From the Guidelines
Bronchiolitis is a common viral respiratory infection affecting the small airways (bronchioles) in infants and young children, typically under 2 years of age, and treatment is primarily supportive care, focusing on ensuring adequate hydration and oxygen saturation, as recommended by the American Academy of Pediatrics 1. The clinical manifestations of bronchiolitis include rhinitis, tachypnea, wheezing, cough, crackles, use of accessory muscles, and/or nasal flaring, with the most common etiology being respiratory syncytial virus (RSV) 1. Key aspects of management include:
- Nasal suctioning with saline drops to help clear secretions, especially before feeding
- Supplemental oxygen if oxygen saturation falls below 90-92%
- Hospitalization for infants with severe respiratory distress, oxygen requirement, dehydration, or those under 3 months with fever
- Prevention strategies such as handwashing, avoiding exposure to sick contacts, and breastfeeding to provide passive immunity
- Palivizumab prophylaxis may be considered for high-risk infants (premature, with chronic lung disease or congenital heart disease) during RSV season, as stated in the clinical practice guideline 1. Medications like albuterol, epinephrine, corticosteroids, and antibiotics are not routinely recommended as they have not shown significant benefit in bronchiolitis, according to the evidence-based literature 1. Parents should be educated about the expected course and warning signs requiring medical attention, such as increased work of breathing, poor feeding, or lethargy, to ensure prompt recognition and management of potential complications 1.
From the FDA Drug Label
The safety and efficacy of Synagis have not been established for treatment of RSV disease Children who develop an RSV infection should continue to receive monthly doses throughout the RSV season.
The FDA drug label does not answer the question.
From the Research
Clinical Manifestations of Bronchiolitis
- Bronchiolitis is the leading cause of lower respiratory tract infection and hospitalization in children less than 1 year of age worldwide 2
- Clinical diagnosis of bronchiolitis is mainly based on medical history and physical examination (rhinorrhea, cough, crackles, wheezing, and signs of respiratory distress) 2
- Infants with pre-existing risk factors (prematurity, bronchopulmonary dysplasia, congenital heart diseases, and immunodeficiency) may be predisposed to a severe form of the disease 2
Management of Bronchiolitis
- Current evidence does not support the routine use of chest radiographs, viral testing, or laboratory evaluation in children with bronchiolitis 3
- Routine administration of bronchodilators, including albuterol and nebulized epinephrine, corticosteroids, and hypertonic saline are not recommended for infants and children with bronchiolitis 3, 4
- Supportive care, comprising of taking care of oxygenation and hydration, remains the cornerstone of therapy in bronchiolitis 3, 2, 4
- Intravenous or nasogastric hydration and nutritional support, supplemental oxygen, and respiratory support are recommended 3
- Nebulized adrenaline may be sometimes useful in the emergency room or hospital setting for treatment as needed 2
High-Risk Patients with Bronchiolitis
- Patients with critical bronchiolitis requiring invasive mechanical ventilation possess high-risk features, including younger age, history of prematurity, neurologic or genetic co-morbidities, and a propensity for multi-microbial infections 5
- Criteria for hospitalization include low oxygen saturation, moderate-to-severe respiratory distress, dehydration, and presence of apnea, especially in children with pre-existing risk factors 2
- Management guidelines for bronchiolitis advocate for supportive care and exclude those with high-risk conditions, but a varied approach to the management of bronchiolitis in both standard-risk and high-risk children may occur institutionally 6