Management of Bronchiolitis
Bronchiolitis management is primarily supportive care—no routine medications, no routine testing, just oxygen when SpO₂ drops below 90%, hydration support, and careful monitoring. 1
Diagnosis
Bronchiolitis is a clinical diagnosis that requires no routine diagnostic testing in typical presentations. 1
- Do not order chest radiographs, laboratory studies, or RSV testing routinely—these tests do not change management and increase costs without improving outcomes. 2
- Diagnose based on: viral upper respiratory prodrome + lower respiratory signs (tachypnea, wheezing, rales, cough) + increased respiratory effort (grunting, nasal flaring, retractions) in children under 2 years. 2
- Count respiratory rate for a full 60 seconds—tachypnea ≥70 breaths/minute suggests increased risk of severe disease. 2
Risk Stratification
Identify high-risk children who need closer monitoring: 2
- Age <12 weeks
- Prematurity
- Hemodynamically significant congenital heart disease
- Chronic lung disease
- Immunodeficiency
- In utero smoke exposure
Supportive Care (The Core Treatment)
Hydration
- Assess the child's ability to feed and hydrate orally. 1
- Provide intravenous or nasogastric hydration if oral intake is inadequate. 1
Oxygen Therapy
- Administer oxygen only if SpO₂ persistently falls below 90%, with a goal of maintaining SpO₂ ≥90%. 1
- Discontinue oxygen when SpO₂ ≥90%, the child feeds well, and has minimal respiratory distress. 1
- Continuous SpO₂ monitoring is not necessary routinely as the clinical course improves. 1
- Infants with hemodynamically significant heart or lung disease and premature infants require close monitoring during oxygen weaning. 1
Airway Management
- Perform nasal suctioning to clear secretions. 3
- Consider nebulized 3% hypertonic saline, which has shown promise in decreasing length of hospital stay when mixed with a bronchodilator. 4
What NOT to Do
Bronchodilators
- Do not use bronchodilators routinely. 1
- The only exception: a carefully monitored trial of α-adrenergic or β-adrenergic medication, which should only be continued if there is a documented positive clinical response. 1
- Nebulized epinephrine may offer short-term benefit in the emergency room setting but is not recommended for routine use. 4
Corticosteroids
- Do not use corticosteroids routinely—they provide no benefit in bronchiolitis. 1
Antibiotics
- Use antibiotics only when there are specific indications of coexisting bacterial infection, not routinely. 1
Other Ineffective Therapies
- Avoid ribavirin, chest physiotherapy, anticholinergics, and mist therapy—none have demonstrated measurable clinical benefit. 5
Hospitalization Criteria
Admit children with: 3
- Low oxygen saturation (<90-92%)
- Moderate-to-severe respiratory distress
- Dehydration
- Presence of apnea
- Pre-existing risk factors requiring careful assessment
Prevention
Palivizumab Prophylaxis
- Consider palivizumab for high-risk infants (premature infants, those with bronchopulmonary dysplasia or congenital heart disease). 1
- Administer 5 monthly doses at 15 mg/kg per dose intramuscularly, typically starting in November or December. 1
Environmental Measures
- Hand hygiene is the most important step in preventing nosocomial spread of RSV—use alcohol-based disinfectants. 1
- Avoid exposure to tobacco smoke. 1
- Recommend breastfeeding to decrease risk of lower respiratory tract disease. 1
Common Pitfalls to Avoid
- Do not over-test: Routine chest X-rays and viral testing lead to inappropriate antibiotic prescribing without improving outcomes. 2
- Do not over-treat: The vast majority of pharmacological interventions (bronchodilators, steroids) have been proven ineffective and should not be used routinely. 1
- Do not under-hydrate: Assess feeding and hydration status carefully, as dehydration is a common reason for clinical deterioration. 2
- Do not ignore risk factors: Children with prematurity, cardiac disease, or age <12 weeks need closer monitoring even if they appear stable initially. 2