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About 80 years ago, Hubble and Osborn described acute viral bronchiolitis (AVB) as a disease with obstructive dyspnea distinct from acute respiratory disease and specifically affecting young children. At the time, there was already a remarkable understanding of its characteristics, including the staggering speed with which mild symptoms can progress to life-threatening illness. AVB is currently one of the most common causes of non-elective admission to Pediatric Intensive Care Units (PICU). Although initially reported as an underweight disease, AVB is now considered to have a substantial impact on the overall health of children under 2 years of age (mostly under 6 months of age), with significant morbidity and mortality.1,2
In the late 1950s, it was discovered that the syncytial virus Respiratory (RSV) is one of the main pathogens that cause AVB, responsible for 50 to 80% of cases.1,2 Even the World Health Organization (WHO) considers the prevention of lower respiratory tract infection by RSV as a fundamental priority, due to the substantial morbidity and mortality it causes in young children. RSV infection is estimated to result in more than 3 million hospitalizations and approximately 199,000 deaths annually in children under 5 years of age, with 99% of deaths occurring in low- and middle-income countries. 3,4
The incidence of AVB is higher in the autumn and winter months, being considered a seasonal viral disease. The frequencies of respiratory virus detection in the various regions of the world depend mainly on climatic, sociodemographic and cultural factors, and may even vary from year to year. In Brazil, the peaks of RSV circulation occur between the months of January and June, with greater prevalence in the Southeast, Northeast and Midwest regions in the months of April and May. In the southern region, the peak occurs between June and July, at a later time.5,6 In mid-March 2020, due to the pandemic caused by the new coronavirus disease (Covid-19), social isolation was recommended in Brazilian territory , aiming to reduce the dissemination of the severe acute respiratory syndrome coronavirus 2 (Severe Acute Respiratory Syndrome Coronavirus 2 – SARS-CoV-2), and this may have been one of the factors that contributed to the change in the seasonality of childhood respiratory diseases, in which AVB cases were rare, reflecting in the reduction unexpected increase in the number of pediatric admissions during this period. 7,8
Learn more: Use of non-invasive ventilation in the treatment of bronchiolitis: is there an improvement in the prognosis?
Despite the change regarding seasonality, AVB in pediatrics is still a huge challenge. Even with great advances in pediatric intensive care medicine, treatment remains symptomatic and supportive, as no specific treatment has yet been shown to be effective. Furthermore, morbidity and mortality is still quite high. Thus, this article consists of a narrative review of the literature, showing an overview of AVB in pediatrics, including updated data on etiology, epidemiology, diagnostic methods, therapeutic approaches and prevention measures.
AVB is broadly defined as a clinical syndrome of respiratory distress that occurs in children under 2 years of age. age and is characterized by the presence of upper respiratory symptoms, such as rhinorrhea, followed by lower respiratory infection with inflammation, resulting in wheezing and/or rales. It usually occurs with primary infection or reinfection with a viral pathogen. In young children, clinical diagnosis may overlap with virus-induced recurrent wheezing and virus-triggered acute asthma. For clinical research purposes, AVB is usually defined as the first episode of wheezing in a child under 12 to 24 months of age who presents with physical findings of a viral lower respiratory infection and no other explanation for the occurrence of wheezing.9.10 However, despite the relevance of this concept, a new infection caused by the same agent or by another pathogen can occur. Therefore, a second episode of BVA cannot be excluded in this context.11
Etiology
RSV is the most common etiologic pathogen in AVB. It is an RNA virus of the family Paramyxiviradae. There are two subtypes : A (which usually causes more severe disease) and B. The dominant strains vary from year to year. Furthermore, RSV infection does not determine lasting immunity, which favors the emergence of reinfections. 11.12
