Lung ultrasound systematic review shows its prognostic and diagnostic role in acute viral bronchiolitis.

AIM: Lung ultrasound (LUS) has not been included in the current guidelines for the diagnosis of bronchiolitis so far, even though data concerning its effectiveness have been published. METHODS: A systematic literature review was carried out to determine the role of LUS scores in the diagnosis and prognosis of patients aged 0-2 years with bronchiolitis, using MEDLINE, Scopus and ScienceDirect databases from their inception to December 2021. RESULTS: A total of 18 studies matching our eligibility criteria were analysed for the purposes of this review and 1249 patients with bronchiolitis were included. The sonographic and radiological findings were comparable and chest radiography was found to have a higher sensitivity in ruling out severe complications such as concomitant pneumonia. The LUS scores were correlated to the clinical course of bronchiolitis and it was able to predict the need of admission in paediatric intensive care unit, the duration of hospitalisation and the need for respiratory support. CONCLUSION: This review suggests that LUS could have both a diagnostic and a prognostic role in bronchiolitis during first evaluation in the emergency department and hospitalisation. Physicians could adjust management according to sonographic findings as a useful adjunct to the clinical ones.

Measurement of the interbronchial angle in acute viral bronchiolitis.

BACKGROUND: Acute viral bronchiolitis (AVB) is the most common lower airway infection in children under 2 years. Attempts to determine disease severity based on clinical and radiological manifestations are a major challenge. Measurements of the anatomy of the trachea and main bronchi are not only limited to pure anthropometry, but are also useful for better care of critically ill patients. The purpose of the study is to verify the association between measurements of the interbronchial angle (ITB) and the severity of respiratory disease. METHODS: A cross-sectional study, which included all patients admitted to the Santo Antônio Children's Hospital, over a period of 1 year, with diagnosis of AVB by respiratory syncytial virus (RSV) was designed. ITB angle was measured and clinical characteristics were analyzed. Quantitative variables were compared and correlation analysis was performed using Pearson's correlation coefficient. A receiving operator characteristic (ROC) curve was performed. P-value <0.05 was statistically significant. RESULTS: A total of 425 patients with AVB due to RSV were included. Most of these patients were male and the median age was 130 days, 91.11% of them required oxygen therapy through a nasal catheter, 3.3% used noninvasive ventilation and 4% used mechanical ventilation. Those who required MV or NIV and intensive care unit support were considered severe. The mean ITB was lower for these patients than for those of lesser severity (p < 0.05). CONCLUSION: The present study demonstrates that there is an association between ITB and AVB severity. The smaller the ITB, the greater the disease severity.

[Cost-effectiveness of chest x-rays in infants with clinically suspected viral bronchiolitis in Colombia]. / Costo-efectividad de la radiografía de tórax en lactantes con sospecha clínica de bronquiolitis viral en Colombia.

OBJECTIVE: Estimate the cost-effectiveness of not taking chest x-rays of any infant with clinically suspected viral bronchiolitis versus routinely taking them of all such patients, the most common practice today in Colombia. METHODS: A cost-effectiveness study was conducted, comparing strategies of taking chest x-rays of all infants with clinically suspected viral bronchiolitis and not x-raying any of these infants. The principal outcome was the proportion of correct diagnoses. The time horizon was the clinical course of the bronchiolitis. The perspective was that of the third-party payer, and the costs were obtained from the rates in effect in a clinic in Bogotá. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: The strategy of not taking a chest x-ray of any patient prevailed over that of routinely taking one in all cases, with an average cost of US$ 111.00 and a correct diagnosis rate of 0.8020, versus the respective values of US$ 129.00 and 0.7873 for the strategy of routinely x-raying all of these patients. The most influential variable was pneumonia-related hospital costs. In the probabilistic sensitivity analysis, the strategy of not x-raying any infant prevailed in 61.1% of the simulations. CONCLUSIONS: The results suggest that not taking routine chest x-rays of infants with clinically suspected viral bronchiolitis is a cost-effective strategy compared with the common practice of taking them in all cases, since the former yields a greater proportion of correct diagnoses at a lower average cost per patient. Nevertheless, new studies will be needed that have more representative samples from all of the health facilities and include the strategy of taking chest x-rays only of patients with predictors of radiologic abnormalities.

