Bronchiolitis, usually seen in chil...

Bronchiolitis, usually seen in children younger than couple years, manifests as rhinorrhea, cough expiratory wheezing, and respiratory distress. After several days, cough worsens and there is evidence of lower respiratory tract involvement including difficulty breathing and intercostal retractions. Bronchiolar narrowing is exacerbated according to the positive expiratory pressure when the child tries to forcefully exhale to conquer narrowed passageways. Symptoms usually begin eight to 12 days after infection secondary to inflammation, smooth though viral load peaks in four to five days. The differential diagnosis includes infantile asthma, in which infants not away with recurrent cough, wheezing, and tachypnea. Panitch reviews the supportive care and therapies designed to surmount airway obstruction in patients with respiratory syncytial virus bronchiolitis.

Although the foundation of management of respiratory syncytial virus disease is supportive care with fluid replacement and supplemental oxygen treatments to dilate constricted bronchi can be useful. These treatments include corticosteroids, bronchodilators, helium/ oxygen therapy, and exogenous surfactant, which are used to decrease disease duration and improve morbidity and mortality.

Supportive treatment with parenteral fluids is frequently required to maintain hydration still must be administered carefully because of the risk of pulmonary congestion. Hospitalized infants should be given humidified, supplemental oxygen when they are hypoxemic, and beating [i]or[/i] throbbing of an artery oximetry monitoring is recommended. Mechanical ventilation may be exigencyed in severe cases in children who cause to grow apnea or respiratory failure. Saline very littles and suction can help hold the nasal passages clear. Airway obstruction is caused through plugs formed from mucus and desquamated epithelial confined apartments Enhanced smooth muscle tone increases bronchospasm. Beta-adrenergic agonists may be useful when bronchospasms are existing and anti-inflammatory therapy may be useful when an inflammatory proces dominates the clinical picture.

No clear evidence supports the use of chest physiotherapy, inhaled corticosteroids, mucolytic agents, or theophylline in the management of bronchiolitis. Beta2 agonists are helpful in asthma, on the other hand bronchospasm is not a major characteristic of bronchiolitis. Combinations of alpha and beta agonists may be more helpful because of the resultant decrease in airway mucosal edema, still benefits have not been consistent. Theophylline does not affect the clinical course of bronchiolitis, further theoretic benefits include increased responsiveness to carbon dioxide, stimulation of respiration, and increased diaphragmatic contractility. Use of systemic corticosteroids appears to shape the duration of symptoms, especially if given early and if used in infants with more rigorous symptoms. Recent studies also display decreased hospitalization if systemic steroids are used early in infants with mild to moderate cases of bronchiolitis. Inhaled epinephrine or anticholinergics have not demonstrated consistent clinical benefit. Combination therapy with systemic corticosteroids and inhaled beta agonists has shown one promise. Further studies are urgencyed to examine the ability of exogenous surfactant to stop small airway obstruction. Helium/ oxygen therapy can decrease airway resistance, providing symptom relief and time for the disease to interpret naturally.

The author finishs that treatments beyond supportive care in children with bronchiolitis should be individualized. Further studies are penuryed to make specific universal recommendations about treatments beyond hydration and oxygen maintenance.

In the same journal issue, Jafri reviewed antiviral therapies with ribavirin respiratory syncytial virus immunoglobulin intravenous (RSV-IGIV), and palivizumab, an IgG monoclonal antibody for bronchiolitis. Aerosolized ribavirin may be useful early when the viral load is maximal (four to five days after infection). RSV-IGIV may decrease disease severity, further more studies are needed. Palivizumab inhibits viral fusion to the epithelial confined apartments and is approved for prophylaxis in high-risk infants. The use of palivizumab during acute disease has not shown clear significant benefit.

Panitch HB Respiratory syncytial virus bronchiolitis: supportive care and therapies designed to surmount airway obstruction. Pediatr Infect Dis J February 2003;22:S83-8 and Jafri H Treatment of respiratory syncytial virus: antiviral therapies. Pediatr Infect Dis J February 2003; 22:S89-93

RICHARD SADOVSKY, MD

COPYRIGHT 2003 American Academy of Family Physicians

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