What is the management approach for bronchiolitis?

Management of Bronchiolitis

The management of bronchiolitis should focus primarily on supportive care, including oxygen supplementation for SpO₂ <90%, adequate hydration, and nasal suctioning, while avoiding unnecessary interventions such as routine bronchodilators, corticosteroids, and antibiotics. 1

Diagnosis and Assessment

• Bronchiolitis is a clinical diagnosis based on:

  • Typical presentation: 2-4 days of upper respiratory symptoms (fever, rhinorrhea, congestion) followed by lower respiratory symptoms (cough, wheezing, increased respiratory effort) 2
  • Physical examination findings of wheezing, crackles, and increased work of breathing
  • Age typically <2 years, with peak incidence at 3-6 months

• Diagnostic testing is not routinely recommended:

  • Chest radiographs are not indicated for typical presentations 1, 3
  • Viral testing is unnecessary for typical cases 1
  • Laboratory evaluation is not recommended for routine cases 1

Evidence-Based Management Approach

Supportive Care (First-Line)

1. Oxygen Therapy:

   • Provide supplemental oxygen only when SpO₂ <90% in previously healthy infants 1
   • Consider higher SpO₂ targets in children with fever, acidosis, or hemoglobinopathies 1
   • Continuous monitoring is not required in stable patients 1

2. Hydration and Nutrition:

   • Ensure adequate hydration through oral, intravenous, or nasogastric routes 1, 3
   • Consider IV or nasogastric hydration if respiratory distress impairs oral intake 3

3. Airway Management:

   • Nasal saline and gentle suctioning to clear secretions 1
   • Consider high-flow nasal cannula if respiratory distress worsens 1
   • Minimal handling to reduce oxygen consumption and stress 4

Interventions NOT Routinely Recommended

1. Bronchodilators:

   • The American Academy of Pediatrics strongly recommends against routine use 1
   • May be considered only in select cases with audible wheezing and objective evaluation of response within 15-20 minutes 1

2. Corticosteroids:

   • Not recommended for routine management of bronchiolitis 1, 3, 5
   • Do not prevent development of asthma 4

3. Antibiotics:

   • Should be avoided unless there is specific evidence of bacterial co-infection 1, 3

4. Other Medications:

   • Nebulized epinephrine: not routinely recommended 2
   • Leukotriene receptor antagonists: not routinely recommended 4

Emerging Therapies with Limited Evidence

• Hypertonic saline: May improve airway clearance in some cases, but evidence is mixed 5
• Heliox (helium/oxygen mixtures): Limited evidence for benefit in severe cases 6

Special Considerations

High-Risk Patients

• Closer monitoring is required for:
  • Infants with hemodynamically significant heart or lung disease 1
  • Premature infants 1, 2
  • Children with immunodeficiency 1, 2

Prevention and Prophylaxis

• RSV prophylaxis (palivizumab) for eligible high-risk infants:

  • Premature infants born before 29 weeks' gestation 1, 2
  • Children with chronic lung disease of prematurity 1, 2
  • Children with hemodynamically significant heart disease 1, 2
  • Administer 15 mg/kg IM in 5 monthly doses starting before RSV season 1

• Additional preventive measures:

  • Encourage breastfeeding 1
  • Avoid exposure to tobacco smoke 1, 4
  • Practice good hand hygiene 1

Discharge Criteria and Follow-up

• Consider discharge when:

  • Oxygen saturation is maintained ≥90% on room air 1
  • Adequate oral intake is established 1
  • Respiratory distress has significantly improved 1

• Monitor for risk of recurrent wheezing:

  • RSV infection is associated with increased risk of subsequent wheezing 1
  • History of allergic rhinitis increases risk for recurrent wheezing or asthma development 1
  • Educate parents about expected course and potential for recurrent episodes 1

Common Pitfalls to Avoid

• Overuse of diagnostic testing (chest X-rays, viral panels, blood work) in typical presentations
• Routine use of bronchodilators without objective evaluation of response
• Prescribing antibiotics without evidence of bacterial infection
• Failing to identify high-risk patients who need closer monitoring
• Inadequate parent education about the expected course and warning signs