[CT imaging features of bronchiolitis]. / Aspect TDM des bronchiolites.

Bronchiolitis may be encountered in numerous clinical circumstances. Previous history of smoking, infections, toxic exposure, immunodeficiency, chronic inflammatory disorders or transplantation must be known. CT findings consist in centrilobular micronodules with sharp or ill borders of various density and/or a mosaic attenuation with expiratory air trapping. Tree-in-bud pattern suggest an inflammatory or infectious bronchiolitis. The associated presence of bronchiectasis and bronchiolectasis must be considered. Imaging-pathologic correlations will be presented for inflammatory bronchiolitis (infectious bronchiolitis, hypersensitivity pneumonitis, respiratory bronchiolitis, follicular bronchiolitis, diffuse panbronchiolitis) and fibrosing bronchiolitis (constrictive bronchiolitis, post-infectious bronchiolitis, toxic fume exposure, transplant-related bronchiolitis).

Late onset of spontaneous pneumothorax complicating acute bronchiolitis in a 5-month-old infant: case report and literature review.

The literature contains only a few reported cases of spontaneous pneumothorax complicating acute bronchiolitis in infants. We present a case of a 5-month-old infant with a presentation of spontaneous pneumothorax 7 days after hospitalization for acute bronchiolitis. The characteristics of this particular manifestation are discussed.

[Severe bronchiolitis. Epidemiology and clinical course of 284 patients]. / Bronquiolitis grave. Epidemiología y evolución de 284 pacientes.

INTRODUCTION: Bronchiolitis is the leading cause of hospital admission and a frequent cause of pediatric intensive care unit (PICU) admission among infants during the winter months. The objective of this study was to analyze the characteristics and clinical course of patients admitted to the PICU for bronchiolitis. PATIENTS AND METHOD: We performed a descriptive, observational study by clinical chart review of all patients admitted to the PICU for severe bronchiolitis from November 1994 to March 2006. RESULTS: A total of 284 patients were included. Most were admitted during December and January and 74% had respiratory syncytial virus (RSV) infection. At least one risk factor for severe disease was present in 68% of the patients: the most frequent risk factor was age < 6 weeks (45%), followed by prematurity (30%). Mechanical ventilation was required in 64 of the 284 patients (24%). Mortality was 1.8% and was associated with chronic pre-existing illness (p < 0.001). The factors associated with a greater risk of mechanical ventilation and a longer PICU stay were the association of two or more risk factors (42/284; 15%), the presence of apnea (73/284; 25.7%), and images of pulmonary consolidation or atelectasis on admission chest X-ray (157/284; 55%). CONCLUSIONS: Most patients admitted for severe bronchiolitis to the PICU are healthy infants whose principal risk factor is young age. The main predictors of severe clinical course during PICU stay are the association of two or more risk factors, the presence of apnea, and pulmonary consolidation on admission chest X-ray. Bronchiolitis-associated mortality is low and is associated with pre-existing chronic illness.

Beta-agonist aerosol distribution in respiratory syncytial virus bronchiolitis in infants.

UNLABELLED: Bronchodilator aerosols are frequently administered to infants with bronchiolitis but with little success. The efficacy of aerosol treatments depends mainly on adequate targeting of the aerosol particles to the inflamed airways. This study evaluated the lower respiratory tract distribution characteristics of nebulized bronchodilators in infants with acute bronchiolitis. METHODS: Twelve infants (mean age +/- SD, 8 mo +/- 4 mo) who were admitted for acute respiratory syncytial virus bronchiolitis were treated with (99m)Tc-albuterol aerosol. Gamma-scintigraphy was used to assess total body and lung deposition as well as pulmonary distribution of the medication. RESULTS: Of the total 6-min nebulized dose (i.e., drug aerosol dose leaving the nebulizer [not the nebulizer charge]), 1.5% +/- 0.7% reached the right lung, with only approximately one third of that (0.6%) penetrating to the peripheral lung zone. There was 7.8% +/- 4.9% deposition in the upper respiratory and gastrointestinal tracts and 10%-12% remained on the face. No correlation was found between any of the deposition indices and the clinical response data or any of the demographic parameters (e.g., height, weight, body surface area, or clinical score). CONCLUSION: Poor total aerosol deposition in infants may be related as much to their small conducting airways as to the disease state. There is considerable room for improvement in aerosol delivery in this age group, with greater emphasis on targeting narrowed peripheral airways with superfine aerosols.

