Acute bronchiolitis against the background of exacerbation of chronic bronchitis. Clinical case

Types of bronchiolitis in children

Depending on the duration of symptoms, pathology is divided into two main types:

• Acute – bronchiolitis, which lasts in children for 7-10 days. Coughing and wheezing may persist for up to 2-4 weeks. As a rule, it passes without consequences for the baby’s health Source: Delyagin V.M. Acute bronchiolitis in children Medical Council No. 1 2013, pp. 64-68.
• Chronic - bronchiolitis, which appears in children as a result of complications of the acute form of the disease. Characterized by the persistence of symptoms for 3-4 months a year with periodic remissions and exacerbations.

Material and methods

The study included 52 children under 12 months of age who were hospitalized for OB no later than 72 hours from the onset of broncho-obstructive syndrome. Exclusion criteria were chronic lung and heart diseases, diagnosed bronchial asthma, as well as the extremely serious condition of the child, requiring transfer of the patient to the intensive care unit.

To assess the degree of respiratory disorders, indicators such as respiratory rate (RR), hemoglobin oxygen saturation (SpO2) and a scale of respiratory disorders (RDAI - Respiratory Distress Assessment Instrument), showing the degree of bronchial obstruction, were used (Table 1).

. Respiratory Disorders Inventory (RDAI).

By randomization, patients were divided into three groups (Fig. 1), which subsequently received various inhalation therapies 3 times a day at 8-hour intervals.

. Distribution of children into treatment groups.

Patients underwent aspiration of nasal mucosa and, if indicated, oxygen therapy and intravenous rehydration. If necessary, additional inhalations of a bronchodilator were performed or systemic corticosteroids were administered, and such cases were necessarily recorded. Dynamic indicators of the child's condition were assessed upon admission, 60 minutes after inhalation, then daily in the morning before and 60 minutes after inhalation. Additional criteria for the effectiveness of therapy were the duration of oxygen therapy and the duration of hospitalization. The “duration of hospitalization” was taken to be the period of time from admission to the hospital until the moment when the child met the following criteria: normal appetite, respiratory distress scale score less than 4 points, SpO2 ≥95% when breathing room air, remaining at this level for at least 4 hours. Adverse effects that could be related to the therapy were also assessed: tachycardia, tremor, hyperexcitability, sleep disturbance, increased cough, pallor, hypertension and vomiting.

Symptoms

Often the pathology begins as a classic cold. The baby develops a runny nose, a slight rise in temperature, and a slight cough. However, if certain signs are present, the acute stage of bronchiolitis in children can be suspected within a few days. Distinctive symptoms include:

• Dyspnea. One of the main symptoms of bronchiolitis in young children. At first it occurs only when the baby is active, and after some time it persists even at rest.
• Increased breathing rate. Due to difficulty breathing, the baby begins to characteristically inflate the wings of the nose with each breath. At the same time, breathing is superficial and shallow.
• Worsening cough, appearance of wheezing, characteristic hissing and whistling when exhaling. The cough is predominantly dry and does not bring relief.
• Blue skin. Occurs very rarely. Caused by a lack of oxygen in the body.
• Ear infection. In rare cases, in children the disease is accompanied by ear pathologies.
• Dehydration. Manifests itself in the form of dry skin and oral mucosa.

It is important to consider that in children under one year of age, bronchiolitis may not cause pronounced symptoms. The child is conscious, eats normally, and plays in a good mood. At the same time, his breathing only slightly accelerates and shortness of breath appears. If the disease occurs in a more severe form, the baby becomes nervous and capricious.

Ensuring normal oxygenation during bronchiolitis

Supplemental oxygen is prescribed when blood oxygenation decreases, which is monitored by the level of hemoglobin oxygen saturation (SpO2) [16]. It should be remembered that SpO2 threshold values ​​depend on the clinical indicators of the child’s condition. To decide whether oxygen therapy is necessary, it is important to assess the presence and severity of shortness of breath. For an initially healthy child without shortness of breath, fever and normal appetite, it is recommended to administer additional oxygen when SpO2 drops below 90%. Since the affinity of hemoglobin for oxygen decreases during acidosis and fever, a significantly higher partial pressure of oxygen in the alveoli and arterial blood is required to achieve the same SpO2 values. Therefore, in these cases, oxygen therapy should be started already at SpO2≤94% [5].

