What is the treatment for bronchiolitis?

Treatment for Bronchiolitis

Bronchiolitis treatment is primarily supportive care—most commonly used therapies like bronchodilators, corticosteroids, and antibiotics should NOT be used routinely. 1, 2

Core Management Principles

Bronchiolitis is a clinical diagnosis based on history and physical examination alone, without requiring laboratory tests or chest radiographs in typical presentations. 1, 2 The disease is self-limited, and treatment focuses on maintaining adequate hydration, oxygenation, and monitoring for deterioration. 1

Supportive Care (What TO Do)

Hydration Assessment and Management

• Assess the child's ability to take fluids orally at every encounter. 1, 2
• Provide intravenous or nasogastric hydration if oral intake is inadequate. 2
• This is a strong recommendation as dehydration prevention is critical, though be cautious of overhydration, especially if SIADH is present. 1

Oxygen Therapy

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

Risk Stratification

Identify children requiring closer monitoring based on: 1, 2

• Age less than 12 weeks
• History of prematurity
• Underlying cardiopulmonary disease
• Immunodeficiency

Pharmacologic Therapies (What NOT To Do)

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
• Despite some research suggesting nebulized epinephrine may offer short-term benefits 3, 4, the guideline recommendation remains against routine use. 1

Corticosteroids

• Do NOT use corticosteroids routinely. 1, 2
• Multiple studies and meta-analyses have failed to show significant benefit. 5

Antiviral Therapy

• Do NOT use ribavirin routinely. 1
• Ribavirin has not demonstrated measurable clinical effect. 5

Antibiotics

• Use antibiotics only when there are specific indications of coexisting bacterial infection. 1, 2
• Treat bacterial infections the same as in the absence of bronchiolitis. 1

Other Non-Recommended Therapies

• Do NOT use chest physiotherapy routinely. 1, 2
• Avoid mist therapy, anticholinergics, and vitamin A—these have shown no clinical benefit. 5

Prevention Strategies

Palivizumab Prophylaxis

Administer palivizumab to high-risk infants: 1, 2, 6

• Premature infants ≤35 weeks gestational age who are ≤6 months at RSV season start
• Infants with bronchopulmonary dysplasia requiring medical treatment within previous 6 months who are ≤24 months at RSV season start
• Infants with hemodynamically significant congenital heart disease who are ≤24 months at RSV season start

Dosing: 15 mg/kg intramuscularly monthly for 5 doses, typically beginning November/December. 1, 2, 6

Special consideration: Children undergoing cardiopulmonary bypass should receive an additional dose as soon as possible after the procedure. 6

Infection Control

• Hand decontamination before and after patient contact is the most important step in preventing nosocomial RSV spread. 1, 2
• Use alcohol-based hand rubs preferentially over antimicrobial soap. 1, 2
• Educate personnel and family members on hand hygiene. 1

General Prevention

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

Common Pitfalls to Avoid

The evidence shows persistent overuse of non-beneficial therapies despite clear guideline recommendations. 7 Physicians continue to favor bronchodilators and corticosteroids despite lack of evidence. 5 Resist the temptation to "do something" pharmacologically—supportive care is the evidence-based approach. 1, 7

Do not confuse palivizumab's role: it is for prevention in high-risk infants, NOT for treatment of active RSV disease. 6