What is the initial treatment for bronchiolitis?

Initial Treatment of Bronchiolitis

The initial treatment of bronchiolitis should focus on supportive care, including oxygen supplementation when SpO₂ falls persistently below 90%, and assessment of hydration status with appropriate fluid management. 1, 2

Diagnosis and Assessment

• Bronchiolitis is a clinical diagnosis based on history and physical examination
• Key clinical features include:
  • Rhinorrhea, cough, wheezing, crackles
  • Signs of respiratory distress (tachypnea, nasal flaring, retractions)
  • Fever may be present
• Routine laboratory tests and radiologic studies are not recommended 1, 2
• Risk factors for severe disease requiring careful assessment:
  • Age less than 12 weeks
  • History of prematurity
  • Underlying cardiopulmonary disease
  • Immunodeficiency 1, 2

Supportive Care (First-Line Treatment)

Oxygen Therapy

• Provide supplemental oxygen when SpO₂ falls persistently below 90% 1, 2
• Maintain SpO₂ at or above 90%
• Discontinue oxygen when SpO₂ is ≥90% with minimal respiratory distress and good feeding
• More intensive monitoring required when weaning oxygen in high-risk infants 1

Hydration and Nutrition

• Assess hydration status and ability to take fluids orally 1, 2
• Provide IV or nasogastric fluids if oral intake is compromised
• Small, frequent feeds may be better tolerated

Pharmacological Interventions (Generally Not Recommended)

Bronchodilators

• Should not be used routinely 1, 2
• A carefully monitored trial of bronchodilator (albuterol/salbutamol) may be considered in select cases with objective evaluation of response 1
• If no documented positive response, treatment should be discontinued
• Anticholinergic agents (ipratropium) are not recommended 1

Corticosteroids

• Not recommended for routine use 1, 2
• Multiple randomized controlled trials have shown no significant benefit 1

Antibiotics

• Should only be used when specific bacterial co-infection is suspected 1, 2
• Common scenarios warranting antibiotics:
  • High fever (>38.5°C) persisting for more than 3 days
  • Associated purulent acute otitis media
  • Confirmed pneumonia or atelectasis on chest X-ray 1

Other Interventions

• Chest physiotherapy is not recommended for routine management 1, 2
• Ribavirin should not be used routinely 1, 2, 3
  • May be considered only for severe RSV infection in high-risk patients 3
• Hypertonic saline (3%) may be considered in hospitalized infants to potentially decrease length of stay 4

Infection Control Measures

• Hand decontamination before and after patient contact is essential 1, 2
• Alcohol-based hand rubs preferred with antimicrobial soap as alternative
• Educate staff and family on hand hygiene

Common Pitfalls to Avoid

1. Overuse of diagnostic testing: Routine chest X-rays and laboratory tests do not improve outcomes and may lead to unnecessary antibiotic use 1, 5

2. Inappropriate use of bronchodilators: Despite widespread use, bronchodilators have not consistently shown benefit in bronchiolitis and should not be continued without documented improvement 1, 5

3. Unnecessary antibiotic therapy: Bacterial co-infection is uncommon in bronchiolitis; antibiotics should be reserved for specific indications 1

4. Overreliance on pharmacologic interventions: The evidence consistently shows that supportive care remains the cornerstone of bronchiolitis management 1, 2, 5

5. Inadequate monitoring of high-risk infants: Infants with risk factors require closer monitoring, especially during oxygen weaning 1, 2