What is the best approach to control moderate to severe cough in bronchiolitis in infants?

Management of Moderate to Severe Cough in Bronchiolitis in Infants

Supportive care is the mainstay of treatment for moderate to severe cough in bronchiolitis in infants, with no pharmacological interventions routinely recommended for cough management. 1, 2

Assessment of Bronchiolitis Severity

When evaluating an infant with bronchiolitis and moderate to severe cough:

• Assess for risk factors for severe disease:

  • Age less than 12 weeks
  • History of prematurity
  • Underlying cardiopulmonary disease
  • Immunodeficiency 1, 2

• Evaluate respiratory status:

  • Respiratory rate (count for full minute)
  • Work of breathing (retractions, nasal flaring, grunting)
  • Oxygen saturation (SpO₂)
  • Presence of wheezing, crackles
  • Ability to feed and maintain hydration 1

Evidence-Based Management Approach

First-Line Interventions

1. Nasal Suctioning

   • Perform gentle nasal suctioning to clear secretions
   • Avoid deep suctioning as it may be associated with longer hospital stays 1
   • Frequent but gentle suctioning can improve breathing and feeding 2

2. Adequate Hydration

   • 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 2

3. Oxygen Therapy

   • Provide supplemental oxygen if SpO₂ <90% 1, 2
   • Consider high-flow nasal cannula if respiratory distress worsens 2

Interventions NOT Recommended for Cough Management

The following interventions are not recommended for routine use in managing cough in bronchiolitis:

1. Bronchodilators (albuterol, nebulized epinephrine)

   • Not recommended for routine use 1, 2, 3
   • May be considered only in emergency settings with objective evaluation of response 2

2. Corticosteroids

   • Not recommended for routine use 1, 2, 3
   • No evidence of significant benefit for cough management 1, 4

3. Antibiotics

   • Should not be used unless specific bacterial co-infection is suspected 1, 2
   • Consider only with high fever persisting >3 days, purulent acute otitis media, or confirmed pneumonia 2

4. Inhaled Osmotic Agents (hypertonic saline)

   • Not recommended for chronic cough after bronchiolitis 1
   • Limited evidence for benefit in acute bronchiolitis 5, 6

Special Considerations for Persistent Cough

For infants with persistent cough (>4 weeks) after acute bronchiolitis:

• Manage according to pediatric chronic cough guidelines 1
• Consider 2-week course of antibiotics only if wet/productive cough persists without other specific cough pointers 1
• Do not use asthma medications unless other evidence of asthma is present (recurrent wheeze, dyspnea) 1

Monitoring and Follow-up

• Frequent reassessment of respiratory status is necessary 2
• Educate caregivers about warning signs requiring return evaluation:
  • Increased work of breathing
  • Poor feeding
  • Lethargy
  • Apnea 2

Common Pitfalls to Avoid

1. Overuse of medications: Avoid routine use of bronchodilators, corticosteroids, or antibiotics as they provide no benefit for cough in bronchiolitis and may cause adverse effects 1, 3

2. Unnecessary diagnostic tests: Avoid routine chest radiographs and laboratory tests as they do not improve outcomes and may lead to inappropriate antibiotic use 1, 2

3. Inadequate hydration monitoring: Dehydration can worsen secretions and cough; ensure adequate fluid intake 2

4. Insufficient suctioning: Failure to clear nasal secretions can worsen respiratory distress and cough 1, 2

The management of cough in bronchiolitis remains primarily supportive, focusing on maintaining adequate oxygenation, hydration, and clearing of secretions. Despite the temptation to use various pharmacological interventions, current evidence does not support their routine use for cough management in bronchiolitis.