Causes of the disease

Pathology is quite often diagnosed in infants. Before the first year, about 10-11% of infants suffer from it. Doctors list the main reasons for the development of the disease:

• infection with respiratory syncytial virus, rhinovirus, adenovirus;
• entry into the body of respiratory, fungal and other infections.

As soon as any of the listed viruses or infections enters the body, pathological processes begin to develop. The airways become inflamed, the bronchioles narrow, as a result of which air circulation becomes significantly more difficult. Source: Sukhorukova D.N., Kuznetsova T.A. Epidemiology of acute bronchitis and bronchiolitis in children Eurasian Union of Scientists, 2016.

Experts say that the infection more often enters the body of those infants whose mothers smoke or smoked during pregnancy. In these children, the disease is also more severe. At the same time, breastfed children are less likely to be at risk. Often the virus only causes a cold in them, which does not develop into more complex diseases.

Maintaining adequate fluid balance during bronchiolitis

Children suffering from bronchiolitis often develop dehydration. Firstly, this is due to a decrease in the amount of food and fluid consumed due to lethargy, shortness of breath, and difficulty in nasal breathing. Secondly, dehydration occurs due to additional fluid losses associated with tachypnea, fever, and sometimes vomiting due to coughing [14]. To restore water and electrolyte balance, oral rehydration with saline solutions is performed [15]. Breastfeeding should not be stopped. Since a baby with shortness of breath and nasal congestion gets tired quickly during sucking, feeding should be frequent and divided. To reduce shortness of breath and reduce the risk of aspiration of food, a semi-vertical position of the child during feeding is recommended; the head end of the crib should be raised by 30-45 °. In severe cases, rehydration is carried out through a tube or parenterally [15]. Since RS viral infection can lead to the syndrome of inappropriate secretion of antidiuretic hormone, and also due to the risk of developing pulmonary edema, the volume of intravenous infusions should be limited and administered to 2/3 of the calculated fluid requirement [15].

Diagnostics

In most cases, a physical examination and listening to the lungs with a stethoscope is enough for the doctor to make a diagnosis. Acute bronchiolitis in children has fairly pronounced symptoms, so its diagnosis is not difficult and does not require additional tests.

However, in some cases, the disease is difficult to distinguish from a common cold. If the symptoms do not allow an accurate diagnosis to be made, or if the symptoms increase rapidly, the doctor will prescribe an additional examination, which includes:

• Blood tests . They provide information about the development of inflammatory processes in the body and oxygen levels.
• Pulse oximetry . Measuring blood oxygen levels. It is carried out using a special sensor that is attached to the finger. A painless, non-invasive method allows you to instantly obtain information about the oxygen saturation of the body.
• Chest X-ray . The examination allows you to distinguish pathology from pneumonia.
• Laboratory test for the detection of respiratory syncytial virus . This is done using a nasal swab. Mainly prescribed in severe cases of the disease. Source: Sukhorukova D.N., Kuznetsova T.A. Treatment of acute bronchiolitis in children in a pediatric setting Russian Pediatric Journal 20(6) 2022, pp. 329-333.

Bronchiolitis – it still hurts!

Bronchiolitis is a disease of the bronchial tree (bronchioles). Bronchioles take part in air conduction and gas exchange. From a clinical point of view, any inflammatory lesion of bronchioles is interpreted as constrictive (obliterating) bronchiolitis, which is due to a narrowing of their lumen and impaired air circulation function.

In the early stages, bronchiole lesions may be asymptomatic, not accompanied by changes in functional tests, and are an incidental finding on high-resolution computed tomography of the lungs. Then damage to the epithelium of the bronchioles occurs and, as a result, inflammation.

The inflammatory process leads to a concentric narrowing of the lumen of the bronchioles, partial or complete fusion (or closure) with scar connective tissue growing in the submucosal layer. Mucus plugs appear in the lumen, secretion stagnates, bronchiolectasis is formed (an accumulation of macrophages, which form plugs in the bronchioles). As the process progresses, large bronchi may be affected, where cylindrical bronchiectasis is often found. All bronchiolitis occurs in the same way - with progressive shortness of breath and a poor prognosis. Sometimes acute onset, dry cough, wheezing, fever. To clarify all the circumstances, you need to contact experienced specialists at the Pulmonology Center.

