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Bronchiolitis question


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I'm reviewing for the PANRE.

 

Trying to understand a MCQ. Maybe someone here will know the answer they are looking for. I have read Medscape, Up to date, 1st Aid for USMLE step 2 and also did an Internet search. In a patient with bronchiolitis with pulmonary HTN. What would treatment be?

 

My choices are: a. Macrolide (read that studies show abx to not be of benefit) b. Ribavirin (read that antivirals are questionable and not thought to help) c. Methylprednisolone (read steroids not helpful) d. Doxycycline (see a.) e. Ipratropium (also read not thought to be of help.

 

What I've read is Supportive, hydration and O2. nebulized epinephrine sometimes helps. Not sure what answer this question is looking for. Can anyone help? Thanks

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Is that all the background info on the pt that you are given?

What age are we dealing with (I'm guessing pedi)? Ex-preemie? RSV+?

 

I don't like any of the choices without knowing more info...

A and/or D would only fit if you were dealing with mycoplasma which is a very rare cause of bronchiolitis.

C - you're right that steroids are not a first (or second) line tx.

E - I would have no problem giving an albuterol/ipratropium combo, but wouldn't give ipratropium by itself.

A kid with pulmonary HTN and RSV bronchiolitis would definitely be considered high risk enough to give ribavirin, but only if they had confirmed RSV (which is a rapid nasal swab that can be run in any ED with an onsite lab).

 

You are right that the pt needs supportive care more than anything, fluids, deep suctioning, and appropriate O2 (heated humidified high-flow nasal cannula therapy if avaliable)

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I believe the answer is ribavarin as the patient's pulm HTN is hemodynamically significant cardiopulmonary disease.

 

From the AAP:

"Nevertheless, ribavirin may be considered for use in highly selected situations involving documented RSV bronchiolitis with severe disease or in those who are at risk for severe disease (eg, immunocompromised and/or hemodynamically significant cardiopulmonary disease)."

 

Tough question. I would have guessed steroids based on the choices.

http://pediatrics.aappublications.org/content/118/4/1774.full

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I'm approaching the questions with my best 1st guess which was steroids. Then looked up the answers. After looking them up leaned towards anti-viral but there were no clear cut guidelines- not even in the handout with the board review. I am trying to understand and retain as I go as some of this will help in my new job. Just switched from Surgery to Medicine. Thanks for the info/help. Will be so glad when this is over! :-)

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There's a lot of new evidence, including a well designed Cochrane meta-analysis of 10-12 different clinical trials, which showed that inhaled hypertonic saline is a good treatment for bronchiolitis in children < 2 years old. Albuterol is the de facto "standard" of care, but there's lots of evidence showing that it doesnt help. The Cochrane group demonstrated that 3% inhaled saline is superior for decreasing rates of hospitalization, decreasing hospital stay, improving O2. The studies were not powered sufficiently to find a difference in mortality, but there is an NIH study going on right now with other 10,000 kids enrolled that should be able to address the mortality question.

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