What is the management of infectious bronchiolitis?

Management of Infectious Bronchiolitis

Bronchiolitis management should focus on supportive care, as most pharmacological interventions have not been shown to improve clinical outcomes. 1

Diagnosis and Assessment

• Diagnosis should be based on history and physical examination without routine laboratory or radiologic studies 1
• Risk factors for severe disease requiring careful assessment:
  • Age less than 12 weeks
  • History of prematurity
  • Underlying cardiopulmonary disease
  • Immunodeficiency 1

Treatment Algorithm

First-line Management (All Patients)

1. Hydration and Nutrition Support

   • Assess hydration status and ability to take fluids orally 1
   • Provide IV fluids if oral intake is compromised

2. Oxygen Therapy

   • Provide supplemental oxygen when SpO₂ falls persistently below 90% 1
   • Maintain SpO₂ at or above 90%
   • Discontinue oxygen when SpO₂ is ≥90% with minimal respiratory distress and good feeding 1
   • High-flow nasal cannula may improve oxygen delivery in more severe cases 2

3. Nasal Suctioning

   • Gentle nasal suctioning to clear secretions 2

4. Minimal Handling

   • Reduce unnecessary interventions that may agitate the child 2

Interventions NOT Recommended for Routine Use

1. Bronchodilators

   • Should not be used routinely 1
   • A trial of bronchodilator may be considered with objective evaluation of response
   • Discontinue if no documented positive response 1

2. Corticosteroids

   • Not recommended for routine use 1, 3

3. Antibiotics

   • Use only when specific bacterial co-infection is suspected 1

4. Chest Physiotherapy

   • Not recommended for routine management 1

5. Ribavirin

   • Should not be used routinely 1
   • May be considered only for severe RSV infection in high-risk patients (immunosuppressed, cardiopulmonary disease) 4

6. Continuous Positive Airway Pressure (CPAP)

   • Limited evidence suggests possible benefit in reducing respiratory rate 5
   • Consider for patients with worsening respiratory distress not responding to standard therapy

Monitoring

• Continuous SpO₂ monitoring not routinely needed as clinical course improves 1
• More intensive monitoring required when weaning oxygen in:
  • Infants with hemodynamically significant heart disease
  • Premature infants
  • Infants with chronic lung disease 1

Prevention Strategies

1. Infection Control

   • Hand decontamination before and after patient contact 1
   • Alcohol-based hand rubs preferred; antimicrobial soap as alternative 1
   • Educate staff and family on hand hygiene 1

2. Palivizumab Prophylaxis

   • Consider for infants with history of prematurity (<35 weeks) or congenital heart disease 1
   • Administer in 5 monthly doses (15 mg/kg IM) starting in November/December 1

3. Environmental Factors

   • Avoid exposure to tobacco smoke 1
   • Encourage breastfeeding to reduce risk of lower respiratory tract disease 1

Emerging Therapies

• Nebulized hypertonic saline (3%) may improve airway clearance and potentially decrease length of hospital stay 2, 3

Common Pitfalls

1. Overuse of bronchodilators and corticosteroids despite evidence showing lack of benefit 6
2. Unnecessary use of antibiotics without evidence of bacterial infection
3. Failure to recognize deterioration requiring escalation of care
4. Inadequate monitoring of high-risk infants during oxygen weaning
5. Insufficient attention to hydration status

Despite the common practice of using bronchodilators and steroids, the evidence consistently shows these interventions do not improve outcomes in most cases of bronchiolitis, and management should focus primarily on supportive care.