BRONCHIOLITE Definizione Malattia respiratoria acuta a carico dei bronchioli Età colpita : sotto i 2 anni generalmente nel I anno Epidemiologia

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BRONCHIOLITE Definizione Malattia respiratoria acuta a carico dei bronchioli Età colpita : sotto i 2 anni generalmente nel I anno Epidemiologia

1 BRONCHIOLITE Definizione Malattia respiratoria acuta a carico dei bronchioli Età colpita : sotto i 2 anni generalmente nel I anno Epidemiologia stagionale: inverno e primavera ETIOLOGIA VIRALE: virus respiratorio sinciziale nel 80-90% v. parainfluenzale, influenzale adenovirus Mycoplasma pneumonie

2 BRONCHIOLITE Mortalità 1-4% pazienti senza problemi clinici di base 15% paz.. con patologie cardiopolmonari e immunodeficienze acquisite 40% paz con immunodeficienza congenita 70% pazienti con ipertensione polmonare Il rischio aumenta nei neonati e nei piccoli lattanti

3 BRONCHIOLITE fisiopatologia atelettasia ostruzione totale flusso aereo intrappolamento aria meccanismo a valvola ostruzione parziale flusso aereo infiammazione piccole vie respiratorie + edema + secrezione

4 Chest Feb;123(2): Links Nebulized 3% hypertonic saline solution treatment in hospitalized infants with viral bronchiolitis. Mandelberg A, Tal G, G Witzling M, Someck E, Houri S, Balin A, Priel IE. Pediatric Pulmonary Unit, The Edith Wolfson Medical Center,, Holon, Israel.

5 OBJECTIVE: To determine the utility of inhaled hypertonic saline solution to treat infants hospitalized with viral bronchiolitis.. DESIGN: Randomized, double-blind, blind, controlled trial. Fifty-two two hospitalized infants (mean +/- SD age, 2.9 +/- 2.1 months) with viral bronchiolitis received either inhalation of epinephrine, 1.5 mg, in 4 ml of 0.9% saline solution (group 1; n = 25) or inhalation of epinephrine, 1.5 mg, in 4 ml of 3% saline solution (group 2; n = 27). This therapy was repeated three times every hospitalization day until discharge. RESULTS: The percentage improvement in the clinical severity scores after inhalation therapy was not significant icant in group 1 on the first, second, and third days after hospital admission (3.5%, 2%, and 4%, respectively).

6 In group 2, significant improvement was observed on these days (7.3%, 8.9%, and 10%, respectively; p < 0.001). Also, the improvement in clinical severity scores differed significantly on each of these days between the two groups. Using 3% saline solution decreased the hospitalization stay by 25%: from 4 +/- 1.9 days in group 1 to 3 +/- 1.2 days in group 2 (p < 0.05)..

7 We conclude that in nonasthmatic, nonseverely ill infants hospitalized with viral bronchiolitis,, aerosolized 3% saline solution/1.5 mg epinephrine decreases symptoms and length of hospitalization as compared to 0.9% saline solution/1.5 mg epinephrine.

8 Sarrell EM, Tal G, G Witzling M, Someck E, Houri S, Cohen HA, Mandelberg A. Pediatrics and Adolescent Ambulatory Community Clinic of General Health Services, The Edith Wolfson Medical Center,, 62 Halochamim Street, Holon 58100, Israel.

9 CONCLUSIONS: We conclude that in nonasthmatic, nonseverely ill ambulatory infants with viral bronchiolitis,, aerosolized 3% saline solution plus 5 mg terbutaline is effective in decreasing symptoms as compared to 0.9% saline solution plus 5 mg terbutaline

10 Nebulized hypertonic saline solution for acute bronchiolitis in infants (Review) Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP This The cochrane collaboration

11 Background Airway edema and mucus plugging are the predominant pathological features in infants with acute viral bronchiolitis. Nebulized hypertonic saline solution may reduce these pathological changes and decrease airway obstruction. Objectives To assess the effects of nebulized hypertonic saline solution in infants with acute viral bronchiolitis.