Other viruses, including rhinoviruses (second most common agent), influenza, parainfluenza type 3, adenoviruses and enteroviruses are also associated. More recently, some studies have shown that human bocaviruses and human metapneumoviruses can also be etiologic agents of AVB, either alone or by coinfection. 2,10,11,13
Human coronaviruses are also associated with AVB. However, coronaviruses from infections in animals cause epidemics and pandemics when transmitted to humans, with potentially very serious infections and high fatality rates.13 In the case of children with Covid-19, infected with the severe acute respiratory syndrome coronavirus 2 (Severe Acute Respiratory Syndrome Coronavirus 2 – SARS-CoV-2 ), there is histopathological evidence of AVB signs with an increased infiltration of immune cells into the bronchial epithelium and adjacent alveolar wall. Therefore, it is important to maintain a high level of suspicion in young children with respiratory conditions, regardless of an initially negative RT-PCR test, even when other causes of AVB are not identifiable. 6,14,15
In addition, although they are not viruses and do occur more rarely, there are reports in the literature of bronchiolitis by Mycoplasma pneumoniae, Bordetella pertussis, Simkania negevensis, and an intracellular organism similar to Chlamydia also showed in bronchiolitis. 2,9,11 Epidemiology
BVA usually affects babies and children under two years old, especially during autumn and winter. Hospitalization has an incidence peak between two and six months of age: it is the leading cause of hospitalization in infants and young children.9 About 2 to 3% of infants who develop bronchiolitis in the first year of life require hospitalization.16.17 In a study carried out in Italy, Lanari et al. (2015) described that the hospitalization rate for bronchiolitis is 5.4% in premature babies in the first 12 months of life.18 Furthermore, it remains a significant cause of respiratory illness during the first five years of life.9
In Brazil, between January 2008 and December 2015, there were 263,679 hospitalizations for AVB in babies under one year of age, 60% of whom were male. The incidence of hospital admissions for AVB increased by 49% over this period (8.5 to 12.7 per mile-habitants/year).19 However, as mentioned earlier, social isolation due to the Covid-19 pandemic has reduced the number of admissions by respiratory conditions in pediatrics. According to data from the Information Technology Department of the Unified Health System (DATASUS), there was a reduction of more than 70% in hospital admissions for babies under one year of age in all regions of the country, and the incidence from April to June 2020 was the lowest in the last 5 years. 7,8
In a recent study, Leung et al (2020) observed that hospitalization for AVB in children was associated with temperature and exposure to nitrogen dioxide and breathable suspended particulates at different delay times, suggesting the need to adopt sustainable clean air policies, especially to direct pollutants produced by motor vehicles.20
In general, AVB is a self-limited disease, with a low mortality rate (16.17
Risk factors
There are several predisposing conditions for the development of RSV infection in infants: Presence of an older brother;
Be born in the seasonality period of the VSR;
- Male;
- Young age (
Exposure to smoke;
- Prematurity (gestational age ≤ 36 weeks);
Low weight at birth;
- Age under 12 weeks;
Donate chronic lung disease, particularly bronchopulmonary dysplasia and cystic fibrosis;
- Congenic cardiopatics;
Neurological disease such as cerebral palsy;
A transmission of the etiological agent of AVB usually occurs through direct contact or close to secretions contaminated by droplets or fomites. The incubation period varies from 2 to 8 days, with an average of 4 to 6 days. The period of viral spread is usually 3 to 8 days. However, it can be prolonged, especially in younger infants, in which the spread may persist for a period of 3 or 4 weeks. 21