Treatment of bronchiolitis in children

Most children, once diagnosed and a treatment plan developed, recover within a few days at home. Treatment of acute bronchiolitis in children at home includes:

• Taking bronchodilators. The dosage regimen and dosage are prescribed by the doctor.
• Using saline drops. If necessary, it is recommended to remove nasal mucus from the baby using an aspirator.
• Drink plenty of fluids.
• Indoor air humidificationSource: Baranov A.A., Namazova-Baranova L.S., Tatochenko V.K., Davydova I.V., Bakradze M.D., Kulichenko T.V., Vishneva I.V., Selimzyanova L.R., Polyakova A.S., Artyomova I.V. Modern approaches to the management of children with acute bronchiolitis. Pediatric Pharmacology, 2022, pp. 339-348.

However, if a child has difficulty breathing, bluish skin, dehydration and other complications, his hospitalization is required. A child can be placed in a hospital earlier if he has diseases of the lungs, heart, or immune system, since the risk of developing a severe form of the pathology is much higher.

Inpatient treatment includes:

• 24-hour monitoring of blood oxygen levels and timely oxygen therapy through a face mask, oxygen tent, and ventilator.
• Control of body hydration. If the baby does not drink enough fluid, it is administered intravenously.
• Taking bronchodilators, corticosteroids.
• Taking medications to reduce and alleviate the symptoms of the disease Source: Sukhorukova D.N., Kuznetsova T.A. Treatment of acute bronchiolitis in children in a pediatric setting Russian Pediatric Journal 20(6) 2022, pp. 329-333.

Bronchiolitis: from empiricism to scientific evidence

Bronchiolitis is the most common viral infection of the lower respiratory tract, affecting infants in the first year of life. The peak incidence occurs in children aged three to 9 months. The clinical profile of bronchiolitis is a consequence of inflammatory obstruction of the small airways. In more than 50% of cases, the cause is an etiologic agent called respiratory syncytial virus (RSV). The first international guidelines for the treatment of children with bronchiolitis have recently been published. The first such guidelines were compiled by a special subcommittee created by the American Academy of Pediatrics (AAP), with the support of some influential international associations involved in the study of respiratory diseases, including the American Chest Society and the European Respiratory Society. The second guideline was produced by the Scottish Intercollegiate Guidelines Exchange Network (SIGN). This article was written to complement the treatment recommendations for children with bronchiolitis by discussing key points regarding diagnosis, treatment and prevention based on the recommendations given in the above documents.

Diagnostics

Diagnosis of bronchiolitis is a purely clinical procedure and is based on medical history and physical examination [1–3]. The prodromes of bronchiolitis are typical of an upper respiratory tract infection (sneezing and excessive nasal discharge) and last two to three days. They are usually accompanied by a moderate temperature (high temperature is not a typical symptom). After this, difficulty breathing, tachypnea, stridor and cough appear [1]. Breathing difficulties in children caused by bronchiolitis can cause feeding problems [1–3]. Finally, bronchiolitis may be accompanied by apnea in the first two or three months of life [4]. On auscultation, clear crepitations can be heard when inhaling and stridor when exhaling. Different authors interpret these results differently: in particular, European authors believe that the presence of crepitations is the main sign for diagnosing bronchiolitis, while American authors emphasize the presence of stridor during exhalation [3]. One consequence of this controversy is that children with a second or third episode of stridor caused by a viral infection have been included in bronchiolitis studies for a long time. This group may consist in part of children with early-onset asthma, and their inclusion in studies of bronchiolitis has often led to conflicting results and conclusions.

The severity of bronchiolitis may vary. The following clinical indicators are used to determine the severity of the disease: feeding difficulties, apnea, lethargy, respiratory rate exceeding 70/min, dilatation of the nostrils, significant intercostal retractions and cyanosis [3]. Factors leading to a more severe course of the disease are: age less than 12 weeks, premature birth, hemodynamically significant congenital heart diseases, chronic lung diseases and conditions in which the immune system is weakened [2].

Although diagnosing bronchiolitis is a clinical procedure, some examinations using specialized equipment can provide important information that can help when the diagnosis is in doubt or can be relied upon during subsequent treatment of the child.

