What is the management approach for acute bronchiolitis?

Management of Acute Bronchiolitis

Acute bronchiolitis is managed primarily with supportive care alone, as bronchodilators, corticosteroids, antibiotics, and ribavirin should not be used routinely. 1, 2

Diagnosis

• Make the diagnosis clinically based on history and physical examination without routine laboratory tests or chest radiographs 1, 2
• Look for the characteristic constellation: viral upper respiratory prodrome (rhinorrhea) followed by lower respiratory symptoms including cough, tachypnea, wheezing, crackles, and increased work of breathing (grunting, nasal flaring, intercostal/subcostal retractions) in children under 2 years of age 1
• Count respiratory rate over a full minute for accuracy; normal rates decrease from 41 breaths/minute at 0-3 months to 31 breaths/minute at 12-18 months 1

Risk Stratification

Identify high-risk patients who require closer monitoring: 1, 2, 3

• Age less than 12 weeks
• History of prematurity (less than 35 weeks gestation)
• Underlying cardiopulmonary disease (bronchopulmonary dysplasia, hemodynamically significant congenital heart disease)
• Immunodeficiency

Supportive Care (The Only Proven Treatment)

Hydration and Feeding

• Assess the child's ability to feed orally and hydration status 1, 2
• Provide intravenous or nasogastric hydration if oral intake is inadequate 2, 3

Oxygen Therapy

• Administer supplemental oxygen only if SpO₂ falls persistently below 90% in previously healthy infants 1, 2, 4
• Maintain SpO₂ at or above 90% with adequate supplemental oxygen 1, 2
• Discontinue oxygen when SpO₂ remains ≥90%, the infant feeds well, and has minimal respiratory distress 1, 2
• Continuous SpO₂ monitoring is not routinely needed as clinical course improves 1, 2
• High-risk infants (premature, hemodynamically significant heart or lung disease) require close monitoring during oxygen weaning 1, 2

Airway Clearance

• Nasal suctioning facilitates breathing and feeding 3, 4
• Positioning with slight head elevation may facilitate breathing 3
• Chest physiotherapy should NOT be used routinely 1, 2

What NOT to Do (Common Pitfalls)

Bronchodilators

• Do NOT use bronchodilators routinely 1, 2
• A carefully monitored trial of α-adrenergic or β-adrenergic medication is an option, but continue ONLY if there is documented positive clinical response using objective evaluation 1
• Caveat: Bronchodilators can cause hypoxia and increase bronchial compressibility 5

Corticosteroids

• Do NOT use corticosteroids routinely 1, 2, 4

Antibiotics

• Use antibiotics ONLY when specific indications of coexisting bacterial infection are present 1, 2
• When bacterial infection exists, treat it the same as you would in the absence of bronchiolitis 1

Ribavirin

• Do NOT use ribavirin routinely 1

Hospitalization Criteria

Admit patients with: 3, 4

• SpO₂ <90-92%
• Moderate-to-severe respiratory distress
• Dehydration or inability to feed adequately
• Apnea
• Presence of high-risk factors requiring careful assessment

Prevention

Infection Control

• Hand decontamination is the most important preventive measure for nosocomial spread 1, 2
• Use alcohol-based rubs preferentially, or antimicrobial soap as alternative 1, 2
• Educate personnel and family members on hand hygiene 1, 2

Environmental Measures

• Infants should not be exposed to passive smoking 1, 2
• Recommend breastfeeding to decrease risk of lower respiratory tract disease 1, 2

Palivizumab Prophylaxis

• Consider palivizumab for high-risk infants: history of prematurity (<35 weeks gestation) or congenital heart disease 1, 2
• Administer 5 monthly doses at 15 mg/kg intramuscularly, typically beginning November or December 1, 2

Post-Bronchiolitis Management

• Do NOT use asthma medications for persistent cough after bronchiolitis unless additional evidence of asthma exists 3
• Do NOT use hypertonic saline for persistent cough after bronchiolitis 3
• Most children are symptom-free by 21 days; bronchiolitis is self-limited with median duration 8-15 days 3