AVB occurs when viruses infect terminal bronchiolar epithelial cells, causing direct damage and inflammation in the small bronchi and bronchioles. The occurrence of edema, excess mucus and desquamated epithelial cells lead to obstruction of the small airways and, consequently, to atelectasis. Pathological changes begin 18 to 24 hours after infection, according to biopsy or necropsy samples performed in severe cases and animal studies, and include bronchiolar cell necrosis, ciliary disruption and peribronchiolar lymphocytic infiltration9. Bronchiolar obstruction with edema and accumulation of mucus and cellular debris in the airways may persist for many weeks or months after AVB. The rebuild process can result in complete recovery. However, it can also be characterized by an exaggerated proliferation of granulation tissue. Due to the fact that exaggerated proliferation of degranulation tissue causes narrowing or obliteration of the airway lumen, serious clinical findings can be seen in some cases. two
Infants are predisposed to AVB due to the small caliber of their distal airways and the lack of active immunity against respiratory viruses. Viral replication induces the production of inflammatory mediators by infected respiratory epithelial cells, which respond according to the viral pathogen involved. The pathogenesis of AVB, however, is still not well understood. The child’s ability to recover after RSV infection is related to secretory levels of immunoglobulins IgA, IgG and IgM and antibody-dependent cell-mediated cytotoxicity, which may explain the mild symptoms present in reinfections. Variation of clinical manifestations in young children could occur as a consequence of the lack of development of the host’s individual defenses. 21
Clinical condition
AVB may occur primarily with fever, rhinorrhea and congestion, and may progress to lower airway symptoms such as coughing, sneezing, tachypnea and signs of respiratory distress ( nasal wing beat, subcostal, intercostal or supraclavicular retractions, head bobbing and moaning), lasting an average of 7 to 10 days. On examination, the patient may present with tachypnea, hypoxemia, and tachycardia. Dehydration is observed by the decrease in the speed of peripheral capillary refill, skin turgor, presence of dry mucous membranes and fontanelle depression, which may require enteral nutrition or nasogastric tubes. Pulmonary auscultation may reveal wheezing, crackles, prolonged expiratory time, and transmission snores. The course of the disease is variable, with respiratory symptoms starting from the second to the third day, reaching their peak from the third to the fifth day. Bronchiolitis is a self-limited disease since, if there is no unfavorable evolution, recovery takes about 28 days. 9,10,12,19,22,23,24
At most of the times, the respiratory condition is of the obstructive type, with the appearance of atelectasis and pulmonary hyperinflation secondary to air trapping. More infrequently, it can progress to a restrictive condition, such as acute respiratory distress syndrome. In most patients, the condition is mild, but the severity varies greatly. More complicated cases can lead to apnea, decreased oxygen saturation and acute respiratory failure (ARF). Hypoxemia and hypercapnia can occur in children with a respiratory rate greater than 60 breaths per minute (irpm). 11
- Diagnosis
- Upper airway obstruction;
- Laryngeal obstruction;
- Pneumonia;
- Asthma;
The diagnosis is basically clinical. However, despite being nonspecific, the use of chest radiography may reveal pulmonary hyperinflation, costal arch rectification, subsegmental atelectasis, diaphragm rectification or peribronchovascular infiltrates, which do not correlate with the severity of the condition. 9,10,11,12,19,22,23,24. Chest radiography is indicated in suspected complications and not routine. 11
In a systematic review, Kirolos et al showed that, in most guidelines, the use of chest radiography, blood cultures, complete blood counts, urea and electrolyte analyzes and urine culture (to exclude urinary tract infection) has not been recommended for routine use in the diagnosis of AVB. There was agreement in most guidelines to avoid unnecessary investigations and that do not change the treatment. However, guidelines varied in establishing specific recommendations for subgroups, with a number providing recommendations for severe presentations, cases where comorbidities were present, or cases where there was diagnostic uncertainty. The viral panel has not been recommended for routine diagnostic use by most guidelines, but several recommend using these tests to group patients into cohorts or epidemiological studies25 or on suspicion of infection by influenza, in which antiviral agents may be considered. 12