12 Main results We included four trials involving 254 infants with acute viral bronchiolitis (189 inpatients and 65 outpatients) ) in this review. Patients treated with nebulized 3% saline had a significantly shorter mean length of hospital stay compared to those treated with nebulized 0.9% saline (mean( difference (MD) days, 95% CI to -0.40, P = ). The 3% saline group also had a significantly

13 Authors conclusions Current evidence suggests nebulized 3% saline may significantly reduce the length of hospital stay and improve the clinical severity score in infants with acute viral bronchiolitis

14 Hypertonic saline solution has been shown to increase mucociliary clearance in normal subjects,, in asthma, bronchiectasis, cystic fibrosis,, and sinonasal diseases (Daviskas 1996; Kellett 2005; Shoseyov 1998; Wark 2007). Hypertonic saline has recently been trialed in patients with acute bronchiolitis (Kuzik 2007; Mandelberg 2003; Sarrell 2002; Tal 2006). The postulated mechanisms of benefit are as follows: : 1) hypertonic saline breaks the ionic bonds within the mucus gel, thereby reducing the degree of cross-linking and entanglements and lowering the viscosity and elasticity of the mucus secretion (Ziment 1978); 2) hypertonic saline induces an osmotic flow of water into the mucus layer, rehydrating secretions and improving mucus rheology (Robinson 1997);

15 3) hypertonic saline stimulates cilial beat via the release of prostaglandin E2 (Assouline( 1977).Moreover Moreover, by absorbing water from the mucosa and submucosa, hypertonic saline solution can theoretically reduce edema of the airway wall in infants with acute bronchiolitis (Mandelberg 2003; Sarrell 2002). Hypertonic saline inhalation can also cause sputum induction and cough, which can help to clear the sputum outside of the bronchi and thus improve airway obstruction (Mandelberg 2003).The abovementioned theoretical benefits provide the rationale for the treatment of acute bronchiolitis with nebulized hypertonic saline solution

16 1. Length of hospital stay All three inpatient trials (Kuzik 2007; Mandelberg 2003; Tal 2006), with a total of 189 infants, demonstrated a benefit of nebulized 3% saline in reducing the duration of hospitalization.. The pooled results show that infants treated with nebulized 3% saline had a statistically significant shorter mean length of hospital stay compared to those treated with nebulized 0.9%saline, with amd of days (95%CI to -0.40, P = ). This represents a 25.9% reduction from the mean length of hospital stay in the 0.9% saline group.

17 2. Rate of hospitalization One outpatient trial (n = 70) (Sarrell( 2002) used the rate of hospitalization as an outcome. This trial failed to demonstrate the efficacy of nebulized 3% saline in reducing the risk of hospitalization (RR 0.67, 95% CI 0.12 to 3.75, P = 0.65).

18 4. Adverse events No adverse events related to 3%saline inhalation were reported in any of the four trials. Two trials (Mandelberg 2003; Sarrell 2002) reported that pulse rate did not differ,, on any day of the treatment, between the 3%saline group and the 0.9%saline group. One trial (Mandelberg 2003) did not find a significant difference between the two groups in terms of room air saturation of oxyhemoglobin throughout the study period.

19 La ricerca su soluzioni saline ipertoniche e bronchiolite realizzata negli archivi della Cochrane collaboration ha permesso di identificare un protocollo di revisione sistematica Cochrane (ma nessuna revisione sistematica) e 3 trial controllati randomizzati descritti in 5 pubblicazioni. Tutti i trial sono stati realizzati dallo stesso gruppo di autori e confrontavano la nebulizzazione di adrenalina (in un caso terbutalina) ) in soluzione ipertonica al 3% vs gli stessi farmaci in soluzione allo 0,9%. I risultati sembrano confermare l'efficacia della nebulizzazione con soluzione ipertonica sia su score clinici che in termini di durata dell'ospedalizzazione (circa 1 giorno in meno)

20 Il razionale dell'utilizzo della soluzione ipertonica è legato alla migliore rimozione del muco ispessito attraverso l'idratazione osmotica, la riduzione dell'edema della mucosa, la rottura del reticolato dei filamenti di muco. L'efficacia è già stata dimostrata nei pazienti con fibrosi cistica (nebulizzazione di soluzioni al 5-10%). 5

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