Sharp bronkhiolit - the inflammatory obstruction of bronchial tubes of small caliber (bronchioles) which is usually developing at children of early age against the background of a viral infection. Initial signs remind SARS which the phenomena of bronchial obstruction soon join (expiratory short wind, spastic cough, , the krepitiruyushchy or whistling rattles, cyanosis of a nasolabial triangle, etc.). Diagnostics of a sharp bronkhiolit is based on data of a radiological research of bodies of a thorax and gas composition of blood. The basis of therapy of a sharp bronkhiolit is made by adequate oxygenation, oral or parenteral hydration, use of interferon.
Sharp bronkhiolit (capillary bronchitis) - the diffusion inflammatory defeat of terminal departments of respiratory ways proceeding with the phenomena of a bronkhoobstruktion and respiratory insufficiency. In most cases the disease develops at children of the first two-three years of life against the background of an acute respiratory viral infection; the maximum peak of incidence is the share of age of 5-7 months. Annually sharp bronkhiolit transfers 3-4% of children of early age, from them in a severe form - 0,5-2%; the lethal outcome is registered at 1% of the diseased. The heavy current of a sharp bronkhiolit is observed at children with the burdened background: the premature, having congenital anomalies lungs and heart diseases. Prevalence of pathology and high frequency of hospitalization do a problem of a sharp bronkhiolit extremely urgent for practical pediatrics and pulmonology.
Reasons of a sharp bronkhiolit
To 70-80% of all cases of a sharp bronkhiolit at children of the first year of life of an etiologicheska are connected with the respiratory sintsitialnym virus (RSV). As the RS-infection proceeds with annual seasonal epidemic flashes (in the winter and in the early spring), more than a half of children of early age have the RS-infection, and instability of post-infectious immunity causes a frequent reinfitsirovaniye. About 15% of cases of a sharp bronkhiolit are the share of a share of other virus agents (adenoviruses, rhinoviruses, viruses of flu and paraflu, enteroviruses, coronaviruses and so forth). In recent years increase in a role of a metapneumovirus of the person in development of a bronkhoobstruktivny syndrome in children is noted. Decrease in incidence among babies is promoted by early applying to a breast and receiving colostrum by the child with the high content of IgA.
Children of the second year have lives the importance of the viruses causing sharp bronkhiolit, changes: The RS-virus concedes a leading place to enteroviruses and rhinoviruses. At children of preschool and school age among activators of a bronkhiolit mycoplasmas and rhinoviruses prevail, and RS-viruses usually become the reason of viral pneumonia and bronchitis. Except traditional etiologichesky agents, as the reason of sharp bronkhiolit the cytomegalovirus, hlamidiya, viruses of measles, chicken pox, epidemic parotitis, simple herpes can also act. Among children of the senior age group and adults the persons with an immunodeficiency who transferred organ transplantation and stem cells, elderly patients get sick with a sharp bronkhiolit.
Within the first days after penetration of respiratory viruses the necrosis of an epithelium of bronchioles and alveotsit develops, formation of slime increases, there is an active allocation of mediators of an inflammation, there is a lymphocytic infiltration and swelling of a submucous layer. Obstruction of airways at a sharp bronkhiolit is caused not by a bronchospasm (as, for example, at obstructive bronchitis), and hypostasis of walls of bronchioles, a congestion in their gleam of slime and a cellular detrit. In total with a small diameter of bronchial tubes at children these changes lead to increase in resistance to the movement of air, especially on an exhalation, as the valvate mechanism.
The emphysema caused by the increased airfilling of affected areas and a compensatory hyperventilation of intact zones of pulmonary fabric develops. At a full obturation of bronchioles and impossibility of intake of air atelektaza can develop in alveoluses. Sharp violation of respiratory and ventilating function of lungs leads to development of a gipoksemiya, and at heavy respiratory insufficiency – a giperkapniya. At a favorable current of a sharp bronkhiolit in 3–4 days gradual regress of pathological changes begins, however the bronkhoobstruktion remains within 2-3 weeks.
Symptoms of a sharp bronkhiolit
The debut of a sharp bronkhioloit reminds a SARS: the child becomes uneasy, refuses food; body temperature increases to subfebrilny values, rhinitis develops. In 2-5 days signs of defeat of the lower departments of a respiratory path – persuasive cough, svistyashche breath, short wind of expiratory character join. At the same time the hyperthermia to 39 °C and accrues above, there are moderately expressed phenomena of pharyngitis and conjunctivitis.