Pulse oximetry

Currently, there are no published studies that confirm the arterial oxygen saturation limit at which it is recommended to hospitalize a child suffering from bronchiolitis. SIGN guidelines recommend hospitalization for children whose saturation levels are <92% [3], while AAP guidelines recommend oxygen therapy when saturation levels are persistently below 90% [2].

Some authors have shown an association between low saturation scores and more severe disease [5] and longer hospital stay [6]. It is possible that knowledge of oxygen saturation has led to an increase in the number of hospital admissions for patients suffering from bronchiolitis [7]. However, the true benefit of saturation-based hospitalization and its effects on disease outcomes remains to be demonstrated [8].

Chest X-ray

There is currently no evidence that plain chest radiography is helpful in diagnosing bronchiolitis in children. Chest X-ray often reveals pathological aspects during bronchiolitis. However, there is no conclusive evidence that these aspects have prognostic value regarding the severity and course of the disease [2, 9]. A study conducted in 30 pediatric hospitals in the United States found the usefulness of chest x-rays in children with bronchiolitis to be highly variable. It was also found that children who had a chest x-ray received more antibiotics and stayed in hospital longer [10].

Currently, because there have been no randomized, controlled trials to demonstrate the benefit of chest x-ray, this procedure is not recommended for diagnosing children with bronchiolitis. However, this procedure is strongly recommended in cases where children have a prolonged or particularly severe course of the disease, or in cases where the diagnosis is doubtful [2].

Chemical blood test

Blood cell count, white blood cell count, biochemical profile, and C-reactive protein (CRP) are not prescribed for children with typical symptoms of bronchiolitis [2]. Determination of arterial blood gas composition can help in assessing the condition of children suffering from severe respiratory distress [3].

Virological tests

The respiratory syncytyl virus (RSV) test, which can now be performed very quickly using the nasopharyngeal aspirate method, is useful in establishing an appropriate strategy for isolating patients to prevent the spread of infection throughout the hospital (LGP SIGN). In addition, detection of RSV confirms the viral etiology of bronchiolitis and prevents unnecessary antibiotic use.

Treatment

Bronchodilator

Neither the SIGN guidelines nor the AAP guidelines recommend the use of bronchodilators (alpha and beta adrenergic agents) for the treatment of bronchiolitis. The AAP guidelines, however, advise a therapeutic test with a bronchodilator, the use of which should be continued only if a clear clinical response is recorded [2] (Table 1). Some studies conducted in children suffering from bronchiolitis have shown improvements in clinical scores and oxygen saturation immediately after taking Albuterol [11, 12]. However, this effectiveness was not confirmed by all studies [13], and even in those cases where it was nevertheless recorded, these improvements did not last more than 60 minutes after taking the drug [14].

It also found that Albuterol treatment was not effective for children hospitalized with moderate bronchiolitis; in these cases, the drug did not affect the severity and duration of the disease [15]. A recent study [16] assessed the effect of several bronchidilators (levalbuterol, racemic salbutamol and epinephrine) on airway resistance in hospitalized children with bronchiolitis who were prescribed intensive care with mechanical ventilation. All bronchodilators caused a similar decrease in resistance. However, this reduction did not prove to be clinically significant [16].

Even nebulized epinephrine has been found to have no effect in treating children suffering from bronchiolitis. A randomized controlled trial did not show any significant clinical improvement or reduction in hospital stay in children treated with nebulized epinephrine [6]. Comparisons of Albuterol and epinephrine have produced conflicting results. According to a Cochrane review, epinephrine is more effective than albuterol [17]. On the other hand, a recent study [18] showed superiority of albuterol treatment over epinephrine treatment by emergency room data: children treated with Albuterol were discharged more quickly (i.e., they did not have to return to the hospital).

In conclusion, bronchodilators (Albuterol and epinephrine) should not be routinely used to treat children suffering from bronchiolitis [2, 13, 19]. However, although there is no evidence of the effectiveness of bronchodilators, clinical experience suggests that treating children with a bronchodilator may be effective in some cases [2]. Therefore, it is recommended to conduct a therapeutic trial using a bronchodilator, objectively monitor response to treatment (assessment of stridor, respiratory rate, and oxygen saturation), and continue bronchodilator treatment only if clinical efficacy is documented. For such a study, it is recommended to use Albuterol, since adrenaline has a short period of action, significant possible side effects, and, in addition, it is practically not used at home [2].

