What are the current management strategies for bronchiolitis?

Bronchiolitis: Features, Management, and Recent Advances

Clinical Features and Diagnosis

Bronchiolitis is a clinical diagnosis based solely on history and physical examination—do not order routine laboratory tests, viral testing, or chest radiographs in typical presentations. 1, 2

Key clinical features to identify:

• Age: Primarily affects infants <2 years, with highest risk in those <12 weeks 1, 2
• Presentation: Lower respiratory tract infection with wheezing, crackles, increased work of breathing, and respiratory distress
• Risk stratification: Immediately identify high-risk patients with prematurity (<35 weeks gestation), underlying cardiopulmonary disease, or immunodeficiency, as these require closer monitoring 1, 2

Management Algorithm

Step 1: Supportive Care (The Only Proven Therapy)

The cornerstone of bronchiolitis management is supportive care alone—oxygen, hydration, and monitoring—as this is the only intervention proven to improve outcomes. 1, 2, 3

Oxygen therapy:

• Administer supplemental oxygen if SpO₂ persistently falls below 90% 1, 2
• Maintain SpO₂ ≥90% with adequate supplemental oxygen 2
• Discontinue oxygen when SpO₂ ≥90%, infant feeds well, and has minimal respiratory distress 1, 2
• High-flow nasal cannula has improved oxygen delivery in recent years 4

Hydration and nutrition:

• Assess ability to feed and hydrate orally 1, 2
• Provide intravenous or nasogastric hydration if oral intake is inadequate 2

Monitoring:

• Continuous SpO₂ monitoring is not routinely needed as clinical course improves 1, 2
• Exception: Infants with hemodynamically significant heart/lung disease and premature infants require close monitoring during oxygen weaning 1, 2

Step 2: What NOT to Do (Critical Pitfalls to Avoid)

Do not routinely use bronchodilators, corticosteroids, antibiotics, chest physiotherapy, or ribavirin—these have not been shown to improve clinical outcomes and may cause harm. 1, 2, 3

Bronchodilators (albuterol, epinephrine):

• Should NOT be used routinely 1, 2
• Optional: A carefully monitored trial of α- or β-adrenergic medication may be attempted, but continue ONLY if documented positive clinical response using objective evaluation 1, 2
• Recent data shows bronchodilator use (>3 doses) is associated with increased rapid response team activation (OR 8.36), suggesting potential harm 5

Corticosteroids:

• Do NOT use routinely in bronchiolitis management 1, 2, 3
• No evidence of benefit despite continued widespread use 5, 3

Antibiotics:

• Use ONLY when specific indications of coexisting bacterial infection exist 1, 2
• Treat bacterial infection as you would in absence of bronchiolitis 1

Chest physiotherapy:

• Do NOT use routinely 1, 2
• Percussion and postural drainage associated with increased rapid response team activation (OR 5.06) 5

Ribavirin:

• Do NOT use routinely 1, 2
• FDA labeling indicates treatment should be based on severity and reserved for severe RSV infection in high-risk patients (prematurity, immunosuppression, cardiopulmonary disease) 6
• Requires mechanical ventilator expertise and intensive monitoring if used 6

Step 3: Recent Advances and Emerging Therapies

Hypertonic saline:

• Nebulized hypertonic saline enables better airway clearance with potential benefit for respiratory function 4
• However, use of >3 doses associated with increased rapid response team activation (OR 13.94), suggesting caution needed 5

Nebulized epinephrine:

• Has demonstrated short-term benefit in recent studies 4
• Not yet widely recommended in guidelines but shows promise 4, 7

Prevention Strategies

Palivizumab prophylaxis:

• Administer to high-risk infants: prematurity (<35 weeks gestation) or congenital heart disease 1, 2
• Dosing: 15 mg/kg intramuscularly monthly for 5 doses, typically starting November/December 1, 2

Infection control:

• Hand hygiene is the most important step in preventing nosocomial RSV spread 1, 2
• Use alcohol-based hand rubs before/after patient contact and after removing gloves 1, 2
• Educate personnel and family on hand sanitation 1

General prevention:

• Avoid passive smoke exposure 1, 2
• Recommend breastfeeding to decrease lower respiratory tract disease risk 1, 2

Common Pitfalls

Despite clear guideline recommendations, bronchodilators and steroids continue to be used frequently in both standard-risk and high-risk patients 5. This represents low-value care that increases costs without improving outcomes and may actually increase complications 5, 3. Implementation of evidence-based clinical pathways spanning emergency department to inpatient care can reduce unnecessary interventions, decrease length of stay, and lower costs while improving care quality. 3