What is the treatment for inflammatory bronchiolitis?

Treatment of Inflammatory Bronchiolitis

Supportive care is the cornerstone of treatment for inflammatory bronchiolitis, with no routine role for corticosteroids, bronchodilators, or antibiotics unless specifically indicated. 1

Initial Management Approach

Supportive Care

• Hydration and nutrition
  • Assess feeding ability and hydration status
  • Encourage normal feeding or smaller, more frequent feeds
  • Consider IV fluids if unable to maintain adequate oral intake 1

Respiratory Support

• Oxygen supplementation
  • May withhold supplemental oxygen if saturation exceeds 90% 2
  • Monitor for worsening respiratory distress
  • Consider high-flow nasal cannula if respiratory distress worsens 1
• Nasal suctioning to clear secretions when needed 1

Medications to Avoid

Corticosteroids

• Systemic corticosteroids are not recommended for routine management of bronchiolitis 2
  • Multiple high-quality studies show no significant benefit in:
    • Reducing hospital admissions (pooled risk ratio 0.92; 95% CI 0.78-1.08) 2
    • Reducing length of stay for inpatients 2, 3
  • A Cochrane review of 17 trials with 2596 participants confirmed lack of benefit 2

Inhaled Corticosteroids

• Not recommended for acute bronchiolitis 4
• Do not reduce recurrent wheeze or asthma in patients with bronchiolitis 4

Bronchodilators

• Not recommended for routine use 1
• May be considered only in select cases with:
  • Audible wheezing
  • Objective evaluation of response within 15-20 minutes 1
  • Discontinuation if no documented improvement

Antibiotics

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

Special Considerations

Diffuse Panbronchiolitis

• This is a distinct entity from viral bronchiolitis in infants
• Long-term macrolide antibiotics (treatment course of at least 6 months) are recommended 5
• Significant improvement in prognosis has been reported with macrolide therapy 5

Monitoring for Deterioration

• Watch for:
  • Worsening respiratory distress
  • Decreased oxygen saturation below 90%
  • Inability to maintain adequate hydration
  • Lethargy or decreased responsiveness 1

Discharge Criteria

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

Prevention Strategies

• Hand hygiene before and after patient contact
• Encourage breastfeeding to reduce risk
• Avoid exposure to tobacco smoke
• Consider RSV prophylaxis (palivizumab) for eligible high-risk infants 1

Common Pitfalls to Avoid

1. Using corticosteroids despite strong evidence against their benefit
2. Routine use of bronchodilators without objective assessment of response
3. Prescribing antibiotics without evidence of bacterial infection
4. Failing to provide adequate supportive care, which remains the mainstay of treatment

The evidence consistently shows that medications often used in other respiratory conditions (like asthma) do not provide benefit in typical viral bronchiolitis, and management should focus on supportive care while avoiding unnecessary interventions.