There is no evidence of the effectiveness of anticholinergic aerosol therapy in the treatment of bronchiolitis [2, 3].

Corticosteroids

Neither the SIGN guideline [3] nor the AAP guideline [2] recommend the use of systemic or inhaled steroids for the treatment of bronchiolitis (Table 1).

A Cochrane review of 13 articles did not show any statistically significant difference in clinical effectiveness between children with bronchiolitis treated systematically with corticosteroids and children treated with placebo [20]. In support of these findings, a recent study of 600 children 2 to 12 months of age presenting to the emergency department for bronchiolitis found that treatment with a single dose of oral dexamethasone (1 mg/kg) did not significantly affect the need for and duration of hospitalization and does not change clinical parameters in children four hours after taking cortisone [21]. Also, no efficacy was reported after subgroup analysis consisting of atopic children and children in whom RSV was isolated in nasopharyngeal aspirate. In contrast to these results, a study from Thailand in children under 24 months of age hospitalized for a first episode of stridor showed an effective response to an intramuscular dose of dexamethasone (0.6 mg/kg) on ​​disease duration [22]. However, the etiology of bronchiolitis in these children has not been established. Therefore, it can be assumed that some of these children actually experienced a first episode of asthma caused by rhinovirus [23].

For inhaled corticosteroids, published studies have shown no efficacy [2]. In addition, a recently published Cochrane review concluded that there is no evidence that inhaled steroids given during the acute phase of bronchiolitis are able to prevent recurrent postbronchiolitis stridor [24].

Ribavirin

Ribavirin is a synthetic analogue of guanosine that has an antiviral effect. It is not recommended for use as a routine treatment for bronchiolitis (Table 1).

Data on the effectiveness of ribavirin in the treatment of bronchiolitis are very uncertain. Some of the studies that examined the effects of such treatment in the acute stages of the disease showed clinical improvements that were not confirmed by other of these trials [25].

The effect of long-term treatment with ribavirin has also been studied. Again, in this case, the results are inconsistent: some studies have shown that such treatment reduces the risk of recurrent bronchospasms and asthma [26, 27]; while others show that there is no long-term protective effect [28, 29].

Given the paucity of efficacy studies, it is recommended that ribavirin should not be used routinely to treat children with bronchiolitis. However, it may be prescribed in a limited dose for children whose disease is very severe or whose life may be at risk due to underlying medical conditions such as immunodeficiency or hemodynamically significant congenital heart disease [2].

Antibiotics

Guidelines do not recommend routine use of antibiotics, which may be prescribed in limited doses when children with bronchiolitis show signs of coexistent bacterial infection [2, 3] (Table 1).

The likelihood of a secondary bacterial infection in children suffering from bronchiolitis is quite low [2]. Thus, preventive treatment with antibiotics has no basis. These secondary bacterial infections primarily affect the upper respiratory tract (acute otitis media in particular is often reported) and should only be treated when they appear.

Chest X-ray in the case of bronchiolitis may reveal the presence of atelectatic areas or infiltrates, which can be interpreted as signs of pneumonia, leading to the erroneous prescription of antibiotics.

A randomized, controlled trial involving children with bronchiolitis and children with pneumonia found that antibiotic treatment had no effect on disease progression in the subgroup of children with RSV bronchiolitis [30]. A recent Cochrane review, although describing only one study that met the established inclusion criteria [31], concluded that there is no evidence to recommend the use of antibiotics for the treatment of bronchiolitis. The review stated, however, that it would be useful to identify subgroups of patients for whom antibiotic treatment may be prescribed (eg, children admitted to the intensive care unit; children with hospital-acquired RSV; children with hemodynamically significant cardiac disease) [32 ].

Recently, the use of macrolides has been proposed for the treatment of bronchiolitis, not because of their antibiotic action, but because of their anti-inflammatory immunomodifying effect. A randomized, controlled trial in a limited number of children showed that three weeks of clarithromycin treatment in cases of RSV bronchiolitis resulted in shorter hospital stay and oxygen supplementation [33]. In addition, the authors describe a significant decrease in several plasma chemokines (IL-6, IL-8 and eotaxin), which supports a possible immunomodifying effect of clarithromycin in children receiving treatment [33]. However, a more recent study using a cycle of azithromycin treatment did not show any beneficial effects on the sequelae of RSV bronchiolitis [34].

