15.curs bronsiolita 2014
DESCRIPTION
grigore alexandrescuTRANSCRIPT
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BRONSIOLITA 2014Carmen ZapucioiuSpital Grigore Alexandrescu
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NU EXISTA CONSENS !
DEFINITIE TRATAMENT
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Bronsiolita – afectiune inflamatorie acuta a tractului respirator inferior constand in obstructia cailor aeriene mici, initiata de o infectie virala la nivelul tractului respirator superior (VSR)
Copil < 2 ani
Este autolimitata si relativ putin influentata de interventia terapeutica agresiva
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Etiologie
• Virala (>95%):– VRS > 50%– V. paragripale, rhinovirusuri, Boca virusuri,
MPV, Adenovirusuri ( forme severe si prelungite)
• Bacteriana:– Chlamidia trachomatis– Mycoplasma( la virsta mare)– Suprainfectia bacteriana este exceptionala
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FAMILIE GEN TIP BOLI Adenoviridae Mastadenoviru
s ADV Faringita
Pneumonie
Gastroenterita
Conjunctivita
Coronaviridae Coronavirus Coronavirus uman
SARS coronaV
Rinofaringita
SARS
Parvoviridae Bocavirus Bocavirus uman
Bronsiolita
Pneumonie
Picornaviridae Rhinovirus Rhinovirus uman A - B
Rinofaringita
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FAMILIE GEN TIP BOLI
Paramixoviridae
MPV HMPV Faringita
Bronsiolita
Pneumonie
Pneumovirus
VSR Crup
Pneumonie
Bronsiolita
Respirovirus
Paragrip 1,3 IACRS
Bronhopneum
Rubulavirus
Paragrip 2,4 Crup, faringita
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Virusul sincitial respirator
• In emisfera nordica – zona temperata noiembrie – aprilie, cu varf in ianuarie- februarie
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PARAINFLUENZA
• Cel mai frecvent tipul 3, dar si 1,2
• Epidemii la inceput de primavara
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METAPNEUMOVIRUS
• Paramyxovirus – prima descriere in 2001
• Se asociaza cu alte virusuri
• La copil produce pneumonie sau bronsiolita
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INFLUENZA
• Asemanator clinic cu RSV si parainfluenza
• Distributie sezoniera ca RSV
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RHINOVIRUS
• Peste 100 serotipuri
• Principalul agent etiologic in sezonul rece pentru raceala comuna
• Se asociaza cu infectii de tract respirator inferior la copiii cu boli pulmonare cronice
• Se asociaza cu alte virusuri
• Mai frecvent primavara
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CORONAVIRUS
• Locul 2 in etiologia racelii comune
• La copil determina bronsiolita
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HUMAN BOCAVIRUS
• Descoperit in 2005
• Produce bronsiolita si manifestari pertusis-like
• Toamna si iarna
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- 81% - la copii < 1 an- Durata medie de spitalizare 3 zile- Rata de spitalizare s-a dublat in ultimii 20 ani- 62% baieti
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MPV17%
ADV1%
EnteroV1%
PG 34%
RhV8%
BocaV1%
PG 11%
VSR66%
CoronaV1%
Totalul cazurilor pozitive la testari 193
VSR = 130 MPV = 32 RhV = 15 PG 3 = 7EnteroV , PG 1, ADV, BocaV = 2 CoronaV = 1
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Patogenie
-Virusul patrunde la nivelul celulelor bronhiolelor terminale detrminand inflamatie- modificarile incep la 18 – 20 ore de la infectie- necroza celulara bronsiolara, rupturi ciliare, infiltrare limfocitara peribronsiolara- edem, mucus, obstructie , atelectaza
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►Semne de infectie virala :- febra - rinoree- tuse
► Manifestari datorate tractului respirator inferior:- polipnee- tiraj - hiperinflatie
+ definitoriu – Wheezing – nordamericani + raluri crepitante, subcrepitante, sibilante, ronflante +/- Wheezing - pentru britanici
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Coinfectie virala 10 – 30 %
VSR MPV RHV Influenza Parainfluenza
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Bronsiolita evolueaza in 2 faze:
1.Rinofaringita 2.Bronsiolita propriu-zisa
3-8% evolutie la IRA din care10-15% internati in ATI
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Severitate Usoara Medie Severa
Alimentatie po
Posibila Dificila Imposibila
Detresa respiratorie
- Medie Severa
Hipoxemie saO2<92%
- Da corectabila cu O2
Da posibil necorectabila cu O2
Apnee - Posibil scurte
