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RSV Bronchiolitis. Mark A. Brown, M.D. Professor of Clinical Pediatrics Pediatric Pulmonary Section University of Arizona. Bronchiolitis: Definition.

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RSV Bronchiolitis


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    1. RSV Bronchiolitis Mark A. Brown, M.D. Professor of Clinical Pediatrics Pediatric Pulmonary Section University of Arizona

    2. Bronchiolitis: Definition Viral infection of the lower respiratory tract characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm AHRQ Evidence Report

    3. Epidemiology • Bronchiolitis statistics • 90% of children 0-2 yrs. are infected with RSV • 20% have lower respiratory infection • 3% hospitalized • 0.002% mortality • Age at presentation • Peak age 2-5 months • Rare in 1st month of life

    4. Viral causes of bronchiolitis • Respiratory syncytial virus (RSV): 70% • Metapneumovirus 10-20% • Newly identified paramyxovirus • Similar seasonality and course to RSV • Parainfluenza • Influenza 10-20% • Adenovirus • Bocavirus ? }

    5. Seasonality Bronchiolitis RSV Isolates Year Hall, NEJM 2001

    6. RSV  Prime Cause of LRTI in Young Child • Hospitalization for RSV Bronchiolitis: • 38% of all LRTI in first year of life • 22% of all LRTI in  5 years of age • 31 / 1,000 children < 12 mos each year Shay ’99 • Economic Burden • Costs for LRTI hospitalizations: • $2.25 billion for infants, 14 to 26% from RSV • $3.73 billion for first 5 years of life, • 1016% from RSV Stang ’01

    7. Clinical course of bronchiolitis • Incubation period: 2-8 days • Upper respiratory infection: 1-3 days • Worsening lower airway disease: 3-5 days • Full recovery: 2-8 weeks Percent Days of symptoms Swingler et al. 2000

    8. Clinical course Severity Days

    9. Risk Factors for Hospitalization with RSV 1708 Hospitalized Infants in Rochester, NY 1 or more Risk Factors Percent with: Prematurity Age < 6 wks Chronic Disease

    10. RSV Roentgenographic Findings • Diffuse interstitial pneumonitis most common in all lobes • Hyperaeration > 50% • Peribronchial thickening • Lobar or segmental consolidation 2050%; • RUL, RML most common

    11. Therapy for RSV Oxygen, administered by means of a small tent, gives these patients with cyanosis definite relief, and is the treatment upon which we have to rely for the most severely ill infants.  J. Adams, Lancet 1945

    12. Therapies • Supportive care • Airway clearance • Hydration • Oxygen • Bronchodilators

    13. Supportive Care • Administer humidified oxygen • Nasal suctioning to clear upper airway • Monitor for apnea, hypoxemia, and impending respiratory failure • Normalize body temperature • Rehydrate with oral or intravenous fluids • Monitor hydration status

    14. Supportive Care • Chest Physiotherapy (CPT) • Little evidence to confirm enhancement of mucociliary clearance Quittell LM, et al. Am Rev Respir Dis. 1988;137:406A;

    15. Bronchodilators • Multiple studies of bronchodilators • Albuterol • Beta2 adrenergic effects • Racemic epinephrine • Beta2 adrenergic effects • Alpha adrenergic effects - ? vasoconstriction • Anticholinergics • No evidence for benefit in bronchiolitis

    16. Effect on clinical score: Cochrane meta-analysis Hartling et al. Cochrane Review 2004

    17. Odds of improvement Hartling et al. Cochrane Review 2004

    18. Effect on hospitalization Hartling et al. Cochrane Review 2004

    19. Bronchodilators • Evidence for modest short-term improvement • Overall, 57% improved vs. 43% for placebo • 1 infant will benefit for every 7 treated • Mild side effects common: tachycardia, hypoxemia • No impact on overall course of disease in inpatients Albuterol Dobson et al. Pediatrics. 1998; 101:361-368. Epinephrine Wainwright et al, N Eng J Med 2003; 49:27-35. • Studies comparing epinephrine vs. albuterol mixed

    20. Hartling et al. Cochrane Review 2004

    21. Bronchodilators and bronchiolitis Bronchodilators have variable effects on infants with bronchiolitis… Some improve…some get worse…and the rest stay the same Unknown