Efficacy of recombinant human deoxyribonuclease I in the hospital management of respiratory syncytial virus bronchiolitis.

OBJECTIVE: To evaluate the effect of recombinant human deoxyribonuclease I (rhDNase) in shortening the length of the hospitalization and improving the chest radiographs (CXRs) in hospitalized infants with respiratory syncytial virus (RSV) infection as a result of its mucolytic properties. METHODS: Randomized, double-blind, placebo-controlled investigation of 75 patients with RSV bronchiolitis. The study was conducted at the University of Michigan Medical Center and St. Joseph Mercy Hospital, both in Ann Arbor, MI. RESULTS: The respiratory rate, wheezing, and retraction difference scores, obtained by subtracting the hospital discharge score from the corresponding hospital admission score, show no difference between the two groups, but the CXR difference scores show that the rhDNase group improved by 0.46 while the placebo group worsened by 0.60 (p < 0.001). Analysis of covariance for the hospital discharge CXR score after adjusting for the hospital admission score for both groups was done. There was a difference in scores between the two groups, with adjusted mean for the study group of 2.03, and 2.76 for the placebo group (p < 0.001). Paired t test statistics in each of the two groups were computed. For the placebo group, the mean increase of 0.60 was significant (p = 0.02), and the mean decrease of 0.46 for the rhDNase group was also significant (p = 0.02). A one-way analysis of covariance with the hospital discharge CXR scores as the dependent variable and the hospital admission score as the covariate showed that there was a significant difference between the groups (p = 0.01). CONCLUSION: In patients with RSV bronchiolitis, there was significant improvement in the CXRs with the use of rhDNase compared to significant worsening in the placebo group. To our knowledge, this is the first report of the use of rhDNase to treat RSV bronchiolitis.

Adenovirus bronchiolitis in Manitoba: epidemiologic, clinical, and radiologic features.

We reviewed our experience with 41 children hospitalized from 1974 to 1978 for adenovirus (ADV) bronchiolitis. Thirty-two patients (78 percent) were native Indians between four and 12 months old. In 18 of the 41 patients (43.9 percent) acute complications developed. The five fatal cases (12.2 percent) were confined to native children. The initial chest roentgenograms showed lobar consolidation in 35 patients (85.4 percent). Atelectasis developed in five (12.2 percent) during hospitalization. Sixteen of 25 patients (64 percent) with adequate radiologic follow-up examination had subsequent pneumonias or showed residual chronic changes. The reasons for the predilection of ADV bronchiolitis in native Indian children and the precise effect on subsequent airway function in survivors are unknown and require further study. We emphasize the importance of ADV as a cause of bronchiolitis in native Indian children. Furthermore, this report focuses attention on the contribution of this disease to the spectrum of chronic pulmonary disorders in the pediatric group.

Observer variation in detecting the radiologic features associated with bronchiolitis.

Chest radiographs are commonly obtained to assess children for bronchiolitis, both to corroborate the diagnosis and to exclude other diagnostic possibilities. Their utility in this setting has not previously been examined. Using a blinded, randomized study design, we examined the interobserver and intraobserver variation in the detection of the radiologic features of bronchiolitis from the chest radiograph using "weighted kappa" statistics. This observer variation was compared with that found by other authors for other diagnoses. We also determined the reported presence of these radiologic features in radiographs from patients with bronchiolitis as compared with normal controls. Our study showed acceptable interobserver (kappa = 0.40-0.66) and intraobserver agreement (kappa = 0.50-0.78) on the radiologic features of bronchiolitis relative to other diagnoses. We demonstrated a higher reported presence of these accepted radiologic features in patients with bronchiolitis as compared to controls. Although kappa statistics are widely used in studies of observer variation, "weighted kappa" has received little attention in the radiologic literature. This statistical analysis allows observers to equivocate on the presence or absence of a feature and therefore allows the format of observer variation studies to simulate more closely the normal clinical setting.