The use of arterial blood gases can help in the assessment of the patient who is showing signs of IRA. However, the clinic is the most important parameter to assess these signs and the need for ventilatory support. 11
- Differential diagnosis
- Apnea;
-
- Worsening of the general condition;
- Respiratory discomfort: moaning, chest retraction, tachypnea with respiratory rate greater than 60 bpm, central cyanosis, saturation
- Dehydration;
- Food refusal, decreased intake, reduced urinary output for 12 hours;
- Comorbidities: dysplasia, heart disease, immunodeficiency, neuromuscular disease, others;
- Age under 3 months;
-
- Prematurity;
Once there is no definitive antiviral therapy for most causes of AVB, the management of these children should be directed towards symptomatic relief and maintenance of hydration and oxygenation. Although several medications and interventions have been studied for the treatment of AVB, at present, oxygen alone considerably improves the condition of young children with this diagnosis, and many other medical therapies remain controversial. 26
The maintenance of oral hydration and breastfeeding are central measures. However, if a hospitalized neonate is unable to feed by mouth due to tachypnea greater than 60 bpm, a nasogastric tube (NGT) can be inserted. The administration of intravenous isotonic fluids does not appear to be superior to nasogastric hydration. in the and however, it is used in children in the PICU, in those patients with a condition of exhaustion and when there is no tolerance to SNG. 3
Patients who have the following situations must be hospitalized:
Discharge criteria include improvement in respiratory distress and respiratory rate according to age, oxygen saturation (> 90% to> 94%) , adequate oral nutrition and the caregiver’s ability to deal with the child with AVB at home. 25.27
β-agonists
There is no evidence that the use of systemic or inhaled corticosteroids demonstrate benefits in the management of AVB10, being, therefore, contraindicated.29 Aerosolized recombinant human DNAse
Randomized controlled studies evaluating aerosolized recombinant human DNAse in AVB showed no differences between the intervention and placebo groups in terms of length of hospital stay, duration of oxygen therapy, improvement in symptoms, and number of PICU admissions . However, as these drugs can be effective in patients with atelectasis, bronchial secretions and plugs of mucus with a high concentration of DNA, further studies are needed in these patients.27
Antivirals
Ribavarin is an antiviral that has shown limited benefits and should not be used routinely, as its use is difficult, costly and potentially toxic, with risks to caregivers.11.12
Antibiotics
Routine antibiotic therapy is not recommended: it should only be used in specific cases of bacterial coinfection. Documented secondary bacterial infection such as urinary tract infection, pneumonia, or acute otitis media (AOM) should be treated appropriately. AOM is present in 50% of patients in some case series, although the RSV itself can cause it. The anti-inflammatory and immunomodulatory effects of macrolides on AVB by RSV have been studied. However, the beneficial effects of azithromycin and clarithromycin seem to be marginal and may be related to the coexistence of atypical bacteria.27
Surfactant
According to Piva et al. (2015), some studies concluded that mechanically ventilated infants with AVB could benefit from use of surfactant, at a dose of 50 to 100 mg/kg. For the authors, the evidence is weak (level 2-b), but this approach could be used in cases where the evolution during mechanical ventilation (MV) was not favorable.29
- Apnea and cyanosis in infants under 3 months of age;
- Worse of dyspnea;
- Eminent signs of fatigue;
- Sensory alteration (agitation/hypoactivity); 29
- Need for larger oxygen supplies to maintain oxygen saturation above 90%;
- Metabolic acidosis associated or not with respiratory acidosis.29
For babies with severe AVB, non-invasive methods such as continuous positive nasal airway pressure (Continuous Positive Airway Pressure
– CPAP), positive pressure at two levels in the airways (Bilevel Positive Airway Pressure – BiPAP) and CNAF, have been proposed to avoid further deterioration that requires intubation and invasive MV.31 CPAP
