Steroid Therapy in Acute Bronchiolitis A New Old Line of Therapy.
Steroid Therapy in Acute Bronchiolitis A New Old Line of Therapy.
The aim of the present study is to evaluate the efficacy of steroid therapy and hospital stay
 in patients with acute bronchiolitis at assiut university children hospital.
Bronchiolitis is an acute lower respiratory tract infection in early childhood.A subcommittee
 of the American Academy of Pediatrics (AAP) together with the European Respiratory Society
 (ERS) underlined that is a clinical diagnosis, recognized as "a constellation of clinical
 symptoms and signs including a viral upper respiratory prodrome followed by increased
 respiratory effort and wheezing in children less than 2 years of age".

 Bronchiolitis is the common reason for hospitalization of children in many countries,
 challenging both economy, area and staffing in pediatric departments. A substantial
 proportion of children will experience at least one episode with bronchiolitis, and as much
 as 2-3% of all children will be hospitalized with bronchiolitis during their first year of
 life. Bronchiolitis is the most common medical reason for admission of children to intensive
 care units (ICU) particularly those with risk Factors will have a severe course of
 bronchiolitis, providing challenges regarding ventilation, fluid balance and general support
 This may be a particular challenge for ICUs without a specialized pediatric section.

 Many respiratory viruses have been associated with acute viral bronchiolitis although
 Respiratory Syncytial Virus (RSV) remains the most common identified virus causing
 bronchiolitis, occurring in epidemics during winter months.The infection starts in the upper
 respiratory tract, spreading to the lower airways within few days.The inflammation in the
 bronchioles is characterized by a peri-bronchial infiltration of white blood cell types,
 mostly mono nuclear cells, and oedema of the submucosa and adventitia. Damage may occur by a
 direct viral injury to the respiratory airway epithelium, or indirectly by activating immune
 responses. Oedema, mucus secretion, and damage of airway epithelium with necrosis may cause
 partial or total airflow obstruction, distal air trapping, atelectasis and a ventilation
 perfusion mismatch leading to hypoxemia and increased work of breathing. Smooth-muscle
 constriction seems to play a minor role in the pathologic process of bronchiolitis.

 Risk factors for bronchiolitis are male gender, a history of prematurity, young age, being
 born in relation to the RSV season, pre-existing disease such as broncho pulmonary- dysplasia
 , underlying chronic lung disease , neuromuscular disease, congenital heart- disease ,
 exposure to environmental tobacco smoke , high parity, young maternal age, short duration/no
 breast feeding , maternal asthma and poor socioeconomic factors.

 Bronchiolitis often starts with rhinorrhoea and fever, thereafter gradually increasing with
 signs of a lower respiratory tract infection including tachypnoea, wheezing and cough. Very
 young children, particularly those with a history of prematurity, may appear with apnea as
 their major symptom.Feeding problems are common.

 On clinical examination, the major finding in the youngest children may be fine inspiratory
 crackles on auscultation, whereas high-pitched expiratory wheeze may be prominent in older
 children. By observation, the infants may have increased respiratory rate, chest movements,
 prolonged expiration, recessions, use of accessory muscles, cyanosis and decreased general
 condition.

 No routine laboratory or radio graphic diagnostic tests for bronchiolitis except for pulse
 oxymetry , have been shown to have a substantial impact on the clinical course of bron-
 chiolitis , and recent guidelines and evidence-based reviews recommend that no diagnostic
 tests are used routinely.

 The present study describes the efficacy of steroid therapy in patients with acute
 bronchiolitis. Theoretically, corticosteroid, an anti-inflammatory agent, should be helpful
 in the treatment of bronchiolitis because airway inflammation and edema are the main
 pathophysiologies. Recent evidence has shown elevation of interleukins and other inflammatory
 mediators in the respiratory tracts of children with acute bronchiolitis. Eosinophil cationic
 protein, implicated in the pathogenesis of asthma, was found to have a significant role in
 RSV bronchiolitis. Most of these mediators could be found during the period of virus
 replication.The clinical effect of dexamethasone, with a long half -life of 36-72 hr, may
 peak after 3-4 hr of treatment. Corticosteroids widely used in different routes in the
 treatment of acute bronchiolitis:

 Dexamethasone injection used in hospitalized children with acute bronchiolitis showed
 significantly reduction in the mean respiratory distress duration, mean duration of oxygen
 therapy and the mean length of hospital stay.

 Oral dexamethasone used in pediatric out patients with acute bronchiolitis produced
 demonstrable clinical improvement in the initial 4 hr of treatment and reduced the
 hospitalization rate.

 Corticosteroid inhalation therapy used in RSV- bronchiolitis showed evidence of prolonged
 positive effects in reduction of the incidence of subsequent respiratory symptoms in the near
 future. However, the best and sufficient length of the treatment period, as well as the dose
 of the inhaled steroid, need to be determined..

 Fluticasone propionate, a potent corticosteroid, has been demonstrated in vitro to inhibit
 virus-induced chemokine production by airway cells in patients infected with Respiratory
 Syncytial Virus. However, the inhibition was found to take at least 48 hr to reach its full
 effect.
Inclusion Criteria:

 1. Infants and young children aged from 3 months to 2 years with acute bronchiolitis.

 2. Infants aged <12 months with respiratory rate over 60 breaths/min, childrens aged
 >12months with respiratory rate over 50 breaths/min.

 3. Patients with an O2- saturation, breathing room air, under 95%.

 4. Patients with apathy and/or refusal to eat.

 5. Patients with normal white blood cell count for age.

 6. Full term babies without chronic disease.

 Exclusion Criteria:

 1. Infants aged < 3 months, children aged >2 years

 2. known or suspected asthma (by observing the good response to first dose of salbutamol
 nebulization especially among those with personal history of atopy).

 3. Proven or suspected acute bacterial infection.

 4. Presence of symptoms more than 7 days.

 5. Previous treatment with corticosteroid by any route within 2 weeks.

 6. Having a contra- indication to corticosteroid.

 7. Severe cases requiring initial admission to intensive care unit with endotracheal
 intubation (in order to reduce confounding factors such as nosocomial infection or
 complication due to mechanical ventilation).

 8. A previous history of intubation.

 9. Premature babies (due to possible respiratory problems associated with prematurity).

 10. Children with chronic cardiopulmonary diseases (Bronchopulmonary- dysplasia ,
 Congenital Heart Disease and Cystic fibrosis)

 11. Children with immunodeficiencies .

 12. Children with neuromuscular disease.