Imaging of small airways diseases.

The idiopathic (BOOP) and secondary forms of proliferative bronchiolitis have similar radiographic appearances. Both are characterized radiographically by patchy airspace disease, which often is peripheral. The radiographic presentation of BOOP may have prognostic significance. In primary or secondary constrictive bronchiolitis, the chest radiograph often is nonspecific, but the CT appearance of patchy, lobular areas of hyperlucency, with or without bronchiectasis, may be diagnostic. Respiratory bronchiolitis usually can be distinguished from IPF on the chest radiograph, and the diagnosis may be suggested on HRCT by the presence of hazy increase in lung density or fine centrilobular nodules.

Chronic unilateral hyperlucent lung. A consecutive series of 40 patients.

A clinical series of 40 consecutive patients with chronic unilateral hyperlucent lung was analysed. Swyer-James (MacLeod) syndrome turned out to be the most common diagnosis (18 patients, 45%). Other causes were localized emphysema (8 patients, 20%), congenital hypoplastic pulmonary artery (4 patients, 10%), previous massive pulmonary embolism (4 patients, 10%), bronchial carcinoma (3 patients, 7.5%), sequelae of radiation therapy (2 patients, 5%) and benign intrabronchial neoplasm (1 patient, 2.5%). The reduction of pulmonary vasculature was scored (0-9). The most extensive reduction was found in patients with Swyer-James syndrome (mean 5.8), whereas patients with bronchial cancer had the smallest changes (mean 3.0).

Is bronchiolitis in infancy an antecedent of chronic lung disease in adolescence and adulthood?

Acute bronchiolitis in infancy appears to be associated with persistence of wheezing or subsequent asthma in later life. Chest imaging techniques have demonstrated persistent structural lung damage such as atelectasis, bronchiectasis, and obliterative bronchiolitis among survivors of the more severe forms of bronchiolitis. In addition, in a significant number of survivors without demonstrable structural damage, pulmonary function studies have revealed a spectrum of disturbances including air-trapping, reduced air flow at low lung volumes, hypoxemia (all indicating disease in the small airways), and bronchial hyperreactivity. However, it has not yet been proven definitively whether the relationship between severe bronchiolitis in infancy and chronic obstructive lung disease is causal or noncausal. Further prospective clinical studies are needed to resolve this question.

Emergency radiology in childhood.

Radiologic aspects of childhood illness and injury differ from those of adults, and specific investigational plans and techniques are necessary. In this article, common illnesses and complaints referred to the respiratory, gastrointestinal, and skeletal systems are discussed. For each, the initial radiologic examination is indicated, and follow-up consultation and investigation are described.

[Chest radiograph in bronchiolitis: is it always necessary?]. / Radiografía de tórax en la bronquiolitis: es siempre necesaria?

BACKGROUND: The routine use of chest radiograph in infants with bronchiolitis increases health costs and can often unnecessarily expose the patient to radiation. OBJECTIVES: To evaluate the prevalence of infiltrate/atelectasis in infants younger than 2 years who presented to the emergency department with bronchiolitis, to assess whether patient management is changed after viewing the chest radiograph and to determine which clinical variables can accurately identify children with normal radiographs, with a view to reducing unnecessary radiological investigations. PATIENTS AND METHODS: From October 2003 to December 2004, infants aged < 24 months evaluated in the emergency department of the Severo Ochoa Hospital (Madrid) with a diagnosis of bronchiolitis were included in this study. The variables registered were age, sex, time since onset, respiratory rate, temperature, asymmetry on auscultation, oxygen saturation and the virus identified. A chest radiograph was obtained and the need for admission was evaluated before and after obtaining the results. RESULTS: Two hundred fifty-two infants were included, of which 50 % were aged less than 5 months. Infiltrate/atelectasis was identified in 14.3 % (95 % CI: 10.1-18.5; kappa coefficient: 0.64). Patients with infiltrate/atelectasis were 2.5 times more likely to have a temperature of > or = 38 degrees C (p: 0.004), O2 saturation of < 94 % (p: 0,006) and to be admitted before the results of chest radiograph were known. No differences were found between children with and without infiltrate in age at presentation, sex, disease duration, respiratory rate or identified virus. Patient management was modified in 30 % of patients with infiltrate/ atelectasis. Patients with a temperature of < 38 degrees and O2 saturation of > 94 % had a 92 % probability of normal chest radiograph. CONCLUSIONS: Most infants presenting with bronchiolitis had a normal chest radiograph. Temperature >or = 38 degrees and O2 saturation < 94 % were significantly associated with infiltrate/atelectasis. In most infants with bronchiolitis, the absence of fever and hypoxia are good predictors of normal chest radiographs.