- Peak Inspiratory Pressure (PIP): in AVB, there is great resistance of the lower airways. Therefore, the use of low PIP does not allow the ventilation of these areas, with consequent collapse and atelectasis. As PIP is increased, there is a progressive inclusion of areas of atelectasis or partially obstructed in the respiratory cycle. Therefore, there is a need for increasingly lower fraction of inspired oxygen (FiO2). Most studies have recommended a PIP between 25 and 32 cmH2O, even in babies younger than 3 months;
- Inspiratory Time (TI): It should be prolonged (0.7-0.9 seconds), to allow obstructed areas to also be ventilated;
- FR: Must be low (16-24 irpm);
-
- FiO2: As there is an adequate tidal volume, the FiO2 will be progressively lower, remaining between 0.3 and 0.5 so that the saturation is around 90%;
- Read too: Study shows more evidence that the use of bronchodilators is not effective in the treatment of bronchus uiolite
Prevention
Suitable for infants under 3 months old with AVB and dysfunction moderate to intense respiratory. It must be used through nasal prongs, applying pressures between 5 and 12 cmH2O.29 Its objective is to maintain airway patency during expiration, preventing bronchioles from collapsing and allowing air to exhale from the alveoli.11 Non-invasive ventilation (NIV)
Indicated in moderate to severe AVB. It should be applied through a nasal or oral/nasal mask, with caution when adjusting the mask to the child’s face, minimizing leakage and exaggerated compressions. In some situations, it is necessary to use mild sedatives so that the patient can adapt to ventilation. The use of specific devices for NIV in the pediatric age group is recommended, such as devices that have systemstrigger sensitive, adequate alarms and with independent controls for numerous variables. In BVA, the ideal is that the IPAP is progressively adjusted 12 to 18 cmH2O, with a mandatory respiratory rate (RR) between 20 and 30 bpm.29
CNAF
Non-invasive method of ventilatory support alternative to conventional oxygen therapy that has get highlighted. Provides a mixture of heated and humidified gases through a nasal cannula, an FiO2 up to 1.0 and a maximum flow of 60 L/min.
32Invasive VM
Piva and collaborators (2015) recommend the following strategies:
Positive Final Pressure (PEEP): in most researches, it is around 4 to 6 cmH2O . Its use does not have a great impact on improving oxygenation, as hypoxemia depends on the tidal volume in this case. However, as the alveolus becomes more compromised, as in acute respiratory distress syndrome, oxygenation becomes refractory to increases in PIP and FiO2, which makes it dependent on PEEP.29
High frequency oscillatory ventilation (VAFO)
VAFO has been successfully used in infants with AVB and severe hypoxemia. However, there is a risk of air trapping in obstructive diseases such as AVB. In addition, further research is needed to evaluate its use in patients with hypercapnic respiratory failure.27 Extracorporeal membrane oxygenation (Extracorporeal Membrane Oxygenation
— ECMO)
It can be indicated in severe cases, refractory to other interventions.27
- Natalia Bonfim dos Santos. Medical Student – Souza Marques School of Medicine
Author:
- GÖKÇE, S. One of the Main Problems of Infants: Bronchiolitis, Update on Critical Issues on Infant and Neonatal Care, René Mauricio Barría.
IntechOpen, 2019. - CABALLERO, M. T.; POLACK, F. P.; STEIN, R. T. Viral bronchiolitis in young infants: new perspectives for management and treatment. Jornal de Pediatria (Rio J.), v. 93, supl. 1, p. 75-83, 2017.
- CARBONELL-ESTRANY, X.; RODGERS-GRAY, B. S.; PAES, B. Challenges in the prevention or treatment of RSV with emerging new agents in children from low- and middle-income countries. Expert Review of Anti-infective Therapy, v. 8, p. 1-23, 2020.
- LANGBECKER, T. B. et al. Bronquiolite aguda: Revisão Bibliográfica. In: ANAIS CONGREGA MIC – MOSTRA DE INICIAÇÃO CIENTÍFICA E ANAIS MIC JR – MOSTRA DE INICIAÇÃO CIENTÍFICA JR. Anais. Bagé, RS: Centro Universitário da Região da Campanha, 2016.
- KENMOE, S. et al. Systematic review and meta-analysis of the prevalence of common respiratory viruses in children PLoS One, v. 15, n. 11, p. e0242302, 2020.
- FRIEDRICH, F. et al. Early Impact of social distancing in response to Covid-9 on hospitalizations for acute bronchiolitis in infants in Brazil. Clinical Infectious Diseases, v. 28, p. ciaa1458, 2020.
