What is the treatment approach for bronchiolitis?

Treatment Approach for Bronchiolitis

The treatment of bronchiolitis should focus primarily on supportive care, avoiding routine use of bronchodilators, corticosteroids, and antibiotics, as these interventions have not been shown to improve clinical outcomes. 1, 2

Diagnosis and Assessment

• Diagnose bronchiolitis based on history and physical examination findings including:
  • Rhinorrhea
  • Cough
  • Wheezing
  • Crackles
  • Signs of respiratory distress
• Do not routinely order laboratory tests or chest radiographs 1, 2
• Assess risk factors for severe disease:
  • Age less than 12 weeks
  • History of prematurity
  • Underlying cardiopulmonary disease
  • Immunodeficiency 1, 2

Treatment Algorithm

1. Supportive Care (First-Line Management)

• Oxygen supplementation:

  • Provide when SpO₂ falls persistently below 90% in previously healthy infants
  • Maintain SpO₂ at or above 90%
  • Discontinue when SpO₂ is ≥90% with minimal respiratory distress and good feeding 1, 2
  • Monitor high-risk infants (premature, heart/lung disease) more closely during oxygen weaning 1

• Hydration and nutrition:

  • Assess hydration status and ability to take fluids orally
  • Provide IV or nasogastric fluids if oral intake is compromised
  • Be cautious of fluid retention related to antidiuretic hormone production 1, 2

2. Interventions NOT Recommended for Routine Use

• Bronchodilators (e.g., albuterol):

  • Should not be used routinely 1, 2
  • A carefully monitored trial may be considered in select cases
  • Continue only if there is a documented positive clinical response using objective evaluation
  • Discontinue if no improvement is observed 1, 2, 3

• Corticosteroids:

  • Not recommended for routine use 1, 2
  • Multiple studies have shown no significant benefit 4

• Antibiotics:

  • Use only when specific bacterial co-infection is suspected:
    • High fever persisting >3 days
    • Confirmed pneumonia
    • Associated purulent acute otitis media 1, 2

• Chest physiotherapy:

  • Not recommended for routine management 1, 2
  • May cause more harm than benefit

• Ribavirin:

  • Not recommended for routine use 1
  • May be considered only for severe RSV infection in high-risk patients 2

3. Prevention in High-Risk Infants

• Palivizumab prophylaxis:
  • Consider for infants with:
    • History of prematurity (<35 weeks gestational age) who are ≤6 months at RSV season start
    • Bronchopulmonary dysplasia requiring treatment in previous 6 months and ≤24 months old
    • Hemodynamically significant congenital heart disease and ≤24 months old 1, 2, 5
  • Administer in 5 monthly doses (15 mg/kg IM) starting before RSV season 1, 5

Monitoring and Follow-up

• Continuous SpO₂ monitoring not routinely needed as clinical course improves 1
• More intensive monitoring required when weaning oxygen in high-risk infants 1, 2
• Continue monthly palivizumab doses throughout RSV season even if infection occurs 5

Common Pitfalls to Avoid

• Overuse of diagnostic testing (chest X-rays, laboratory tests) which does not improve outcomes 2
• Inappropriate use of bronchodilators despite lack of consistent benefit 2, 6
• Unnecessary antibiotic therapy when bacterial co-infection is uncommon 1, 2
• Overreliance on pharmacologic interventions instead of supportive care 2, 4
• Inadequate monitoring of high-risk infants during oxygen weaning 2

Despite the widespread use of bronchodilators and corticosteroids in clinical practice, the evidence consistently shows these interventions do not improve outcomes in most infants with bronchiolitis 4, 6. Standardization of care with evidence-based institutional clinical pathways can help optimize resource utilization while improving care and reducing hospital length of stay and costs 4.