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.

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.

[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.

Automatic detection of tree-in-bud patterns for computer assisted diagnosis of respiratory tract infections.

Abnormal nodular branching opacities at the lung periphery in Chest Computed Tomography (CT) are termed by radiology literature as tree-in-bud (TIB) opacities. These subtle opacity differences represent pulmonary disease in the small airways such as infectious or inflammatory bronchiolitis. Precisely quantifying the detection and measurement of TIB abnormality using computer assisted detection (CAD) would assist clinical and research investigation of this pathology commonly seen in pulmonary infections. This paper presents a novel method for automatically detecting TIB patterns based on fast localization of candidates using local scale information of the images. The proposed method combines shape index, local gradient statistics, and steerable wavelet features to automatically identify TIB patterns. Experimental results using 39 viral bronchiolitis human para-influenza (HPIV) CTs and 21 normal lung CTs achieved an overall accuracy of 89.95%.

[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).

[Unusual course of a Guillain-Barré syndrome in connection with an RS-Virus infection in a 10 months old infant]. / Ungewöhnlicher Verlauf eines Guillain-Barré-Syndroms im Zusammenhang mit einer RS-Virusinfektion bei einem 10 Monate alten Säugling.

Guillain Barré syndrome (GBS; Synonyma: Polyneuritis, Polyradikulitis) is an acute, inflammatory, demyelinating disease of the peripheral nerve system. Clinical hallmarks are symmetric muscle paralysis, areflexia and pronounced autonomic disturbances. Respiratory failure and cardiovascular instability are the main reasons for intensive care support in patients with GBS. We present the process of illness of an 10 month old baby with GBS. The report discusses RSV as possible triggers. For children with ARDS, a nitric oxide ventilation could represent a lifesaving option.

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.

[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.

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.

Previously healthy infants may have increased risk of aspiration during respiratory syncytial viral bronchiolitis.

OBJECTIVE: Respiratory illnesses may cause feeding difficulties in infants. We studied the safety of oral feeding during respiratory syncytial viral (RSV) bronchiolitis in previously healthy infants. METHODS: Twelve previously healthy infants (3-12 months) with RSV bronchiolitis underwent barium swallow studies during the acute phase of illness. Those with abnormal studies underwent repeat studies 2 to 4 weeks later. RESULTS: The initial barium studies revealed aspiration in 3 infants. All repeat studies, performed 2 to 4 weeks later, were normal. CONCLUSIONS: Even previously healthy infants may be at risk of aspiration during RSV bronchiolitis.

Association of fever and severe clinical course in bronchiolitis.

Little attention has been given to the relation between fever and the severity of bronchiolitis. Therefore, the relation between fever and the clinical course of 90 infants (59 boys, 31 girls) hospitalised during one season with bronchiolitis was studied prospectively. Fever (defined as a single recording > 38.0 degrees C or two successive recording > 37.8 degrees C) was present in 28 infants. These infants were older (mean age, 5.3 v 4.0 months), had a longer mean hospital stay (4.2 v 2.7 days), and a more severe clinical course (71.0% v 29.0%) than those infants without fever. Radiological abnormalities (collapse/consolidation) were found in 60. 7% of the febrile group compared with 14.8% of the afebrile infants. These results suggest that monitoring of body temperature is important in bronchiolitis and that fever is likely to be associated with a more severe clinical course and radiological abnormalities.

Lobar emphysema associated with respiratory syncytial virus pneumonia.

The etiology of infantile lobar emphysema is frequently unknown; however, partial airway obstruction is most often implicated. Although infection and lobar emphysema have been linked previously, their cause-and-effect relationship is unclear. We present the clinical, radiographic, and pathologic findings in a 9-day-old infant with acute bronchiolitis due to respiratory syncytial virus (RSV) and a clinical and radiographic appearance suggestive of lobar emphysema. Pathologically, there was diffuse papillary overgrowth of the bronchiolar epithelium due to RSV infection which produced narrowing of the affected airways and alveolar overinflation. We speculate that in this instance RSV infection was at least associated with the development, and was perhaps the direct cause of lobar emphysema.

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.