What is the management of Acute Bronchiolitis?

Management of Acute Bronchiolitis

The management of acute bronchiolitis should focus on supportive care including hydration assessment, oxygen supplementation when needed, and avoidance of unnecessary medications such as bronchodilators and corticosteroids. 1, 2, 3

Diagnosis and Assessment

• Bronchiolitis is a clinical diagnosis based on history and physical examination; routine laboratory tests and radiologic studies are not recommended 1, 2, 3
• Assessment should include evaluation of risk factors for severe disease:
  • Age less than 12 weeks 1, 3
  • History of prematurity 1, 3
  • Underlying cardiopulmonary disease 1, 3
  • Immunodeficiency 1, 3
• Pulse oximetry should be used to assess oxygenation status, but continuous monitoring is not needed once the clinical course improves 3

Supportive Care

• Hydration Management

  • Assess hydration status and ability to take fluids orally 1, 3
  • Consider intravenous or nasogastric hydration for infants who cannot feed safely due to respiratory distress 3
  • Monitor for possible fluid retention related to production of antidiuretic hormone 3

• Oxygen Therapy

  • Provide supplemental oxygen if SpO₂ falls persistently below 90% in previously healthy infants 1, 2, 3
  • Discontinue oxygen when SpO₂ is at or above 90%, the infant is feeding well, and has minimal respiratory distress 1, 2, 3
  • Infants with hemodynamically significant heart or lung disease and premature infants require closer monitoring during oxygen weaning 1, 3
  • High-flow nasal cannula may be considered for improved oxygen delivery in more severe cases 4

• Airway Management

  • Nasal suctioning to clear secretions may be beneficial 4
  • Minimal handling is recommended to avoid distressing the infant 4

Non-Recommended Treatments

• Bronchodilators

  • Bronchodilators (albuterol/salbutamol) should not be used routinely 1, 2, 3
  • If a trial of bronchodilator is attempted, it should be continued only if there is a documented positive clinical response using objective evaluation 1, 3

• Corticosteroids

  • Corticosteroid medications should not be used routinely 1, 2, 3

• Antiviral Therapy

  • Ribavirin should not be used routinely 1, 3

• Antibiotics

  • Antibacterial medications should only be used when there are specific indications of bacterial coinfection 1, 2, 3

• Chest Physiotherapy

  • Chest physiotherapy is not recommended for routine management 1, 3

Emerging Therapies

• Hypertonic Saline

  • Nebulized hypertonic saline has shown some promise for better airway clearance, but evidence is still evolving 4, 5, 6

• Respiratory Support

  • For severe cases with respiratory distress, CPAP may be considered, though evidence for its routine use remains limited 7, 5

Prevention Strategies

• Infection Control

  • Hand decontamination is the most important step in preventing nosocomial spread of RSV 1, 3
  • Alcohol-based rubs are preferred for hand decontamination 1, 3
  • Educate personnel and family members on hand sanitation 1, 3

• Prophylaxis

  • Palivizumab prophylaxis should be considered for high-risk infants (history of prematurity <35 weeks' gestation or with congenital heart disease) 1, 2, 3
  • When given, prophylaxis with palivizumab should be administered in 5 monthly doses (15 mg/kg per dose intramuscularly), usually beginning in November or December 1, 3

• Environmental Factors

  • Advise parents to avoid exposing infants to passive smoking 1, 3
  • Recommend breastfeeding to decrease a child's risk of having lower respiratory tract disease 1, 3

Common Pitfalls to Avoid

• Overuse of diagnostic testing (chest X-rays, viral testing) that does not change management 3
• Routine use of bronchodilators without documented benefit 1, 2, 3
• Unnecessary use of corticosteroids 1, 2, 3
• Inappropriate use of antibiotics without evidence of bacterial infection 1, 2, 3
• Inadequate assessment of hydration status 1, 3
• Failure to identify high-risk patients who may need more intensive monitoring 1, 3