Other treatments

Montelukast

It has recently been shown that treatment with montelukast cannot change the clinical development of the acute phase of bronchiolitis [35] (Table 2). A pilot study conducted in 2003 suggested that montelukast may have a role in controlling recurrent post-bronchiolitis respiratory symptoms [36]. However, in a more recent and larger study, montelukast at onset of bronchiolitis for 24 weeks did not significantly reduce recurrent respiratory symptoms in the 6 weeks following the acute phase [37]. Therefore, montelukast cannot be recommended at this time for the treatment of acute bronchiolitis or for the prevention of post-bronchiolitis symptoms. Further studies are needed to evaluate the effectiveness of this treatment in subgroups of children who have had respiratory symptoms that continue after bronchiolitis [7].

Nebulized hypertonic saline solution

Nebulized hypertonic saline has been shown to be effective for children with bronchiolitis (Table 2). It results in a significant reduction in length of hospital stay compared with placebo [38]. A Cochrane review [39] analyzed four clinical trials in which saline was used to treat bronchiolitis. It was concluded that saline may be effective in the treatment of bronchiolitis in terms of reducing length of hospitalization and reducing clinical scores. In the trials included in this review, saline was used in conjunction with a beta2-adrenergic bronchodilator [39]. Although the exact mechanism of action of the saline solution is not yet fully understood, it is believed to help eliminate mucus through osmotic hydration, stopping mucus secretion and reducing edema. In particular, one of the most rational ways to treat bronchiolitis in young children (from the first year) seems to be the rational use of the Otrivin Baby complex to care for the child’s nasal cavity.

The appearance of the Otrivin Baby complex on the pharmaceutical market greatly facilitates the cleansing and moisturizing of the nasal mucosa in the treatment of rhinitis in young children (from birth to three years). The Otrivin Baby product complex includes: drops for irrigation of the nasal cavity, spray, nasal aspirator, replaceable nozzles for the aspirator.

The design of the Otrivin Baby aspirator does not allow air to penetrate into the nasal passages and prevents mucus from returning. The shape and size of the components eliminate the risk of accidents when used by parents. The safety of the procedure allows it to be performed as often as the child’s condition requires. The use of replaceable disposable nozzles prevents infection of parents. Otrivin Baby helps maintain the normal physiological state of the nasal mucosa, helps thin mucus and facilitates its removal from the nose, increases the resistance of the nasal mucosa to pathogenic bacteria and viruses, and helps remove allergens from the nasal mucosa in allergic rhinitis.

Other drugs that have been proposed for the treatment of acute bronchiolitis are nebulized deoxyribonuclease [40] and furosemide [41], but their effectiveness has not been proven.

It has been suggested that methylxanthines, such as theophylline and caffeine, may play a role in the treatment of apnea associated with RSV bronchiolitis [42, 43].

As other therapeutic options for the treatment of bronchiolitis, the potential effectiveness of nasally administered small interfering RNAs targeting specific RSV genes has been demonstrated in animal models.

Maintenance therapy

Supportive care plays a fundamental role in the treatment of infants suffering from bronchiolitis. It basically comes down to ensuring proper fluid and oxygen intake.

Fluid intake via a nasogastric tube [3] or intravenously [2] should be provided when the child can no longer be fed safely due to respiratory distress, i.e. without the risk of inhalation [2, 3]. Respiratory RSV infection may be accompanied by inappropriate antidiuretic hormone (ADH) release and fluid retention [44–46]. In this case, fluids must be properly administered intravenously.

Oxygen supplementation is recommended in all cases where a previously healthy child has consistently recorded oxygen saturation below 90% [2] or 92% [3] during bronchiolitis. Oxygen therapy may, however, also be prescribed in cases of significant breathing difficulties. This supplementation should be discontinued when saturation is consistently greater than 90%, the child is feeding well, and respiratory distress is minimal [2].