    22. Therapies Supportive Care • Suctioning/Airway Clearance • Upper airway congestion can contribute to symptoms • No evidence for role of deep suctioning • One RCT suggests benefit for using 3% saline with nebs Sarrell, et al. Chest 2002; 122:2015-2020. • Chest physiotherapy • One small RCT found no benefit of routine Chest PT Webb et al. Arch Dis Child 1985; 60:1078- 1079. • Hydration • Assess and follow I/Os (potential for SIADH)

    23. Oxygen • Pulse oximetry detects hypoxemia not apparent on PE • Significance of mild hypoxemia (> 90%) unclear • Variability in saturation due to plugging / mismatch • Indication for starting oxygen unclear • Oxygen requirement associated with worse outcomes • Increased risk of need for ventilation Wang et al. J Peds 1995; 126:212-219. • 4 x increased inpatient LOS Wainwright et al. 2003 • ? Continuous pulse oximetry vs. spot checking

    24. Protection against lower respiratory infection Natural immunity to RSV • Antibody to F and G surface proteins protect against LRI • Humoral immunity controls and terminates infection Reinfections with RSV • Usually limited to URI • Healthcare workers at risk • Significant cause of illness in elderly

    25. Prevention • Non-Specific Measures • Avoidance • Hygiene • Nutrition • Passive Immunization • Palivizumab (Synagis®)

    26. RSV immunoprophylaxis Attempts to provide immunity to RSV • Vaccine in 1960s worsened course of infection • New intra-nasal vaccine undergoing trials • Passive immunity via hyperimmune globulin • Monoclonal antibody to F protein (palivizumab) • 55%  hospitalizations for preterm/chronic lung disease • 45%  hospitalizations for congenital heart disease

    27. 14 12.8 12 11 10.6 9.8 10 8.1 7.9 8 RSV Hosp Rate 5.8 5.8 6 4.8 4.5 4 2.9 2.2 2.1 2 1.8 1.7 1.9 1.5 1.6 1.6 2 1.3 1.2 1.2 1.1 0.7 0 All Patients Premature w/o CLD All <32 weeks GA All 32-35 weeks Patients with CLD IMpact-RSV study based on active collection of hospital data; Outcomes Registry based on passive reporting Reduction in RSV Hospitalization Rate 1996-1997 IMpact-RSV Trial-Placebo 1996-1997 IMpact-RSV Trial-Synagis 2000-2001 Synagis Outcomes Registry 2001-2002 Synagis Outcomes Registry 2002-2003 Synagis Outcomes Registry The IMpact-RSV Study Group. Pediatrics. 1998;102(3):531-7; Palivizumab Outcomes Study Group. Pediatric Pulm. 2003;35:484-9; Hudak et al. J Perinatol. 2002;22:619, abstract P32; Data on file, MedImmune Inc.

    28. Guidelines for RSV Prophylaxis ≤28 wks GA Palivizumabif ≤12 months at start of RSV season Premature, no CLD, no CHD 29-32 wks GA Palivizumabif ≤6 months at start of RSV season 32-35 wks GA Palivizumabif ≤6 months at start of RSV seasonwith two risk factors present Hemodynamically Significant CHD Palivizumab if ≤2 years old at start of RSV season ChronicLung Disease* (CLD) *Receiving medical therapy for CLD within 6 months

    29. Apnea and RSV • Apnea reported in 20% of hospitalized infants with RSV • Risk factors for apnea • Age < 2-3 months • Prematurity • May be presenting symptom but usually follows URI/LRI • Recurrence rate 50% • Mortality < 2% Levine et al. 2004

    30. RSV and asthma link • 40-50% of hospitalized bronchiolitics will wheeze again • Increased risk if > 12 months, atopy, eosinophilia Reijonen 1997 Ehlenfield 2000 Martinez FD, Godfrey S, 2003

    31. Otitis media • Otitis media a common complication • Cohort study of 42 infants with bronchiolitis • 62% acute OM (tympanocentesis confirmed) • 24% otitis media with effusion • 14% normal throughout course Andrade et al. 1998 • Usual guidelines for AOM and OME apply

    32. May therenever develop in me the notion that my education is complete, but give me the strength and leisure and zeal continually to enlarge my knowledge. Moses Maimonides