- NASCIMENTO, M. S. et al. Impact of social isolation due to Covid-9 on the seasonality of pediatric respiratory diseases. PLoS One, v. 15, n. 12, p. e0243694, 2020.
- PIEDRA, P.; STARK, A. Bronchiolitis in infants and children: Clinical featuresand diagnosis. 2020. Disponível em: https://www.uptodate.com/contents/bronchiolitis-in-infants-and-children-clinical-features-and-diagnosis. Acesso em: 07/02/2021.
- MOREIRA, M. C. A.; COSTA, L. D. C. Bronquiolite. In: COSTA, P. S. S.; NAGHHETTINI, A. V. (autores); PORTO, C. C.; PORTO, A. L. (ed.). Pediatria na Prática Diária. Rio de Janeiro: Guanabara Koogan, 2021. Cap. 37. p. 115-117.
- MARÓSTICA, P.; PIVA, J. P. Bronquiolite Viral Aguda. In: PIVA, J. P.; GARCIA, P. C. R. Medicina Intensiva Pediátrica. 2. ed. Rio de Janeiro: Revinter, 2015. Cap. 50, p. 1127-1152.
- KFOURI, R. A. Profilaxia das infecções causadas pelo vírus sincicial respiratório (VSR). 2010. Revista Imunizações da SBIM, v. 3, n. 10, p. 80-87, 2010.
- ALMEIDA, F. J.; OTSUKA, M.; BEREZIN, E. Síndrome respiratória pelo novo coronavírus (2019N-CoV): o que precisamos saber?. 2020. Disponível em: https://www.spsp.org.br/2020/02/06/sindrome-respiratoria-pelo-novo-coronavirus-2019n-cov-o-que-precisamos-saber/. Acesso em: 07/02/2021
- ANDRÉ, M. C. et al. Can SARS-CoV-2 cause life-threatening bronchiolitis in infants? Pediatric Pulmonology, v. 55, n. 11, p. 2842-2843, 2020.
- MANSBACH, J. M. et al. Severe Coronavirus Bronchiolitis in the Pre-Covid-19 Era. Pediatrics, v. 146, n. 3, p. e20201267, 2021.
- COSTA, D. et al. Destacando tratamentos aplicados em lactentes com bronquiolite viral aguda: uma análise retrospectiva. Fisioterapia Brasil, v. 13, n. 1, p. 32-36, 2016.
- FERLINI, R. et al. Características e evolução de crianças com bronquiolite viral aguda submetidas à ventilação mecânica. Revista Brasileira de Terapia Intensiva, v. 28, n. 1, p. 55-61, 2016.
- LANARI, M. et al. Risk factors for bronchiolitis hospitalization during the first year of life in a multicenter Italian birth cohort. Italian Journal of Pediatrics, v. 41, p. 40, 2015.
- TUMBA, K. et al. Tendência temporal das hospitalizações por bronquiolite aguda em lactentes menores de um ano no Brasil entre 2008 e 2015. Revista Paulista de Pediatria, São Paulo, v. 38, p. e2018120, 2020.
- LEUNG, S. Y. et al. Short-term association among meteorological variation, outdoor air pollution and acute bronchiolitis in children in a subtropical setting. Thorax, v. 20, p. thoraxjnl-2020-215488, 2021
- AMANTÉA, S. L. Bronquiolite Viral Aguda. In: SOCIEDADE BRASILEIRA DE PEDIATRIA. Tratado de Pediatria, 2. ed. Barueri, Manole: 2017. Volume 2, Cap. 4, p.1720-1729.
- SILVER, A. H.; NAZIF, J. M. Bronchiolitis. Pediatrics in Review, v. 40, n. 11, p. 568-576, 2019.
- ALMASSIO, A. B. et al. Oxigenoterapia de alto flujo: Experiencia en pediatría en un hospital general. Medicina Infantil, v. 26, n. 4, p. 364-367, 2019.