Guidelines also recommend nasal aspiration (including the use of Otrivin Baby) to clear secretions from the nostrils and improve the baby's breathing [2, 3]. This procedure must be carried out before measuring the saturation level [2]. In addition, performing nasal aspiration using the Otrivin Baby aspirator before eating can make feeding the baby easier. On the other hand, there is no evidence that hypopharyngeal or laryngeal aspiration has any beneficial effects.

Respiratory physiotherapy is recommended for the treatment of children suffering from bronchiolitis [2, 3]. A systematic Cochrane review concluded that respiratory physiotherapy reduces length of hospital stay, improves clinical outcomes, but unfortunately does not reduce the need for supplemental oxygen in children with bronchiolitis.

Disease prevention and prevention

The guidelines describe several effective measures to reduce the risk of RSV infection in children and to prevent infection of other children, especially in hospital settings.

One of the protective factors against RSV infection is breastfeeding [2]. Breast milk contains various antibodies that protect against RSV (IgG, IgA and interferon-alpha). In addition, the relative risk of hospitalization in breastfed children due to RSV infection has been shown to be half that of non-breastfed children [47].

In contrast, a significant risk factor for RSV infection in infants is passive smoking. Numerous studies have shown a higher incidence of lower respiratory tract diseases in children exposed to secondhand smoke. In this case study, exposure of a child to secondhand smoke at home was shown to increase the risk of RSV bronchiolitis by four times [48]. Therefore, guidelines strongly recommend against exposing children to secondhand smoke [2].

Hand disinfection is considered another important measure to prevent infection, especially in hospital settings [2, 3]. It has been shown that RSV, like many other viruses, can be transmitted through the hands of those caring for sick children [49]. Therefore, it is recommended to wash your hands before and after contact with children in the hospital. Hands should be washed using alcohol-based products or antibacterial soap. Frequent hand washing is a fundamental measure in hospital and family settings to limit the spread of infection. Therefore, this measure should also be recommended to parents.

Finally, palivizumab, a humanized monoclonal antibody against RSV, has a specific role in the prevention of RSV. Palivizumab, given at a dose of 15 mg/kg monthly during the 5 months during which RSV peaks (November to March), provides passive protection against RSV and leads to a significant reduction in RSV hospitalizations among high-risk children ( premature babies, children with bronchial or cardiac diseases) [50, 51]. On the other hand, palivizumab is ineffective for the treatment of acute bronchiolitis [52].

According to the 2006 report of the Committee on Infectious Diseases [53], the AAP guidelines recommend palivizumab in the following categories of children:

1) children under 24 months of age suffering from bronchodysplasia requiring medical treatment (oxygen, bronchodilators, diuretics or corticosteroids) within six months before the start of the RSV epidemic season;

2) all children with gestational age at birth ≤ 28 weeks;

3) children with a gestational age at birth from 28 to 32 weeks, if the RSV epidemic season begins during the first six months of their life;

4) children with a gestational age at birth of 32 to 35 weeks, who are less than six months old at the beginning of the RSV epidemic season and who are exposed to one or two of the following risk factors: attending a nursery, having a school-age sibling exposed to pollutants the environment, congenital airway anomalies and serious neuromuscular diseases;

5) children 24 months of age or younger who have hemodynamically significant congenital heart disease (especially children who are being treated for cardiac decompensation, children with pulmonary hyperpressure, and children with cyanotic heart disease).

In addition to passive prophylaxis with palivizumab, parental education in effective measures to prevent RSV is necessary for all of the above groups of children with an increased risk category. Particular emphasis should be placed on the importance of frequent hand washing, avoiding crowded places, and not exposing the child to second-hand smoke.

Conclusion

Recommendations made in the SIGN and AAP guidelines are an important source of information about evidence-based treatments for children with bronchiolitis. They show that the effectiveness of the various elements that are part of the diagnostic and therapeutic procedures for children suffering from bronchiolitis is, in fact, unproven. Adjustments to clinical practice based on these guidelines will help improve the effectiveness of treatment of children with bronchiolitis in the home or hospital setting.

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For the rest of the bibliography, please contact the editor.

