tipic de bronsiolita ?

Are risc de boala bacteriana un sugar cu bronsiolita, daca are febra inalta (> 39C) ?

Are risc de boala bacteriana un sugar cu bronsiolita si varsta mica (< 2 luni) ?

BRONSIOLITA ACUTAPrognostic in faza acuta (3-2)

1. Sepsis evaluations in hospitalized infants with bronchiolitis. Antonow JA, Hansen K, McKinstry CA, Byington CL - Pediatr Infect Dis J. 1998

1,8% din tot lotul de sugarii cu tablou de bronsiolita au avut infectie bacteriana (Salt Lake City, Department of Pediatrics, University of Utah) Cel mai putin probabil sa aiba infectie bacteriana au fost cei > 1 luna si cei cu tablou tipic de bronsiolitaRisk of serious bacterial infection is low; the costs of a sepsis evaluation outweigh the benefits in infants with obvious bronchiolitis.

BRONSIOLITA ACUTAPrognostic in faza acuta (3-3)

2. Low risk of bacteremia in febrile children with recognizable viral syndromes. Greenes DS, Harper MB, Pediatric Infectious Disease Journal. 18(3):258-261, 1999.

21.216 copii 3 36 luni, internati cu febra > 39C6% aveau tablouri clinice evocatorii de boli virale (bronsiolita, crup, stomatita aftoasa, varicela)Au avut hemoculturi pozitive 2/876 copii (1/411 cu bronsiolita, 0/249 cu crup, 0/123 stomatita, 1/93 cu varicela)

BRONSIOLITA ACUTAPrognostic in faza acuta (3-4)

3. Prevalence of Serious Bacterial Infections in Febrile Infants With Respiratory Syncytial Virus Infection . M. Olivia Titus, Seth W. Wright PEDIATRICS Vol. 112 No. 2 August 2003, pp. 282-284.

348 copii < 2 luni, internati cu febra174 aveau tablou clinic evocatoriu de bronsiolita si serologie VSR pozitiva174 au fost lotul de control cu febra si serologie VSR negativaAu avut culturi pozitive 2/174 copii bronsiolita (ITU), Au avut culturi pozitive 22/174 copii din lotul martor, fara VSR (17 ITU).

BRONSIOLITA ACUTAPrognostic in faza acuta (4)Unele cazuri pot evolua letal Respiratory syncytial virus infection in children hospitalised with acute lower respiratory tract infection. Hussey GD, Apolles P, Arendse Z, Yeates J, Robertson A, Swingler G, Zar HJ. - S Afr Med J. 2000 May;90(5):509-12. Suplimentarea cu oxigen si ventilatia mecanica au fost necesare in 68.9% si 8.5% din pacienti, respectiv. Singura diferenta semnificativa a fost prezenta hiperinflatiei, care a aparut la 70.1% din pacientii EIA RSV-pozitivi, comparativ cu 57.1% din cei negativi Rata mortalitatii a fost de 2%, in ambele grupuri.

Respiratory syncytial virus (RSV) http://www.nlm.nih.gov/medlineplus/ency/ article/001564.htmIn fiecare an in SUA sunt internati circa 125 000 sugari cu infectie VSR grava, 1-2% evolueaza letal

BRONSIOLITA ACUTAPrognostic tardiv (1)Legatura cu astm ??Eozinofilia in faza acuta se coreleaza cu o evolutie ulterioara catre astm la 56% din copii, Lipsa eozinofiliei se asociaza doar cu un procent de 22%

RSV - DrGreene.com www.drgreene.com/21_1175.html - 101k - 10 Nov 2005

BRONSIOLITA ACUTAPrognostic tardiv (2)Unele inf cu adenovirusuri f grav (bronsiolita obliteranta)Evolutia este in general letala

BRONSIOLITA ACUTAPrognostic tardiv (3)Elaborarea vaccinurilor

Twenty Years of Outpatient Respiratory Syncytial Virus Infection A Framework for Vaccine Efficacy Trials -- Fisher et al_ 99 (2) 7 -- Pediatrics.htm

BRONSIOLITA ACUTACONCLUZII PRACTICEAparitia dispneei dupa 1-3 zile NU are semnificatie de agravare, ci face parte di tabloul clinic al boliiCel mai frecvent se asociaza cu o evolutie severa cei care au hipoxemie la debutul boliiEtiologia este virala in imensa majoritatea a cazurilor, ANTIBIOTICELE fiind inutileRaspunsul clinic rapid la 2-agonisti si steroizi, eozinofilia si episoadele recurente sunt evocatorii pentru evolutia catre ASTM