From the Guidelines
Management of bronchiolitis primarily involves supportive care rather than medications, focusing on ensuring adequate hydration and oxygenation, with supplemental oxygen provided when oxygen saturation falls below 90-92%. The diagnosis of bronchiolitis is clinical and does not require diagnostic testing 1. Supportive care measures include nasal suctioning to clear secretions, especially before feeds, and monitoring of respiratory status, feeding, and hydration. Most infants can be managed at home with careful monitoring, while hospital admission is indicated for those with respiratory distress, oxygen requirement, dehydration, or inability to feed.
The use of bronchodilators like albuterol is not routinely recommended as they show minimal benefit 1. Similarly, corticosteroids, antibiotics, and nebulized hypertonic saline are not recommended for routine use due to lack of evidence showing significant benefits in improving the clinical course of the illness 1. For severe cases requiring hospitalization, high-flow nasal cannula therapy may be used before considering mechanical ventilation. Prevention strategies are crucial and include handwashing, avoiding exposure to cigarette smoke, and limiting contact with sick individuals. Palivizumab prophylaxis may be considered for high-risk infants (premature, with chronic lung disease or congenital heart disease) during RSV season 1. Bronchiolitis is typically self-limiting, with most children improving within 1-2 weeks, though cough may persist for several weeks.
Key aspects of management include:
- Ensuring adequate hydration and oxygenation
- Nasal suctioning to clear secretions
- Monitoring of respiratory status, feeding, and hydration
- Avoiding routine use of bronchodilators, corticosteroids, antibiotics, and nebulized hypertonic saline
- Considering high-flow nasal cannula therapy for severe cases
- Implementing prevention strategies such as handwashing and avoiding exposure to cigarette smoke
- Considering Palivizumab prophylaxis for high-risk infants during RSV season, as supported by evidence from 1 and 1.
From the Research
Management of Bronchiolitis
- The mainstay of treatment for bronchiolitis remains supportive care, with emphasis on fluid replacement and oxygen therapy 2, 3, 4.
- Evidence does not support the use of bronchodilators, racemic epinephrine, deep suctioning, systemic corticosteroids, or antibiotics in the absence of a concomitant bacterial infection 2, 3, 4.
- Nebulized hypertonic saline is not routinely recommended, though it may provide some benefit for patients with anticipated prolonged length of stay 2, 3.
- Continuous pulse oximetry should not be routinely used in stable patients as it may be associated with longer length of stay 2.
- Supplemental oxygen should be used to maintain oxyhemoglobin concentrations ≥90% 2.
- High-flow nasal cannula may reduce intubation rate, but its effect on length of stay is unclear 2.
- Intravenous or nasogastric tube hydration should be used when oral hydration is not sufficient 2.
Pharmacologic Options
- Bronchodilators and steroids continue to be used frequently despite practice recommendations and regardless of risk status 5.
- Agents with evidence of no benefit in acute bronchiolitis include β2 agonists, ipratropium, montelukast, corticosteroids, antiviral agents such as ribavirin or RSV immunoglobulin, physiotherapy, nebulized deoxyribonuclease or antibiotics 3, 6.
- Nebulized epinephrine may have a small short-term effect, and nebulized 3% hypertonic saline administered with a bronchodilator may decrease length of stay in hospital 3.
- Exogenous surfactant, helium/oxygen mixtures (heliox) and combination therapies may offer clinical benefit as well 6.