What is the management approach for bronchiolitis?

Management Approach for Bronchiolitis

The management of bronchiolitis should focus on supportive care while avoiding unnecessary interventions, as bronchodilators, corticosteroids, and routine diagnostic tests are not recommended for typical cases. 1, 2

Diagnosis and Assessment

• Bronchiolitis is a clinical diagnosis that does not require routine laboratory or radiologic studies 1, 2
• Risk factors for severe disease that warrant closer evaluation include:
  • Age less than 12 weeks 1, 3
  • History of prematurity 1, 3
  • Underlying cardiopulmonary disease 1, 3
  • Immunodeficiency 1, 3

Recommended Management Approach

Supportive Care

• Assess hydration status and ability to take fluids orally 1, 2
• Provide intravenous or nasogastric hydration if oral intake is inadequate 2, 4
• Nasal suctioning to clear secretions and facilitate breathing and feeding 3, 5
• Consider elevating the head of the bed slightly to facilitate breathing 3

Oxygen Therapy

• Administer supplemental oxygen if SpO₂ falls persistently below 90% in previously healthy infants 1, 2
• Maintain SpO₂ at or above 90% with adequate supplemental oxygen 1, 2
• Oxygen may be discontinued when SpO₂ is ≥90%, the infant is feeding well, and has minimal respiratory distress 1, 2
• Continuous SpO₂ monitoring is not routinely needed as the clinical course improves 1, 2
• Infants with hemodynamically significant heart or lung disease and premature infants require closer monitoring during oxygen weaning 1, 2

Interventions NOT Recommended

• Bronchodilators should not be used routinely 1, 2, 4
  • A carefully monitored trial may be considered, continuing only if there is a documented positive clinical response 1
• Corticosteroids should not be used routinely 1, 2, 4
• Antibiotics should only be used when there are specific indications of bacterial coinfection 1, 2
• Chest physiotherapy is not recommended for routine management 1
• Ribavirin is not recommended for routine use 1

Prevention Strategies

• Hand hygiene is the most important step in preventing nosocomial spread of RSV 1, 2
  • Alcohol-based rubs are preferred for hand decontamination 1, 2
• Palivizumab prophylaxis may be administered for high-risk infants (history of prematurity <35 weeks' gestation or congenital heart disease) 1, 2
  • When given, administer in 5 monthly doses (15 mg/kg per dose intramuscularly), typically starting in November or December 1, 2
• Avoid exposure to tobacco smoke 1, 2
• Breastfeeding is recommended to decrease risk of lower respiratory tract disease 1, 2

Criteria for Hospitalization

• Moderate to severe respiratory distress 3
• Difficulty feeding or dehydration 3
• Apnea 3
• Inability to maintain adequate oxygenation (SpO₂ <90%) 1, 2

Important Clinical Considerations

• Bronchiolitis is typically self-limiting, with a duration of 8-15 days in most children 3
• 90% of children are free of cough by 21 days 3
• Standardization of care with evidence-based clinical pathways can optimize resource utilization while improving outcomes 4
• For infants requiring hospitalization, questions remain regarding optimal approaches to nasogastric feeding, supplemental oxygen protocols, and the role of newer therapies like hypertonic saline 6

Management of Post-Bronchiolitis Chronic Cough

• Asthma medications are not recommended for children with persistent cough after bronchiolitis unless there is additional evidence of asthma 3
• Inhaled hypertonic saline is not recommended for post-bronchiolitis chronic cough 3
• For persistent wet/productive cough, consider evaluation for specific cough indicators and possibly a 2-week course of antibiotics targeting common respiratory bacteria 3