[Bronchiolitis obliterans and bronchiolitis obliterans with focal organizing pneumonia, a confusing terminology].
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Bronchiolitis Obliterans↗
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[Bronchiolitis obliterans with organizing pneumonia and bronchiolitis obliterans].
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Bronchiolitis Obliterans↗
Obliterative bronchiolitis, cryptogenic organising pneumonitis and bronchiolitis obliterans organizing pneumonia: three names for two different conditions.
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Bronchiolitis Obliterans↗
[Dyspnea, coughs and purulent sputum (pulmonary function tests): (diffuse bronchiolitis) (diffuse respiration bronchiolitis and peribronchiolitis)].
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Bronchitis↗
The two forms of bronchiolitis obliterans in heart-lung transplant recipients.
Bronchiolitis obliterans has emerged as the major long-term complication of heart-lung transplantation. We reviewed the histologic findings in lungs obtained from 11 patients who had received a combined heart-lung transplant at The Johns Hopkins Hospital. Ten lungs were obtained at autopsy, and one was obtained from a patient who was retransplanted because of severe bronchiolitis obliterans. Bronchiolitis obliterans was identified in seven of these 11 lungs. Three of the seven lungs with bronchiolitis obliterans were from patients who had received their transplants more than 6 months previously; the bronchiolitis obliterans in these patients was characterized by a relatively acellular concentric fibrosing process that was limited to the terminal bronchioles. The bronchiolitis obliterans in these three patients was felt to be secondary to chronic lung allograft rejection. Four of the seven patients with bronchiolitis obliterans had received their transplants less than 6 months previously; the bronchiolitis obliterans in these patients was focal and cellular. It extended into the distal alveolar spaces and, in several cases, was associated with aspirated material and foreign body-type giant cells. All four of these patients had concurrent infections, aspiration, or large airway obstruction, which were felt to be responsible for the development of bronchiolitis obliterans. Bronchiolitis obliterans in lung allograft recipients may have a variety of etiologies, and the etiology of this process in a particular case can often be deduced by the morphologic appearance of this lesion.
Adult↗
[Obstructive bronchiolitis].
The term "obstructive bronchiolitis" used in this review covers different clinicopathological aspects. On the one hand, it refers to "small airways disease", where bronchiolar narrowings are widespread, secondary to post inflammatory fibrotic changes linked to tobacco smoke or fibrogenic dust inhalation. These obstructive changes at the level of small airways are responsible for a fixed airflow limitation. The specificity and sensibility of functional tests designed for early detection of such an obstruction (the frequency dependence of compliance, the nitrogen slope and the density dependence of the flow-volume curve) are still controversial. On the other hand, the entity covers a disease described at the beginning of the century under the name "bronchiolitis obliterans". It usually appears as a consequence of various causes: viral infection, toxins acting either inhalation or by systemic route, immunological mechanisms as in connective tissue diseases or in graft versus host reactions. A special emphasis is put on idiopathic bronchiolitis obliterans associated with organizing pneumonia. Some clinicopathologic correlations are of basic interest in relation to etiological factors: bronchiolitis obliterans due to viral infection in children involving mainly membranous bronchioles; by contrast, bronchiolitis obliterans related to other causes seems to extend further down from the terminal bronchioles to the respiratory bronchioles. Lymphoid bronchiolitis appears non specific and is mostly observed in association with systemic connective tissue diseases, such as rheumatoid arthritis.
Bronchiolitis↗
Bronchiolitis in the history of the asthmatic child.
In a retrospective analysis of the history of 1,700 asthmatic children, 167 (9.8%) were found to have had bronchiolitis during the first 2 years of life. These 167 cases with asthma and bronchiolitis were matched against 215 selected cases of asthma without bronchiolitis. Both groups attended our Ambulatory Care Unit for Asthma. Data were collected from the clinical cards of the children. Asthmatics who had bronchiolitis were found to have an earlier onset of asthma (p less than 0.001), earlier resolution of symptoms (p less than 0.05 total; p less than 0.01 females), and less evidence of atopy (p less than 0.005). It is suggested therefore that the bronchial hyperreactivity in asthma following bronchiolitis may have different underlying mechanisms than in the typical atopic case, without preceding bronchiolitis. Long-term follow-up studies in infants with bronchiolitis are still necessary in order to clarify the process by which bronchiolitis predisposes to bronchial hyperreactivity and asthma. The consequences of the viral infection itself may lead to pathophysiological processes that promote bronchial hyperreactivity. On the contrary, an underlying condition of bronchial hyperreactivity could be the "primum movens" of the bronchiolitis itself.
