Conditions of vulnerability to the inadequate treatment of bronchiolitis

SUMMARY OBJECTIVE To analyze clinical and demographic variables possibly associated with the prescriptions of non-recommended but routinely used therapies for infants with acute viral bronchiolitis. METHODS A cross-sectional study included hospitalized infants with bronchiolitis caused by the respiratory syncytial virus. Those with other associated infections and/or morbidities were excluded. The data were collected from medical records. RESULTS Among 120 cases, 90% used inhaled beta-agonists, 72.5% corticosteroids, 40% antibiotics, and 66.7% inhaled hypertonic saline solution. The use of bronchodilators did not present an independent association with another variable. More frequent use of corticosteroids was associated with low oximetry, longer hospitalization time, and age>3 months. Antibiotic therapy was associated with the presence of fever, longer hospitalization, and age>3 months. Inhaled hypertonic saline solution was associated with longer hospitalization time. CONCLUSIONS Non-recommended prescriptions were frequent. Corticosteroid and antibiotic therapy were associated with signs of severity, as expected, but interestingly, they were more frequently used in infants above 3m, which suggested less safety in the diagnosis of viral bronchiolitis in these patients. The use of bronchodilators was even more worrying since they were indiscriminately used, without association with another variable related to the severity or characteristics of the host. The use of the inhaled hypertonic solution, although not associated with severity, seems to have implied a longer hospitalization time. The identification of these conditions of greater vulnerability to the prescription of inappropriate therapies contributes to the implantation of protocols for the bronchiolitis treatment, for continuing education and for analysis of the effectiveness of the strategies employed.

RESUMO OBJETIVOS Analisar variáveis clínicas e demográficas possivelmente associadas às prescrições de terapêuticas não recomendadas, porém rotineiramente utilizadas, para lactentes com bronquiolite viral aguda. MÉTODOS Estudo transversal incluiu lactentes hospitalizados com bronquiolite por vírus sincicial respiratório. Excluídos aqueles com outras infecções e/ou morbidades. Dados coletados de prontuários. RESULTADOS Analisados 120 casos, para os quais foram prescritos: beta-agonistas inalatórios a 90%; corticosteroides a 72,5%, antibióticos a 40% e solução salina hipertônica inalatória a 66,7%. O uso de broncodilatadores não apresentou associação independente com outra variável. Maior uso de corticosteroide associou-se à baixa oximetria, maior tempo de internação e idade >3 meses. Antibioticoterapia associou-se à presença de febre, maior tempo de internação e idade >3 meses. Solução salina hipertônica inalatória associou-se a maior tempo de internação. CONCLUSÕES A frequência das prescrições não recomendadas foi elevada. Corticosteroide e antibioticoterapia foram associados a sinais de gravidade, como esperado, porém, interessantemente, foram mais utilizados nos lactentes com idade acima de 3 meses, o que sugeriu menor segurança no diagnóstico de bronquiolite viral nesses pacientes. O uso de broncodilatadores foi ainda mais preocupante, uma vez que foram indiscriminadamente utilizados, sem associação com outra variável, seja relacionada à gravidade, seja a características do hospedeiro. O uso de solução hipertônica inalatória, apesar de não associado à gravidade, parece ter implicado maior tempo de internação. A identificação dessas condições de maior vulnerabilidade à prescrição de terapêuticas inadequadas contribui para a implantação de protocolos para o tratamento da BVA, para educação continuada e para posteriores comparações e análises de eficácia das estratégias empregadas.

Etiological diagnosis reduces the use of antibiotics in infants with bronchiolitis

OBJECTIVE: Acute bronchiolitis is a leading cause of infant hospitalization and is most commonly caused by respiratory syncytial virus. Etiological tests are not required for its diagnosis, but the influence of viral screening on the therapeutic approach for acute bronchiolitis remains unclear. METHODS: A historical cohort was performed to assess the impact of viral screening on drug prescriptions. The study included infants up to one year of age who were hospitalized for bronchiolitis. Virus screening was performed using immunofluorescence assays in nasopharyngeal aspirates. The clinical data were obtained from the patients' medical records. Therapeutic changes were considered to be associated with viral screening when made within 24 hours of the release of the results. RESULTS: The frequency of prescriptions for beta agonists, corticosteroids and antibiotics was high at the time of admission and was similar among the 230 patients. The diagnosis of pneumonia and otitis was associated with the introduction of antibiotics but did not influence antibiotics maintenance after the results of the virus screening were obtained. Changes in the prescriptions were more frequent for the respiratory syncytial virus patients compared to patients who had negative viral screening results (p =0.004), especially the discontinuation of antibiotics (p<0.001). The identification of respiratory syncytial virus was associated with the suspension of antibiotics (p= 0.003), even after adjusting for confounding variables (p = 0.004); however, it did not influence the suspension of beta-agonists or corticosteroids. CONCLUSION: The identification of respiratory syncytial virus in infants with bronchiolitis was independently associated with the discontinuation of antibiotics during hospitalization.