S. Carraro S. Zanconato E. Baraldi, Professor University of Padua, Padua

Contact information for authors for correspondence

Advantages of treatment at SM-Clinic

Our clinics provide treatment for bronchiolitis and other pulmonary pathologies in children of any age. Therapy in our medical centers has a number of important advantages:

• the child is treated by qualified pulmonologists, doctors of the highest category with scientific titles, whose experience is at least 5 years;
• The clinic’s staff includes experienced pediatric doctors of all specialties, who, if necessary, are involved in the treatment process;
• the examination is carried out on the basis of a modern diagnostic center, which is equipped with modern high-precision equipment of the European standard;
• The clinic’s inpatient facility provides the most comfortable conditions for effective therapy under the round-the-clock supervision of doctors and medical staff.

At SM-Clinic you don’t have to wait your turn in the corridors. All consultations and examinations take place at a clearly designated time by appointment. To make an appointment with a pulmonologist, call us by phone or fill out the feedback form.

Sources:

1. Delyagin V.M. Acute bronchiolitis in children. Medical Council No. 1 2013, pp. 64-68
2. Boytsova E.V., Ovsyannikov D.Yu. Post-infectious obliterating bronchiolitis in children. Children's infections No. 2 2014, pp. 24-28
3. Sterkhova E.V., Simanova T.V., Tyulkina R.R. Chronic obliterating bronchiolitis in children. Russian Bulletin of Perinatology and Pediatrics 62:(4), 2022, p. 211
4. Sukhorukova D.N., Kuznetsova T.A. Epidemiology of acute bronchitis and bronchiolitis in children. Eurasian Union of Scientists2016.
5. Baranov A.A., Namazova-Baranova L.S., Tatochenko V.K., Davydova I.V., Bakradze M.D., Kulichenko T.V., Vishneva I.V., Selimzyanova L.R., Polyakova A.S., Artyomova I.V. Modern approaches to the management of children with acute bronchiolitis. Pediatric Pharmacology, 2022, pp. 339-348
6. Baranov A.A., Namazova-Baranova L.S., Tatochenko V.K., Davydova I.V., Bakradze M.D., Vishneva E.A., Selimzyanova L.R., Polyakova A.S. Acute bronchiolitis in children. Modern approaches to diagnosis and therapy. Pediatric Pharmacology 2015, pp. 441-446
7. Sukhorukova D.N., Kuznetsova T.A. Treatment of acute bronchiolitis in children in a pediatric setting. Russian Pediatric Journal 20(6) 2022, pp. 329-333

Improving respiratory function in bronchiolitis

In foreign clinics, to facilitate the passage of the gas mixture through narrowed respiratory tracts, heliox, which is a mixture of helium and oxygen, is used. Ease of breathing is achieved due to the fact that the density of helium is lower than that of air. The use of heliox improves clinical indicators of disease severity, but does not affect the frequency of tracheal intubation and mechanical ventilation [17].

Respiratory support includes continuous positive airway pressure (CPAP) to prevent dynamic airway collapse and improve gas exchange. The CPAP method is indispensable for severe respiratory failure, when an increase in the oxygen fraction in inspired air of 50% is required, as well as for children with apnea. In rare cases, tracheal intubation and artificial ventilation (ALV) are required. Sometimes surfactant is administered during mechanical ventilation [15]. To improve ventilation of the posterior-lower sections of the lungs, it is recommended to position the child on his stomach, which is used in a 24-hour hospital setting [15].

To facilitate nasal breathing, the nasopharynx is sanitized with saline solutions and an electric aspirator. The effect of local vasoconstrictors for children in the first months of life has not been proven [5]. Steam inhalations are ineffective for bronchiolitis [18]. There is also no convincing data in favor of the effectiveness of chest drainage massage for bronchiolitis [19].

Use of probiotics

Probiotics provide good assistance in the complex treatment of bronchiolitis. Liquid probiotics Bifidum BAG and Trilact combine the possibility of antimicrobial, antiviral and immunostimulating therapy. The preparations contain physiological bifidobacteria and lactobacilli and their metabolic products: vitamins, amino acids, lysozyme, bacteriocins. The composition of the nutrient medium of the drug Bifidum BAG is as close as possible to the composition of mother's milk (amino acids, lysozyme, vitamins). Bifidobacteria and lactobacilli strengthen the immune system, act against viruses, bacteria, fungi and help cope with various infectious diseases. The drugs have a pleasant taste and smell, and children really like them.