Asthma↗
The epidemiology of bronchiolitis.
From the data presented a composite epidemiologic picture of bronchiolitis can be drawn. If one uses a large brush the picture would be that of a common, mild disease during the first 2 years of life, due primarily to RSV and occurring predominantly in males during the winter and spring months. If the drawing is examined more closely, however, a more complex picture is seen. Our data suggest that this syndrome is very common indeed if children are followed closely and examined carefully, but under these circumstances is quite mild. If more strict criteria, such as hospitalization, are applied for inclusion of patients with bronchiolitis a different age distribution is seen. Most children who become severely ill are under 6 months of age and in this group morbidity and mortality are high. Agents other than RSV cause bronchiolitis but in these instances the age occurrence and seasonal occurrence are different from those seen with RSV disease. The predominance of bronchiolitis in males is striking. Our day care center data suggest that mild bronchiolitis occurs with equal sex frequency. This would suggest that the reason more boys are carried to the pediatrician or hospitalized is because they get sicker. Further studies on this phenomenon are in progress. Finally, our data suggest that many bronchiolitis cases from whom no agents were isolated were due to RSV. There is, however, a segment of bronchiolitis cases that occurs in the young child during all seasons which suggests that the young bronchiole may react to a variety of stimuli. This poses a real problem for the investigator of bronchiolitis; hopefully meaningful answers will be available soon.
Age Factors↗
Structural changes in airways of rats exposed to nitrogen dioxide intermittently for seven days. Comparison between major bronchi and terminal bronchioles.
Structural changes caused by exposure to NO2 were compared between the largest intrapulmonary bronchi (major bronchi) and the terminal bronchioles. Rats were exposed to 50 ppm NO2 for 5 h a day for 7 consecutive days, and microscopic findings were assessed subjectively and quantitatively. Destruction of airway epithelium was present on Day 1, and the reparative phase was observed between Days 3 and 7. Light microscopy showed that on Day 1, loss of cilia and disintegration of epithelium occurred, and that the latter was worse in major bronchi than in terminal bronchioles; apical projections of Clara cells in terminal bronchioles were lost almost totally. Recovery of epithelium began by Day 3 and cilia by Day 5, and ciliogenesis progressed less promptly in terminal bronchioles. Clara cells did not return to normal during the experiment. Furthermore, a decrease in the airway diameter occurred in peripheral airways along with an increase in mural thickness in terminal bronchioles. Mural inflammation was also seen more conspicuously in terminal bronchioles. Electron microscopy revealed that epithelial cells lost secretory granules on Day 1 and began to repair them by Day 5 in major bronchi and by Day 7 in terminal bronchioles. It is likely that epithelium in terminal bronchioles is not particularly sensitive to NO2 compared with that in major bronchi, but that recovery occurs more promptly in major bronchi than in terminal bronchioles. Mechanisms underlying bronchoconstriction occurring preferentially in peripheral airways are also discussed.
Animals↗
Parental smoking, presence of older siblings, and family history of asthma increase risk of bronchiolitis.