Patognomonichny signs of a sharp bronkhiolit are (ChD till 60-80 in min.), tachycardia (ChSS 160-180 . in min.), participation in breath of auxiliary muscles, inflating of wings of a nose, retraction of intercostal intervals and podrebery, perioralny cyanosis or cyanosis of all integuments. At premature or children with a patrimonial trauma there can be episodes in a dream. Due to the increased lightness of lungs and flattening of a dome of a diaphragm the liver and a spleen act on 2-4 cm from under costal arches. Intoxication, refusal of food and vomiting lead to dehydration and violation of a water and electrolytic homeostasis.
From extra pulmonary complications average otitis, myocarditis, premature ventricular contraction can meet. Weight of a condition of the patient bronkhiolity is caused by degree of sharp respiratory insufficiency. At the weakened patients the respiratory distress syndrome can develop, come a lethal outcome.
Diagnostics of a sharp bronkhiolit
When drawing the diagnosis of a sharp bronkhiolit the pediatrician or the pulmonologist consider communication of bronchial obstruction with a viral infection, characteristic clinical and fizikalny data. The typical auskultativny picture of "a moist lung" includes multiple rattles (melkopuzyrchaty, krepitiruyushchy), the extended exhalation, the distantny whistling rattles. Owing to the raised swelling of lungs the perkutorny sound decides on a box shade.
For assessment of parameters of oxygenation the pulsoksimetriya, a research of gas composition of blood is conducted. The radiological picture in lungs is characterized by signs of a giperpnevmatization and peribronkhialny infiltration, strengthening of the pulmonary drawing, existence of atelektaz, flattening of a dome of a diaphragm. From laboratory tests by the greatest value the express analysis for definition of RSV in nazofaringealny dab possesses the IFA, RIF or PTsR method. These bronkhoskopiya (diffusion catarrhal bronchitis, a significant amount of slime) at a sharp bronkhiolit are not indicative. Children of early age do not manage to execute the spirography.
To differentiate sharp bronkhiolit it is necessary with obstructive bronchitis, bronchial asthma, HSN, pneumonia (aspiration, virus, bacterial, mikoplazmenny), whooping cough, foreign matters of airways, mukovistsidozy lungs, a gastroezofagealny reflux.
Treatment of a sharp bronkhiolit
So far etiotropny a lecheyoniya of a sharp bronkhiolit it is not developed. Inhalation application of a ribavirin is recognized inexpedient in view of insufficient efficiency and frequent reactions of hypersensitivity. Purpose of bronchial spasmolytics, physical therapy, inhalation steroids is also not recommended. The basis of basic therapy of a sharp bronkhiolit is made by sufficient oxygenation and hydration of the patient. Children of younger age are subject to hospitalization and isolation.
Supply of the moistened oxygen is carried out by means of a mask or an oxygen tent. At repeated apnoe, preservation of a giperkapniya, the general serious condition transfer to IVL is shown. Completion of losses of liquid is provided at the expense of frequent fractional drink or infusional therapy (under control of a diuresis, electrolytic structure and BRAIDS of blood). For removal of slime of their airways its aspiration by an electrosuction, vibration massage of a thorax, a posturalny drainage, salt inhalations with hypertensive solution or inhalations of adrenaline via the nebulizer is carried out.
To elimination the viral infection applies interferon medicines. Glucocorticoids can be used by a short course for removal of a bronkhoobstruktion. Clinical efficiency of inclusion in the scheme of therapy of a sharp bronkhiolit of medicine , possessing the expressed anti-inflammatory action is proved. Antibacterial means have to be appointed only at suspicion to bacterial complications.
Forecast and prevention of a sharp bronkhiolit
In not hard cases sharp bronkhiolit can independently be resolved, without special pathogenetic therapy. In 3-5 days there occurs improvement though the bronkhoobstruktion and cough can remain up to 2-3 weeks and longer. In the next five years after the postponed sharp bronkhiolit at children hyperreactivity of bronchial tubes and high risk of development of bronchial asthma remains. Lethal outcomes are registered mainly at persons with the burdened accompanying background.
As means of passive immunoprevention specific immunoglobulin with anti-RSV activity is developed. Medicine is intended for application during the periods of raising of the RS-infection for categories of the children and adults threatened on development of severe forms of a sharp bronkhiolit.