- VÁZQUEZ LÓPEZ, B. et al . Caracterización clínico epidemiológica de lactantes con bronquiolitis aguda grave. Multimed (Granma), v. 24, n. 3, p. 499-514, 2020.
- KIROLOS, A. et al. A Systematic Review of Clinical Practice Guidelines for the Diagnosis and Management of Bronchiolitis. The Journal of Infectious Diseases, v. 222. suppl. 7, p. S672–S679, 2020.
- MARAQA, N. Bronchiolitis Treatment & Management. 2018. Disponível em: https://emedicine.medscape.com/article/961963-treatment. Acesso em: 10/02/2021.
- CARVALHO, W. B. et al. Pneumonia and Bronchiolitis. In: NICHOLS, D. G.; SHAFFNER, D. H. Rogers’ Textbook of Pediatric Intensive Care. 5. ed. Philadelphia: Wolters Kluwer Health, 2016. Chapter 1440, p.745-765.
- GADOMSKI, A. M.; SCRIBANI, M.B. Bronchodilators for bronchiolitis. Cochrane Database of Systematic Reviews, v. 6, p. CD001266, 2014.
- PIVA, J. P. et al. Ventilação Mecânica na Bronquiolite Viral Aguda – Qual seria o consenso?. 2015. Disponível em: https://www.sbp.com.br/fileadmin/user_upload/2015/02/VM_na_BVA_Consenso_AMIB-jpiva2008.pdf. Acesso em: 10/02/2021
- SELIEM, W.; SULTAN, A. M. Heliox delivered by high flow nasal cannula improves oxygenation in infants with respiratory syncytial virus acute bronchiolitis. Jornal de Pediatria (Rio J), v. 94, p. 56-61, 2018.
- CASTRO, R. E. V. Uso de cânula nasal de alto fluxo fora do ambiente da UTI Pediátrica. 2020. Disponível em: https://pebmed.com.br/uso-de-canula-nasal-de-alto-fluxo-fora-do-ambiente-da-uti-pediatrica/. Acesso em: 11/02/2021.
- Saiba como é o uso do cateter nasal de alto fluxo na pediatria. 2019. Disponível em: https://pebmed.com.br/saiba-como-e-o-uso-do-cateter-nasal-de-alto-fluxo-na-pediatria/. Acesso em: 11/02/2021.
The RSV has a high transmissibility, which contributes to increased morbidity and mortality. For this, preventive measures are necessary in order to minimize the risk of exposure. Standard strategies include hand hygiene to minimize the transmission of infectious agents. It is of great importance to inform family members about prophylaxis, during seasonality, in relation to hygiene measures, such as routine hand washing, use of alcohol gel, not exposing the baby to crowded places (delaying entry into nurseries and daycare centers) , with people presenting respiratory symptoms and in the presence of smokers (passive smoking). In addition, breastfeeding should always be encouraged until the baby is six months old. 9,10,12,19,22,23,24
In In the hospital environment, transmission control measures are used, such as isolating cases, strict hygiene of equipment, staff and visitors. As well as the use of personal protective equipment and restriction of visits.12,19,22
Palivizumab is an immunoglobulin (monoclonal antibody) indicated in cases of severe respiratory infection by RSV, in high-risk patients, such as children born with a gestational age of less than or equal to 28 weeks, children diagnosed with bronchopulmonary dysplasia and by congenital heart disease with hemodynamic repercussions. It promotes a reduction in the number of days of hospitalization, time of oxygen use and time of moderate to severe infection. It must be administered one month before the seasonality of the virus, according to the region, and has adverse effects, such as irritability at the application site, skin rash and fever. It is provided by the Ministry of Health throughout the national territory. 9,10,12,19, 22,23,24
Co-authors:
