What is the approach to managing bronchiolitis?

Approach to Bronchiolitis

Bronchiolitis management is primarily supportive care, and clinicians should avoid routine use of bronchodilators, corticosteroids, antibiotics, and chest physiotherapy, as these interventions provide no benefit and may cause harm. 1, 2

Initial Assessment and Diagnosis

• Diagnose bronchiolitis clinically based on history and physical examination (rhinorrhea, cough, crackles, wheezing, respiratory distress) without routine chest radiographs or laboratory testing in typical presentations 2
• Identify high-risk patients requiring closer monitoring: infants <12 weeks old, premature infants, those with chronic lung disease, congenital heart disease, or immunodeficiency 2
• Do not routinely perform viral testing unless needed for infection control purposes in the hospital setting 3

Core Supportive Care Measures

Hydration and Nutrition

• Assess oral feeding ability first as the primary priority in management 1
• Provide nasogastric or intravenous fluids when the infant cannot feed safely due to respiratory distress 1, 2

Oxygen Therapy

• Administer supplemental oxygen only if SpO₂ falls persistently below 90% in previously healthy infants 1, 2
• Maintain SpO₂ at ≥90% with adequate supplemental oxygen 1, 2
• Discontinue oxygen when SpO₂ ≥90%, the infant feeds well, and has minimal respiratory distress 1, 2
• Avoid continuous pulse oximetry in stable patients as it may prolong hospital stay 4

Airway Clearance

• Use gentle external nasal suctioning for visible nasal congestion affecting breathing or feeding 5
• Avoid routine deep suctioning, as it has been associated with longer hospital stays in infants 2-12 months of age 5
• Perform suctioning as needed rather than on a fixed schedule, as lapses >4 hours in external nasal suctioning may prolong hospitalization 5

Treatments to AVOID

Bronchodilators

• Do not routinely use albuterol or other bronchodilators, as pulmonary function studies show no benefit in hospitalized infants with bronchiolitis 1
• A carefully monitored trial of bronchodilator may be attempted, but continue only if there is documented positive clinical response 2

Corticosteroids

• Do not use corticosteroids routinely, as multiple high-quality trials demonstrate no benefit 1, 2

Antibiotics

• Use antibiotics only when specific bacterial coinfection is documented (e.g., otitis media, pneumonia, urinary tract infection), as routine antibacterial therapy shows no benefit and promotes resistance 1, 2

Other Ineffective Therapies

• Do not use chest physiotherapy routinely, as Cochrane Review found no clinical benefit from vibration, percussion, or passive expiratory techniques 1
• Nebulized hypertonic saline is not routinely recommended, though it may provide some benefit for patients with anticipated prolonged hospital stay 4
• Nebulized epinephrine may offer short-term benefit in the emergency department but is not recommended for routine inpatient use 6, 3

Prevention Strategies

High-Risk Infant Prophylaxis

• Consider palivizumab prophylaxis for high-risk infants (premature infants, chronic lung disease of prematurity) 1, 2
• Administer in 5 monthly doses (15 mg/kg per dose intramuscularly), typically starting in November or December 2

Infection Control

• Hand hygiene with alcohol-based disinfectants is the most important step in preventing nosocomial spread 1, 2
• Recommend breastfeeding to decrease risk of lower respiratory tract disease 2
• Avoid tobacco smoke exposure to reduce disease severity 2

Common Pitfalls to Avoid

• Over-treating with ineffective medications (bronchodilators, steroids) that increase costs and potential adverse effects without clinical benefit 1, 7
• Setting oxygen saturation targets too high (>90%), which may unnecessarily prolong hospitalization 4
• Performing deep suctioning routinely, which can traumatize airways and extend hospital stay 5
• Ordering unnecessary chest radiographs, which expose infants to radiation without changing management in typical cases 2