What is the treatment for respiratory bronchiolitis?

Treatment of Respiratory Bronchiolitis

The treatment of respiratory bronchiolitis depends critically on whether you are dealing with pediatric viral bronchiolitis (infants/young children) or adult respiratory bronchiolitis (RB), as these are fundamentally different conditions requiring distinct management approaches.

Pediatric Viral Bronchiolitis (Infants and Young Children)

Supportive Care is the Cornerstone

The mainstay of treatment is supportive care—bronchodilators, corticosteroids, antibiotics, and chest physiotherapy should NOT be used routinely. 1, 2, 3

Hydration and Nutrition

• Assess the child's ability to feed and hydrate orally as the first priority. 1, 2, 3
• When respiratory rate exceeds 60-70 breaths per minute, feeding becomes compromised and aspiration risk increases. 1
• Provide intravenous or nasogastric fluids for infants who cannot feed safely due to respiratory distress. 1, 2, 3
• Monitor for fluid retention related to inappropriate antidiuretic hormone secretion and adjust fluid management accordingly. 1, 3

Oxygen Therapy

• Administer supplemental oxygen if SpO₂ falls persistently below 90% in previously healthy infants. 1, 2, 3
• Maintain SpO₂ at or above 90% with adequate supplemental oxygen. 1, 2, 3
• Discontinue oxygen when SpO₂ ≥ 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 close monitoring during oxygen weaning. 1, 3
• Continuous pulse oximetry is not necessary routinely once the clinical course improves. 1, 3

What NOT to Use

Bronchodilators

• Do not routinely administer albuterol or other bronchodilators. 1, 2, 3
• Studies using pulmonary function tests show no effect of albuterol among hospitalized infants with bronchiolitis. 1
• If a trial of bronchodilator is attempted in select cases, continue only if there is a documented positive clinical response using objective evaluation. 2, 3

Corticosteroids

• Corticosteroids should not be used routinely in the treatment of bronchiolitis. 1, 2, 3
• Multiple high-quality trials demonstrate no benefit. 1

Antibiotics

• Antibiotics should only be used when there are specific indications of coexisting bacterial infection. 1, 2, 3
• Children with bronchiolitis have a much lower risk (less than 1%) of bacterial infection compared to febrile infants without an identifiable source. 1
• Routine antibacterial therapy shows no benefit and contributes to antibiotic resistance. 1

Chest Physiotherapy

• Chest physiotherapy should not be used routinely in the management of bronchiolitis. 1, 3
• A Cochrane Review found no clinical benefit using vibration, percussion, or passive expiratory techniques. 1
• Deep suctioning was associated with longer hospital stays and should be avoided. 1

Epinephrine

• Epinephrine does not have a routine role in outpatient bronchiolitis management. 1
• While it may provide transient benefit in the emergency department, it does not reduce overall hospitalization rates. 1
• Discharging after observing a response raises concerns for subsequent progression of illness. 1

Prevention Strategies

• Consider palivizumab prophylaxis for high-risk infants (premature <35 weeks, chronic lung disease of prematurity, hemodynamically significant heart disease). 2, 3
• Administer in 5 monthly doses (15 mg/kg per dose intramuscularly), typically starting in November or December. 2, 3
• Hand hygiene with alcohol-based disinfectants is the most important step in preventing nosocomial spread. 2, 3
• Avoid exposure to tobacco smoke and recommend breastfeeding to decrease risk of lower respiratory tract disease. 2, 3

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Adult Respiratory Bronchiolitis (RB)

For adult respiratory bronchiolitis, treatment must be tailored to the specific cause or diagnosis, with infectious bacterial bronchiolitis requiring prolonged antibiotic therapy. 1

Diagnostic Approach

• Comprehensive evaluation requires spirometry with and without bronchodilator, lung volumes, gas exchange testing, chest radiograph, and HRCT with expiratory cuts. 1
• HRCT findings of small nodules, tree-in-bud pattern, and mosaic attenuation on expiratory scanning suggest bronchiolar disease. 1
• Bronchoscopy is required before excluding bacterial suppurative airways disease as a cause when more common causes have been excluded. 1
• Surgical lung biopsy should be performed when the combination of clinical syndrome, physiology, and HRCT findings do not provide a confident diagnosis. 1

Treatment Based on Etiology

Infectious Bacterial Bronchiolitis

• Prolonged antibiotic therapy improves cough and is recommended for infectious bacterial bronchiolitis. 1
• While uncommon in adults, bacterial infection can occur and requires targeted treatment. 1

Toxic/Antigenic Exposure or Drug-Related Bronchiolitis

• Cessation of the exposure or medication is essential. 1
• Add corticosteroid therapy for those with physiologic impairment. 1

Key Pitfalls to Avoid

• Failing to distinguish between pediatric viral bronchiolitis and adult respiratory bronchiolitis—these require completely different management approaches. 1, 2, 3
• Overusing diagnostic tests (chest X-rays, viral testing) in pediatric bronchiolitis that do not change management. 2, 3
• Routinely prescribing bronchodilators, corticosteroids, or antibiotics in pediatric viral bronchiolitis without clear indication. 1, 2, 3
• Inadequate assessment of hydration status in infants with bronchiolitis. 2, 3
• Failing to identify high-risk pediatric patients who need more intensive monitoring. 2, 3