Bronchiolitis is a common lower respiratory tract illness in infants and has substantial acute morbidity and sequelae. To identify risk factors for bronchiolitis, a case-control study was conducted in which 53 subjects who had bronchiolitis were matched with two controls who had no bronchiolitis in infancy. In multivariate analysis, direct effects of passive smoking and older siblings achieved statistical significance. Family history of asthma appeared to interact with older siblings. Among subjects without a family history of asthma, statistically significant predictors proved to be older siblings (odds ratio, 2.31) and passive smoking (odds ratio, 3.87). Among subjects with a family history of asthma, older siblings proved to be an even stronger predictor (odds ratio, 46.81), while the odds ratio for passive smoking did not change much (odds ratio, 4.03). The combined presence of older siblings and passive smoking yielded an odds ratio of 8.94 among subjects without a family history of asthma and 181.67 among subjects with a family history of asthma. Analysis provided risk estimates that were particularly high for certain groups. Among infants with a family history of asthma, 49% who have an older sibling may develop bronchiolitis. If they are also exposed to cigarette smoke, almost 80% may develop bronchiolitis. Among infants without a family history of asthma, bronchiolitis may develop in 46% of infants if there is both an older sibling and exposure to smoke. Exposure of infants to cigarette smoke might diminish more rapidly if clinicians and parents were aware of such high risks. Efforts to reduce morbidity from bronchiolitis in infants might best be directed at the reduction of smoking in families with previous children, particularly if there is a family history of asthma, and at methods that protect infants from respiratory virus carried by siblings.
Asthma↗
Lung permeability in adult obliterative bronchiolitis.
There is histopathological evidence that, in certain inflammatory disorders involving the smaller airways, extension of the inflammatory process may occur distally into the respiratory bronchioles, alveolar ducts and alveoli (1,2). The objective of this study was to perform a non-invasive evaluation of the possible involvement of gas exchanging regions of the lung in obliterative bronchiolitis presenting with severe airways obstruction. We measured the clearance of technetium 99m-labelled diethylene triamine penta-acetate (99m Tc-DTPA) with time from the lungs to the blood, in 11 normal, non-smoking subjects (mean age 30 years), ten non-smoking patients with cryptogenic fibrosing alveolitis (CFA, mean age 57 years) and ten patients who were non-smokers with obliterative bronchiolitis (mean age 51 years). There was a substantial increase in clearance in patients with CFA, (mean T1/2 19.9 min), compared with either patients with obliterative bronchiolitis (mean T1/2 52.2 min; mean difference 32.3; 95% confidence intervals (CI) 18.40; P less than 0.001) or normal controls (mean T1/2 84.3; mean difference 64.4; 95% CI 55, 74; P less than 0.001). Clearance was also significantly faster in patients with obliterative bronchiolitis than in normal controls (mean difference 32.1; 95% CI 18.48; P less than 0.001). Peripheral deposition of 99m Tc-DTPA was uniform in normal subjects and patients with CFA, but patchy in patients with obliterative bronchiolitis, possibly resulting from altered patterns of ventilation associated with patchy distribution of bronchiolitis within affected lungs. Increased clearance of 99m Tc-DTPA from the lungs in these patients suggests that subtle derangement of the alveolar-capillary membrane occurs in adult obliterative bronchiolitis.
Adult↗
The importance of acquired diffuse bronchomalacia in heart-lung transplant recipients with obliterative bronchiolitis.
The results of heart-lung transplantation are improving with increasing experience in postoperative management, but obliterative bronchiolitis may still develop late postoperatively. We have performed 19 heart-lung transplants, with 1-month, 1-year, and 2-year actuarial survival rates of 95% +/- 5%, 84% +/- 8%, and 69% +/- 16%, respectively. Three early recipients died of bronchiolitis, and four patients who were operated on more than 2 years ago are currently being followed up with bronchiolitis. Since August 1988, 13 surviving recipients have undergone serial postoperative bronchoscopies and transbronchial biopsies with topical analgesia. Diffuse bronchomalacia, involving the main bronchi down to the fifth-order bronchi bilaterally, has developed in four patients with bronchiolitis 9 +/- 2 months after the diagnosis of bronchiolitis was confirmed. Pulmonary function tests have revealed a lower ratio of forced expiratory volume in 1 second to forced vital capacity, lower specific airway conductance, and higher airway resistance in heart-lung recipients with bronchomalacia than in patients with bronchiolitis alone. We conclude that diffuse bronchomalacia occurs frequently in heart-lung transplant recipients who have obliterative bronchiolitis. Bronchomalacia worsens the functional airflow obstruction caused by bronchiolitis and may play an important role clinically in the declining respiratory status of heart-lung transplant recipients.
Adolescent↗
Bronchiolitis obliterans and usual interstitial pneumonia. A comparative clinicopathologic study.
