What is the treatment approach for bronchiolitis?

Treatment Approach for Bronchiolitis

Bronchiolitis treatment should focus on supportive care measures, as there is no evidence supporting routine use of bronchodilators, corticosteroids, or antibiotics in the management of this condition. 1, 2

Diagnosis and Assessment

• Bronchiolitis is a clinical diagnosis based on history and physical examination; routine laboratory tests and radiologic studies are not recommended 1
• Risk factors for severe disease that require closer evaluation include:
  • Age less than 12 weeks 1, 3
  • History of prematurity 1, 3
  • Underlying cardiopulmonary disease 1, 3
  • Immunodeficiency 1, 3

Supportive Care (First-Line Treatment)

• Ensure adequate hydration:
  • Evaluate the child's ability to feed and hydrate orally 2
  • Consider intravenous or nasogastric hydration if oral intake is compromised 2
• Provide supplemental oxygen:
  • Administer oxygen when SpO₂ falls persistently below 90% 2
  • Maintain SpO₂ ≥ 90% with appropriate oxygen supplementation 2
  • Discontinue oxygen when SpO₂ ≥ 90%, feeding improves, and respiratory distress is minimal 2
• Nasal suctioning:
  • Perform gentle suctioning of nasal secretions to improve breathing and feeding 4, 5
• Positioning:
  • Elevate the head of the bed slightly to facilitate breathing 4

Treatments Not Recommended for Routine Use

• Bronchodilators:
  • The American Academy of Pediatrics recommends against routine use of bronchodilators 2, 5
  • A carefully monitored trial may be considered in select cases, continuing only if there is a documented positive clinical response 2
• Corticosteroids:
  • Should not be used routinely in bronchiolitis treatment 2, 5, 6
• Antibiotics:
  • Should only be used when there are specific indications of coexisting bacterial infection 2, 5
• Other interventions with no proven benefit:
  • Ribavirin 5, 6
  • Montelukast 5
  • Routine chest physiotherapy 5
  • Nebulized deoxyribonuclease 5

Monitoring

• Continuous measurement of SpO₂ is not necessary as the child's clinical course improves 2
• Infants with hemodynamically significant heart or lung disease and premature infants require closer monitoring during oxygen weaning 2

Hospitalization Criteria

• Moderate to severe respiratory distress 4
• Difficulty feeding or signs of dehydration 4
• Apnea 4
• Hypoxemia despite supplemental oxygen 2

Special Considerations

• Bronchiolitis is typically self-limiting, with most children recovering within 2-3 weeks 3
• The mean time to cough resolution is 8-15 days, with 90% of children cough-free by day 21 3
• Despite guidelines recommending against their use, bronchodilators and steroids continue to be frequently prescribed in clinical practice 7
• Emerging evidence suggests nebulized 3% hypertonic saline may decrease length of hospital stay, but this is not yet widely recommended in guidelines 5, 8

Prevention

• Hand hygiene is crucial in preventing nosocomial spread of respiratory syncytial virus 2
• Palivizumab prophylaxis should be considered for high-risk infants 2
• Avoid exposure to tobacco smoke and encourage breastfeeding to decrease risk of lower respiratory tract disease 2