[Bronchiolitis. Our clinical experience in the 4 years from 1981 to 1984]. / La bronchiolite. La nostra esperienza clinica nel quadriennio 1981-1984.

The clinical experience of 661 children with bronchiolitis is reported in four-years period to gain a better understanding of diagnosis and pathogenesis of bronchiolitis. Upper airways infections, expiratory dyspnea, clear sound by chest percussion, vesicular rales and whistling by chest auscultation, air trapping on the chest radiography were considered as essential data of diagnosis. It was found in 595 patients: expiratory dyspnea, air trapping, vesicular r. and whistling in 85% and whistling only in 15%; hypoxemia in 20% combined with hypercapnic acidosis in 10%; normoxemia in 80% combined with hypocapnia in 54%; hyperlactemia in 64% combined with an increment in the serum of CPK in 50% and of GPT in 30%; virus were cultured in 27%, adenovirus and RSV were identified in 90%. Instead it was found in 66 patients: air trapping but no difficult breath, with normal chest auscultation; crisis of cyanosis or paleness-cyanosis chilly sweat in 80% were motive of admission. The clinical and/or radiological features of "air trapping" were considered as essential symptoms and signs of bronchiolitis. The insufficient systemic perfusion was considered as a frequent occurrence and as cause for sudden respiratory and circulatory emergency.

["Minimal" viral pneumopathies and respiratory virosis in Campagna in 1978: pathology for research]. / Pneumopatie virali "minime" e virosi respiratoria campana del 1978: patologia da ricercare.

High frequency of bronchilitis, 70% of 1117 infants with respiratory infections, and clinical, radiological and laboratory features concerning partial tension of haematic gases, haematic lactate, enzymic activities of serum (CK, GPT, GOT) in 31 infants hospitalized with symptoms of shock in course of respiratory infections apparently affecting the upper respiratory tracts, are reported. This minimal respiratory pathology, evidenced in 3% of 1117 infants, defined as "minimal" viral pneumopathy, can be brought out trough a shock: lactacidosis, combined in half the cases with an increase of serum levels of CK and GPT and with normal PaO2 was ascertained in 87% of the cases. Three groups of bronchiolitis can be differentiated by haemogasanalytic monitoring: 1st group with a "serious" respiratory functional damage (hipercapnia hypoxemia), 14%. 2nd group with a "moderate" damage (normocapnia-hypoxemia), 20%. 3rd group with a "sligth" damage (hypocapnia-normoxemia), 66%. Decompensated shock is considered as a frequent occurrence and it is referred to the widespread involvement of the pulmonary circulation caused by the immunity-flogistic process.

[Lung sequestration; a rare congenital lung disorder]. / De longsekwester; een zeldzame congenitale longaandoening.

Pulmonary sequestration is a rare congenital malformation. It is characterized by an abnormal arterial supply and venous drainage and a part of the lung which is not taking part in ventilation. Asymptomatic cases have been reported, but 37% of intralobar and 60% of extralobar sequesters became symptomatic before the age of ten years and need to be removed surgically. In this article one case-report illustrates the clinical course described in most cases whilst the other describes a patient in which the course mimicked an 'untreatable' bronchiolitis.