Posibil frecvente si prelungite
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FORMA USOARA MEDIE SEVERA
Sa O2 +/- + +
ASTRUP - - +
Ionograma - +/- +
Rx pulmon - +/- +
O2 - + +
PEV - +/- +
monitoriz - + +
Dispens MF La 2-3 zile
La 7 zile de la externare
La 7 zile de la externare
Spitalizare - + +
Altele Trat la domic Internare sectie
Consult ATI
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SCORUL RESPIRATOR
CINCINATI
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0 1 2 3
FR – NN
sugar
copil
<60
<40
<30
60-80
41- 60
31 - 40
81-99
61 – 79
41 - 59
>100
>80
>60
SaO2 >94 90-93 86-89 <86
Stare generala
Constient calam
Usor iritabil, consolabil
Moderat iritabil dilicil de consolat
F. Agitat
Neconsolabil . Tipa
Tiraj absent Usor Mediu Sever
Auscultatie
normal Discret W expirator
W expirat moderat
+/- Winspir
W expirat si inspirat sever
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SCORUL RESPIRATOR:
- La prezentare - La 15 minute - la 30 minute - La 1 ora - la 2 ore - la 4 ore
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Un scor respirator > 5
=
INTERNARE
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Cand facem radiografia toracică
?• în următoarele situaţii:
– (1) formă severă de boală;
– (2) deteriorare bruscă;
– (3) pneumopatie sau cardiopatie subjacentă; şi
– (4) diagnostic incert de bronşiolită
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Deoarece nu exista tratament specific antiviral, in bronsiolita se face tratament simptomatic Nu exista suficiente date bazate pe dovezi
Internarea in spital si mijloacele terapeutice variaza foarte mult in diversele protocoale Sunt descurajate toate tratamentele clasice utilizate
Se recomanda orientarea catre tratamente complementare si medicina alternativa
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CONSENS TRATAMENT :
1. OXIGEN 2. HIDRATARE 3. ASPIRARE SECRETII
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EVALUAREA INITIALA:
- Izolarea copilului pe sectia de boli respiratorii- apreciarea scorului respirator- aspirarea secretiilor
FAZA I
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ADMINISTRARE DE O2
Mentinerea SaO2 > 90%(>88% daca doarme
Reevaluarea statusului respirator si a scorului
Evaluarea terenului astmatic
- Istoric de wheezing recurent - istoric familial de atopie sau astm - varsta > 12 luni
DA NU
HIDRATARE
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- Scor respirator = 9 – 12 - FR > 60
Internare obligatorie
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Indicatia internarii
• Virsta < 3 luni;• Fostii prematuri;• Asocierea cardiopatiei congenitale, pneumopatie
cronica, imunodeficiente; patologie neurologica • Detresa respiratorie care limiteaza aportul
lichidian cu aparita SDA• Apnee;• Cianoza, hipoxemie;• Letargie • Lipsa posibilitatii urmaririi atente.• Familie anxioasa
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FAZA II – la 1 ora de la internare
FAZA III – la 2 ore de la internare
FAZA IV – la 4 ore de la internare
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SCOR = 1-4 :- se intrerupe PEV - se trece la alimentatie po
SCOR = 5-8:- se continua O2 + PEV hidratare
SCOR = 9 – 12 : - albuterol / ventolin - se face ASTRUP
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1.Oxigenoterapia - oxigenul devine necesar in prezenta cianozei (semn clinic de hipoxie)- concentratia de oxigen variaza intre 21% (concentratia normala a aerului atmosferic) pana la 100%- posologia optima de oxigen - cel mai mic FiO2 (fractia inspirata de oxigen) care permite mentinerea PaO2 in limite de siguranta = 80 - 100mmHg- clinic se creste debitul O2 pana dispare cianoza si apoi se majoreaza cu inca 25%
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Reguli de baza in cadrul oxigenoterapiei
. administrarea de oxigen umidificat, incalzit, pur. administrarea de oxigen in concentratii stabile . administrarea de oxigen nu trebuie sa depaseasca durata minima necesara. trebuie evitate hipotermia (creste consumul O2) si acidoza (scade perfuzia pulmonara). se corijeaza hipovolemia si anemia
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OXIGENOTERAPIE :
-Cort de oxigen : concentratii de O2 pana la 100% la debit de 3-8 l/min- incubator – concentratie de 45 – 70% la un debit de 15l/min - narine – concentratie 50%- 0,5 – 1 l/min < varsta de 2 luni si 2 l/min > 2 luni
- SE EVITA INFOMETAREA COPILULUI!