The clinical, radiographic, and pathologic features were studied in 24 cases of bronchiolitis obliterans and 16 cases of usual interstitial pneumonia, to define better their distinguishing characteristics. Bronchiolitis obliterans had a more acute onset often associated with fever, while the presentation of usual interstitial pneumonia was insidious with dyspnea and cough. The radiographs in usual interstitial pneumonia uniformly showed bilateral interstitial opacities, while they were more variable in bronchiolitis obliterans, with air space densities in 15 and interstitial opacities in nine. Prognosis was considerably better for bronchiolitis obliterans patients. Resolution of disease occurred in nearly half, while no patient with usual interstitial pneumonia recovered. Three individuals with bronchiolitis obliterans (12.5%) died of progressive disease, compared to 10 with usual interstitial pneumonia (62.5%). Pathologically, the lesion in bronchiolitis obliterans affected mainly air spaces in a peribronchiolar distribution, while the changes in usual interstitial pneumonia were mainly interstitial and randomly distributed. The fibrosis in bronchiolitis obliterans was composed of proliferating fibroblasts, compared to collagen deposition in usual interstitial pneumonia. These findings emphasize that bronchiolitis obliterans and usual interstitial pneumonia represent separate and distinct clinicopathologic entities.
Adult↗
Bronchiolitis in tropical south India.
In a prospective hospital-based study of 328 children under 5 years of age with acute lower respiratory infections, 114 (35%) were diagnosed to have acute bronchiolitis. Of them, 87 (76%) were less than 1 year and 107 (94%) were less than 2 years of age. Signs of severe lower respiratory infections, namely tachypnea (respiratory rate greater than 50/min) and subcostal retraction, were present in 95% and 93%, respectively. Of 88 children of whom roentgenographs were taken, 30 (34%) had evidence of pneumonia. No clinical signs discriminated between those with and without pneumonia. By culture or immunofluorescence antigen detection, viruses were found in 81 (71%) children with bronchiolitis; respiratory syncytial virus was the most common agent, found in 65 (57%). Parainfluenza viruses were the next most common, found in 12 (11%). Most cases of bronchiolitis occurred in outbreaks during the rainy months of August through November, coinciding with respiratory syncytial virus outbreaks. Although bacterial culture of blood was done in 56 children, no respiratory pathogen was isolated. In one child with bronchiolitis and consolidation, postmortem lung aspirate yielded Staphylococcus aureus. Thus, bronchiolitis is primarily a viral syndrome in this tropical region, just as it is in temperate regions. Eight (7%) children died (all were infants); 5 had roentgenographic pneumonia and the remaining had other abnormalities contributing to death; all had been treated with antibiotics. Since one third of lower respiratory infections are bronchiolitis, and among infants under 1 year of age bronchiolitis comprises 47% of all lower respiratory infection cases, criteria for antibiotic management must take into account the availability of roentgenographic investigation.
Anti-Bacterial Agents↗
Study of 8-year-old children with a history of respiratory syncytial virus bronchiolitis in infancy.
Thirty-five children known to have had respiratory syncytial virus bronchiolitis in infancy were examined at the age of 8 and their respiratory function tested. The results were compared with those in 35 controls matched for age, sex, and social class. Although 18 of the children who had had bronchiolitis in infancy had experienced subsequent episodes of wheezing, these were neither severe nor frequent in most cases and had apparently ceased by the age of 8. Nevertheless, the mean exercise bronchial lability of the children who had had bronchiolitis was significantly higher than that of the control children and the mean peak expiratory flow rate at rest significantly lower. Atopy, assessed by family and personal history alone, did not seem to be related to either bronchiolitis or wheezing episodes after bronchiolitis. The parents of the children who had had bronchiolitis smoked significantly more cigarettes during the infant's first year of life than those of the control children. The results suggest that bronchiolitis and childhood asthma are not closely related. Bronchial hyperreactivity might be inherited independently of atopy, but environmental factors seem the most likely link between severe respiratory infection in infancy and chronic or recurrent respiratory illness in adult life.