Alessandra Yutani Kuroiwa. Medical Student – Souza Marques School of MedicineGraduated in Medicine from the Faculty of Medicine of Valença ⦁ Medical residency in Pediatrics from the Cardoso Fontes Federal Hospital ⦁ Medical residency in Pediatric Intensive Medicine from the Hospital dosServers of the State of Rio de Janeiro. Master in Maternal and Child Health (UFF) ⦁ Doctor in Medicine (UERJ) ⦁ Improvement in Neurointensivism (IDOR) ⦁ Physician at the Pediatric Intensive Care Unit (UTIP) of the Pedro Ernesto University Hospital (HUPE) of UERJ ⦁ Pediatrics Professor of the course of Medicine of the Souza Marques Technical-Educational Foundation ⦁ Member of the Brazilian Network for Research in Pediatrics at IDOR in Rio de Janeiro ⦁ Followed the Pediatric and Cardiac ICU at the Hospital for Sick Children (Sick Kids) in Toronto, Canada, supervised by Dr. Peter Cox ⦁ Member of the Brazilian Society of Pediatrics (SBP) and the Brazilian Association of Intensive Care Medicine (AMIB) ⦁ Member of the committee on sedation, analgesia and delirium of the AMIB and the Latin American Society of Pediatric Intensive Care (SLACIP) ⦁ Member of the board of the American Delirium Society (ADS) ⦁ Coordinator and co-founder of the Latin American Delirium Special Interest Group (LADIG) ⦁ Supporting member of the Society for Pediatric Sedation (SPS) ⦁ Consultant for infant sleep and breastfeeding.
References:
- WELL, RA; BONT, LJ; VAN WOENSEL, JBM Life-threatening bronchiolitis in children: eight decades of critical care.
The Lancet Respiratory Medicine
, v. 8, n. 2, p. 142-144, 2020.
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Its use is very controversial.10 According to the review published in Cochrane, bronchodilators such as albuterol or salbutamol do not improve oxygen saturation, do not reduce hospital stay after outpatient treatment, do not shorten the length of hospital stay, and do not reduce the time to disease resolution at home. Given the adverse side effects and costs associated with these treatments, bronchodilators are not effective in the routine treatment of AVB.28 The American Academy of Pediatrics (AAP) does not recommend the administration of albuterol (or salbutamol) to infants and children diagnosed with AVB . 22
Its use has been associated with positive effects as it is vasoconstrictor, reducing edema of the bronchial mucosa. However, there is no evidence to support its routine use, especially at home, due to the risk of adverse events and the short action period.10 The AAP does not recommend its use.22 For the Brazilian Society of Pediatrics (SBP), its use according to the clinical response can be evaluated occasionally, but can only be maintained if there is evidence of immediate improvement. 12
3% hypertonic saline solution
It has osmotic properties, increasing the free space of the airways, through the reduction of edema, mucus production and rehydration of the airway surface. Some authors propose that nebulization with this solution may be beneficial only for hospitalized neonates, but its impact is weak in preventing hospitalizations.3 For AAP, nebulized hypertonic saline solution should not be administered to babies diagnosed with AVB in the emergency room, but it can be administered in hospitalized patients.22 Maróstica and Piva (2015) recommend it every 6 or 8 hours. 11
There is no evidence in the literature to support its use.3,11
Corticosteroids
Heliox
Heliox is a mixture of gases , containing 70 to 80% helium. The rest is made up of oxygen. It should not be used routinely, as further studies are needed.11,27 Recently, Seliem and Sultam (2018) observed a momentary beneficial effect of the Heliox mixture when administered with a high-flow nasal catheter (CNAF), in relation to the clinical picture and the exchange of blood gases in patients with AVB by RSV in the initial phase of non-invasive therapy.30
Nitric Oxide (NO)
Some patients with AVB may have elevated pulmonary arterial pressure, greater than 25 mmHg, associated with prolonged hospital stay hospital. However, there is no evidence that the use of NO is beneficial, neither as a pulmonary vasodilator, nor as a bronchodilator, in this population. 27 Indications for ventilatory support
Objective parameters :
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