What is the treatment for viral bronchitis in pediatric (peds) patients?

Treatment of Viral Bronchiolitis in Pediatric Patients

Supportive care is the mainstay of treatment for viral bronchiolitis in pediatric patients, with no pharmacological interventions routinely recommended. 1

Assessment and Supportive Care

• Risk assessment: Evaluate for risk factors for severe disease:

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

• Respiratory support:

  • Gentle nasal suctioning to clear secretions (avoid deep suctioning) 1
  • Provide supplemental oxygen if oxygen saturation is <90% 1
  • Consider high-flow nasal cannula if respiratory distress worsens 1

• Hydration:

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

Medications to AVOID

1. Bronchodilators:

   • Should not be used routinely 2, 1
   • The American Academy of Pediatrics (AAP) states that the harm (adverse effects, cost) outweighs the benefit 2
   • Only consider a trial in select cases with objective evaluation of response 1

2. Corticosteroids:

   • Should not be used routinely 2, 1
   • Systematic reviews of RCTs have shown no significant benefit 2
   • Preponderance of harm over benefit 2

3. Antibiotics:

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

4. Ribavirin:

   • Should not be used routinely 2
   • Preponderance of harm over benefit 2

5. Asthma medications:

   • Should not be used unless other evidence of asthma is present 2, 1
   • Symptoms of asthma include recurrent wheeze and/or dyspnea 2

6. Inhaled osmotic agents/hypertonic saline:

   • Should not be used for chronic cough after bronchiolitis 2, 1

Management of Persistent Cough (>4 weeks)

For children with chronic cough (>4 weeks) after acute viral bronchiolitis:

1. Manage according to pediatric chronic cough guidelines 2, 1
2. Consider a 2-week course of antibiotics targeted to common respiratory bacteria (S. pneumoniae, H. influenzae, M. catarrhalis) only if wet or productive cough persists without other specific cough pointers 2, 1

Prevention Strategies

• Hand decontamination before and after patient contact 1
• Avoid exposure to tobacco smoke 1
• Encourage breastfeeding to reduce risk of lower respiratory tract disease 1
• Consider RSV prophylaxis (palivizumab 15 mg/kg IM in 5 monthly doses) for high-risk infants 1

Monitoring and Follow-up

• Infants under 6 months with bronchiolitis are at highest risk for major medical interventions within the first 5 days of illness 1
• Monitor high-risk infants more closely during oxygen weaning 1
• Educate caregivers about warning signs requiring return evaluation:
  • Increased work of breathing
  • Poor feeding
  • Lethargy
  • Apnea 1

Common Pitfalls to Avoid

1. Overuse of medications: Despite evidence against their routine use, bronchodilators and corticosteroids continue to be widely prescribed 3, 4, 5
2. Unnecessary diagnostic testing: Chest radiographs and viral testing are not routinely necessary 4
3. Inadequate hydration monitoring: Dehydration can worsen outcomes and requires close attention 1
4. Deep suctioning: May be associated with longer hospital stays 1
5. Failure to identify high-risk patients: Those with underlying conditions require closer monitoring 1

The evidence consistently shows that supportive care focusing on oxygenation, hydration, and airway clearance remains the cornerstone of bronchiolitis management, while most pharmacological interventions lack evidence of benefit and may cause harm.