What is the management of bronchiolitis?

Management of Bronchiolitis

Supportive care is the cornerstone of bronchiolitis management, with supplemental oxygen only needed when SpO₂ is <90% in previously healthy infants. 1

Definition and Overview

Bronchiolitis is the leading cause of hospitalization in infants during their first year of life. It is a viral infection of the lower respiratory tract that causes inflammation and obstruction of the small airways (bronchioles).

Supportive Care Measures

Oxygenation

• Monitor oxygen saturation in all infants with bronchiolitis
• Provide supplemental oxygen only when SpO₂ <90% in previously healthy infants 1
• Consider high-flow nasal cannula if respiratory distress worsens 1
• Transient decreases in SpO₂ can occur in healthy infants; continuous monitoring is not required in stable patients 1

Hydration and Nutrition

• Ensure adequate hydration through oral, nasogastric, or intravenous routes as needed
• Monitor fluid intake and output, especially in infants with increased work of breathing

Airway Management

• Perform gentle nasal suctioning to clear secretions 1
• Nasal saline drops may help loosen secretions 1

Medications

Bronchodilators

• Not recommended for routine use in bronchiolitis 1, 2
• May be considered only in select cases with audible wheezing, with objective evaluation of response within 15-20 minutes 1
• If no improvement is observed, discontinue use

Corticosteroids

• Not recommended for routine management of bronchiolitis 1, 2
• No evidence of significant clinical benefit

Antibiotics

• Not recommended unless specific evidence of bacterial co-infection 1
• Unnecessary use contributes to antibiotic resistance

Hypertonic Saline

• Some evidence suggests nebulized 3% hypertonic saline may be beneficial, but not universally recommended 3

Diagnostic Testing

• Chest radiographs are not routinely indicated 1, 2
• Viral testing is not necessary for typical presentations 1
• Laboratory evaluation is not recommended for routine cases 1

Prevention and Prophylaxis

RSV Prophylaxis with Palivizumab

• Indicated for high-risk infants 1, 4:

  1. Premature infants ≤35 weeks gestational age who are ≤6 months at the beginning of RSV season
  2. Children with bronchopulmonary dysplasia requiring medical treatment within the previous 6 months and ≤24 months of age
  3. Children with hemodynamically significant congenital heart disease ≤24 months of age

• Dosing: 15 mg/kg IM monthly during RSV season 4

• Start before RSV season begins and continue monthly throughout the season 4

Additional Preventive Measures

• Encourage breastfeeding to reduce risk 1
• Avoid exposure to tobacco smoke 1
• Practice good hand hygiene 1

Discharge Criteria and Follow-up

• Consider discharge when:

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

• Monitor for risk factors for severe disease:

  • Young age
  • History of prematurity
  • Underlying cardiopulmonary disease
  • Immunodeficiency 1

• Parents should be educated about the potential for recurrent wheezing episodes, particularly in children with a history of allergic rhinitis 1

Common Pitfalls to Avoid

1. Overuse of bronchodilators and corticosteroids despite evidence against their routine use
2. Unnecessary diagnostic testing (chest X-rays, viral panels, blood work)
3. Inappropriate antibiotic prescription
4. Failure to identify high-risk infants who may benefit from closer monitoring
5. Inadequate parental education about the expected course of illness

Remember that bronchiolitis is typically self-limiting, and most children recover with supportive care alone. The focus should be on maintaining adequate oxygenation, hydration, and clearing of secretions rather than pharmacological interventions.