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2. Asigurarea nevoilor de lichide, electroliti si calorii:- intensitatea dispneei contraindica in principiu continuarea alimentatiei orale- in formele medii se administreaza alimentatie pe sonda nazo-gastrica- in formele severe se prefera PEV pentru asigurarea necesarului fiziologic de apa, electroliti si calorii, pentru administrarea medicamentelor intravenos si corectarea dezechilibrului hidro-electrolitic si acido-bazic
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TRATAMENTE A CAROR EFICIENTA ESTE DISCUTABILA IN BRONSIOLITE :
-Antibioticele - bronhodilatatoarele - antiinflamatoarele corticosteroide
- injectabile - sistemice
-Antileucotriene - eufilina /miofilin - nebulizarea de solutie salina hipertona
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1. ANTIBIOTERAPIA
0,6% 11,5%
SUPRAINFECTIE!!!
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Indicatie administrare antibiotic :
-Temperatora >38,5 peste 48 ore- otita medie acuta - patologie pulmonara sau cardiaca asociata - prezenta unui focar de condensare pulmonara dovedit radiologic - cresterea CRP - leucocitoza cu neutrofilie - varsta sub 3 luni-OMS – tari nedezvoltate- handicapuri biologice , malformatii- insuficienta respiratorie severa
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INDICATIILE MEDICATIEI ANTIVIRALE -Ribavirin /virazol - administrat in aerosoli 12 – 18 ore/zi timp de 3 – 7 zile --------------------------------------------------------
- infectie cu VSR - handicapuri biologice - insuficienta respiratorie severa - cardiopatii congenitale -Displazie bronhoplulmonara
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2. BRONHODILATATOARELE SIMILITUDINE CU SIMPTOMATOLOGIA DIN ASTMUL BRONSIC
- beta 2 agonisti: - sunt eficiente - ca si placebo - scaderea SaO2 dupa Ventolin
- adrenalina – - efect beta 2 adrenergic bronhodilatator- efect alfaadrenergic
- vasoconstrictor - scade edemul - scade absorbtia sistemica a medicamentului- tahicardioa este < Ventolin
- este eficient sau ca si placebo !