Comparison of nebulized adrenaline versus salbutamol in wheeze associated respiratory tract infection in infants.

OBJECTIVE: (i) To assess the efficacy of bronchodilators in wheeze associated respiratory tract infection (WRTI); and (ii) To compare L-adrenaline with salbutamol in wheeze associated respiratory tract infection. DESIGN: Randomized controlled trial. METHOD: Ninety one children in age group of 2 months to 2 years with their 1st or 2nd episode of wheezing in association with fever and/or coryza were enrolled. Of these, 45 received L-adrenaline (0.1ml/kg/dose in 1 in 10,000 solution) (Group A) and 46 received salbutamol (0.1mg/kg/dose) (Group B). Three doses of each drug were given, nebulized with oxygen at 20 minutes intervals. Respiratory rate, RDAI score, clinical status and pulse oxymetry was recorded before intervention and 10 minutes after each dose. Patients who showed significant relief were discharged after an observation period of three hours while those who did not were admitted. RESULTS: Both L-adrenaline and salbutamol caused significant improvement in mean symptom score and oxygenation. However, the adrenaline group showed a significantly better improvement in the study parameters than the salbutamol group. More children in the adrenaline group could be sent home after the emergency treatment. CONCLUSION: Adrenergic agonists both specific and non specific are beneficial in WRTI. Adrenaline is more effective than salbutamol and is thus a better, inexpensive and relatively safe alternative.

Miocarditis viral asociada a bronquiolitis por virus sincitial respiratorio

La bronquiolitis por virus sincitial respiratorio (USR) es una enfermedad de las vías aéreas pequeñas, caracterizada por inflamación y obstrucción de los bronquiolos. El VSR fue aislado por primera vez en 1995, pertenece a la familia de los paramixovirus. Es clara la presentación epidérmica anual que compromete especialmente a lactantes pequeños. La tasa de infección por VSR durante el primer año de vida alcanza el 69 por ciento y el 83 por ciento durante el segundo. La mortalidad en niños previamente sanos es del 0.005 por ciento al 0.002 por ciento; en pacientes hospitalizados es del 1 al 3 por ciento. Aunque se ha descrito que la infección por VSR no altera la función cardíaca en pacientes con corazón sano, se encuentra en la literatura informes aislados al respecto; a continuación presentamos un caso de un paciente con bronquiolitis por VSR, en el que se documentó miocarditis por este mismo germen.

Infección viral del tracto respiratorio inferior

Las infecciones respiratorias agudas son una de las principales causas de morbilidad y mortalidad entre los niños. Con el desarrollo de tecnologías de diagnóstico rápido para la detección de antígenos virales es posible reconocer el agente viral de la infección respiratoria en horas. El diagnóstico etiológico de infección respiratoria viral es no sólo cada vez más importante para la selección apropiada de los pacientes que deben recibir tratamiento antiviral o con antibióticos, sino también para el control de la diseminación de las infecciones respiratorias virales en salas pediátricas. En la Clínica Amparo Infantil Santa Ana de Medellín ocurrió un brote de infección respiratoria aguda del tracto respiratorio inferior en el último trimestre de 1994 producida por virus. Los virus detectados fueron virus respiratorio sincitial 41.8 por ciento, adenovirus 33,3 por ciento, parainfluenza tipo 1, en el 8.3 por ciento e infección mixta en el 16.7 por ciento. Se describe el método diagnóstico utilizado en la detección de los antígenos virales y las características de este brote.

Bronquiolite viral aguda: terapêutica medicamentosa atual / Acute viral bronchiolitis

O papel que broncodiltadores e glicocorticóides ocupam na terapêutica atual da bronqiolite viral aguda é ainda discutido. A metodologia empregada nas publicaçöes disponíveis sobre o assunto é analisada criticamente. Os mecanismos etiopatogênicos desta doença säo abordados para um melhor entendimento e justificativa de uma proposta terapêutica. Recentes artigos permitem-nos opinar que toda criança com diagnóstico de bronquiolite aguda, de moderada a grave intensidade, deve receber o benefício de uma tentativa terapêutica inicial com broncodilatadores simpaticomiméticos. Da mesma forma, em casos severos refratários a esta primeira medida, é recomendável o uso de aminofilina intravenosa. A açäo dos glicocorticóides é ainda discutível, havendo necessidaade de novos estudos para que se possa fazer alguma afirmaçäo definitiva sobre seu uso nessa afecçäo. Tem sido aceito, no entanto, por alguns autores, sua associaçäo aos broncodilatadores, naqueles casos de agravamento progressivo refratários a terapêutica prévia