Asthma↗
Immunofluorescent evaluation of the lower respiratory tract of healthy horses and of horses with chronic bronchiolitis.
Pulmonary parenchymal tissues from 6 healthy horses and from 9 horses with chronic bronchiolitis were evaluated by use of an indirect immunofluorescent technique. In horses of both groups, the diffuse interstitial immunofluorescence was most intense for immunoglobulin (Ig)G, moderate for IgA, and minimal for IgM. Intensity of fluorescence was increased markedly in diseased lungs exposed to anti-IgA and anti-IgG. Around small bronchi and large bronchioles of healthy horses, IgA-containing cells generally were more numerous than were IgG-Fc fragment (Fc)-containing cells; in small bronchioles, however, IgA-containing cells and IgG (Fc)-containing cells were identified with approximately equal frequency. Immunoglobulin-containing cell types usually were located in the lamina propria and submucosa of airways, with occasional Ig-containing cells seen interepithelially and intraluminally; IgG (T)- and IgM-containing plasma cells were observed infrequently in the same regions. The number of Ig-containing cells became fewer as the diameter of the airway decreased; therefore, at the level of the terminal bronchiole, Ig-containing cells only were observed occasionally. This pattern of Ig-containing cell distribution was similar in horses with chronic bronchiolitis; however, horses with chronic bronchiolitis had more IgA-containing cells forming perivascular and peribronchiolar cuffs than did healthy horses. The number of IgG (Fc)-containing lymphocytes and non-Ig-stainable lymphocytes also were higher in horses with chronic bronchiolitis than in healthy horses, but the number did not approach the magnitude of that observed for IgA-containing cells. One horse had deposits of complement C3 and IgG (Fc) within alveolar septa.
Animals↗
Parainfluenza virus bronchiolitis. Epidemiology and pathogenesis.
An investigation of the epidemiology and pathogenesis of bronchiolitis due to parainfluenza virus (PV) was carried out. Bronchiolitis due to PV occurred most commonly in non-Caucasian males. Breast-fed infants exhibited a reduced risk of developing bronchiolitis. Once an episode of PV bronchiolitis occurred, both exposure to cigarette smoke and bottle feeding were associated with an increased frequency of recurrent wheezing, and subsequent infection with respiratory virus almost uniformly resulted in wheezing. Cell-mediated immune responses to PV antigen and titers of PV-specific IgE were greater among patients with bronchiolitis than among patients with upper respiratory tract infection. The epidemiology and pathogenesis of bronchiolitis due to PV is similar to that of respiratory syncytial virus. Lower respiratory tract infection may predispose to episodes of bronchoconstriction on subsequent exposure to cigarette smoke or other viral infections.
Antigens, Viral↗
Wheezing at 8 and 13 years: changing importance of bronchiolitis and passive smoking.
A group of 153 children (51 with a history of bronchiolitis and 102 matched controls) were evaluated in a historical cohort study at a mean age of 8 years and again at 13 years to test the primary hypothesis that mild bronchiolitis, far more common than severe (hospitalized) bronchiolitis, predicts wheezing. A secondary hypothesis was that passive smoking also predicts wheezing. Many potentially confounding variables such as family history of asthma were controlled in analyses. Analysis at 13 years produced results that were not anticipated from previous analysis of interviews at age 8. Although mild bronchiolitis was a powerful predictor of wheezing at age 8 years, it was no longer a strong predictor of wheezing at age 13 in either bivariate or multivariate analysis. Although epidemiologic studies, by their nature, cannot prove causality, findings are consistent with the hypothesis that sequelae often follow mild bronchiolitis but diminish during childhood. Maternal smoking was a powerful predictor of wheezing at age 13 in bivariate analysis (Kendall's Tau B = 0.19, P less than 0.01) and in multivariate analysis (odds ratio = 2.67, P less than 0.01). In children at highest risk for wheezing, males with a family history of asthma, multivariate analysis suggested that maternal smoking is associated with an increase in wheezing from 36% to 60%. We conclude that passive smoking, previously identified as a risk factor in this population for both bronchiolitis in infancy and wheezing at age 8, is a risk factor for wheezing-associated morbidity throughout the childhood years.
Adolescent↗