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IN FORMELE SEVERE:Bronhodilatatoare
Beta 2 agonisti – Ventolin (5mg=1ml), 0.1 mg/kg/doza – administrat in prima ora din 20 in 20 minute, apoi de 3 – 4 ori pe zi
Adrenalina (1mg=1ml) – 0.01-0.1 mg/Kgc/doza, x 4 ori/ziObservare efect – fara efect in primele 15-30 min – sistare
Monitorizare ritm cardiacSe pune in balanta efectul obtinut cu posibilele efecte adverse (de obicei balanta este orientata catre efectele adverse)
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Corticoterapia :
-Indicata daca se asociaza edem cerebral - solumedrol 2 - 5 mg/kgc- dexanetazona 0,5 – 1 mg/kgc/zi
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Miofilin• Doza mica – 4 mg/kgc/doza impartit in 4
administrari, foarte lent, pentru a nu se crea varfuri de teofilina- risc crescut de agitatie
• Nu am gasit studii care sa recomande utilizarea teofilineii in tratamentul bronsiolitei
• Relaxare musculatura neteda bronhii– Inhiba degranularea mastocitara– Stimuleaza centrul respirator
inapoi
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NaCl in Aerosoli• Administrarea de clorură de sodiu
hipertona 3% - benefică în bronşiolita acută
• Scade edemul, imbunatateste curatarea cailor aeriene
• Pentru evitarea bronhospasmului această soluţie trebuie administrată în asociere cu un bronhodilatator
inapoi
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Anticolinergice
• Ipratropium – Ipravent
– Nu exista date care sa arate eficienta bromurii de ipratropiu
• Antagonist muscarinic neselectiv
• Inhiba bronhoconstrictia si secretia de mucus
inapoi
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Furosemid• Doza mare – 2 mg/kgc/doza, la 6 ore• In barbotor sau in aerosoli• Scade edmul mucoasei
inapoi
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Sedare• Clorarhidrat in doza de 4 ori mai mica
decat sedarea pentru investigatii paraclinice (0.25 mg/kgc) – efecte benefice prin scaderea agitatiei, scaderea consumului de oxigen, respiratii mai eficiente, fara afectarea centrului respirator
• Contraindicat in toate studiile si protocoalele
inapoi
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De luat in considerare• Antivirale
– Aerosoli -ribavirina– controverse. Greu de administrat– Profilactic – palivizumab – 15 mg/kgc/doza, im, 5
administrari pe luna, incepand cu lunile Nov, Dec, la copii cu factori de risc. Eficient, dar foarte scump
• Surfactant– La copiii ventilati mecanic– Studii clinice cu rezultate diferite. 2 studii in care
durata spitalizarii a fost mai mica la copiii care au primit surfactant fata de placebo
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Indicatiile ventilatiei mecanice:-Polipnee - cianoza - PaO2 <50 mm Hg - hipercapnia PCO2 >55 mm Hg- crize de apnee- acidoza pH < 7,2- epuizarea copilului cu diminuarea “ sindromului de lupta”- alterarea starii generale
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1. Internare2. Aspirare secretii3. Oxigen4. Corticoterapie iv 5. Aerosoli cu bronhodilat–x3 in 1h
6. Aerosoli cu corticoid7. Adaugare NaCl 3% in aerosoli 8. Pufuri cu anticolinergice (ipratropium)9. Miofilin10. Furosemid in barbotor, aerosoli11. Sedare – agitatie extrema12. Antibiotic13. Fizioterapie14. De luat in considerare
1. Antivirale in aerosoli2. Terapie cu surfactant
START
ISTORICEXAMEN CLINIC
DIAGNOSTICBRONSIOLITA
INCADRARESEVERITATE
USOARA MEDIE GRAVA
ObservatieAspirare secretiiHidratare Educatie parinti
InternareAspirare secretiiCorticoterapie iv (Dexa)Oxigen la nevoieAerosoli cu VentolinAerosoli cu corticoid (Dexa > Flixo)Aerosoli cu NaCl 3%ObservareHidratare
Raspuns pozitivEND
Scor severitateCincinnati
Beta2 agonisti sau adrenalina
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IDEI PENTRU ACASA : -Boala inflamatorie cai aeriene distale – bronsiole -Etiologie virala - VSR-Tuse , dispnee, wheezing -Forma usoara, medie, severa – scor Cincinati -Nu se dau antibiotice -Indicatie :Hidratare , oxigen , aspirare secretii -Forma severa nu respecta protocolul-Forma severa: aerosoli cu adrenalina, ventolin, flixotide , corticoterapie i.v., antibiotic daca are febra persistenta peste 48 ore sau necesita IOT
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