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BRONCHIOLITIS !!! WHY ?

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.

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BRONCHIOLITIS !!! WHY ?

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  1. BRONCHIOLITIS !!! WHY ? DR.FATMA AL-ZAHRANI DR.BASMA AL-JABRI TEAM C

  2. 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.

  3. 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..

  4. BRONCHIOLITIS!!!WHY? • systemic review of bronchiolitis management in infants & children was presented by University of North Carolina Evidence-based practice center in 2006 …

  5. 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

  6. SEARCH STRATIGIES • Literatures review in 3 database: • MEDLINE • Health Economic Evaluation Data Base HEEDB • Cochrane Collaboration Library

  7. SELECTIONCRITERIA • Diagnostic tools for bronchiolitis: • Prospective cohort studies. • Randomized control trials. • Intervention (therapy + prophylaxis): • Randomized control trials. • Cost effectiveness: • Economic analysis.

  8. 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.

  9. 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.

  10. Key question 1:effectiveness of diagnostic tools for diagnosing bronchiolitis The 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.

  11. Key question 1: effectiveness of diagnostic tools of diagnosing bronchiolitis Utility 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.

  12. 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.

  13. 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: • Numerous tests for RSV exist. • Their tests characteristics vary, • Overall sensitivity of rapid antigen detection test to be in 80%- 90% range.

  14. 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:

  15. 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. • RSV testing may helpful in clinical situations where the diagnosis of bronchiolitis is unclear. • Is an important tool for surveillance of LRTI in infants. • Will be essential in research sitting, where RSV specific therapies are being evaluated for effectiveness…

  16. 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.

  17. 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 …

  18. 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

  19. Nebulised bronchodilators vs. oral bronchodilators, nebulised ipratropium bromide: • 11 studies. • 158 subjects. • Ages: up to 24 months • Outcomes : hospitalization rate clinical scores

  20. 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.

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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.

  26. Conclusion recommendations • Diagnosis: • No specific literature were found regarding the diagnosis of bronchiolitis • The disease is clinically diagnosed • Encourage the

  27. 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

  28. 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,

  29. Thank you

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