What is the management of bronchiolitis in adults?

Management of Bronchiolitis in Adults

Adult bronchiolitis requires cause-specific treatment tailored to the underlying etiology, with infectious bacterial bronchiolitis requiring prolonged antibiotic therapy, while toxic/antigenic exposure or drug-related bronchiolitis necessitates cessation of the offending agent plus corticosteroids for those with physiologic impairment. 1

Critical Distinction: Adults vs. Pediatric Disease

Adult bronchiolitis is fundamentally different from the viral pediatric disease—it encompasses a wide spectrum of chronic bronchiolar disorders with diverse etiologies, not the acute RSV infection seen in infants. 2 The pediatric guidelines 3, 4 do not apply to adult management.

Diagnostic Evaluation Required

Before initiating treatment, comprehensive evaluation is mandatory and includes: 1

• Spirometry with and without bronchodilator
• Lung volumes and gas exchange testing
• Chest radiograph and high-resolution CT (HRCT) with expiratory cuts
• Bronchoscopy when bacterial suppurative airways disease cannot be excluded after common causes are ruled out
• Surgical lung biopsy when clinical syndrome, physiology, and HRCT findings do not provide confident diagnosis 1

Treatment Algorithm by Etiology

Infectious Bacterial Bronchiolitis

Prolonged antibiotic therapy is recommended and improves cough. 1 This differs entirely from pediatric viral bronchiolitis where antibiotics are contraindicated unless bacterial coinfection is documented. 3, 4

Respiratory Bronchiolitis (Smoking-Related)

• Most common form in adults, typically related to cigarette smoking 2
• Smoking cessation is the primary intervention 1
• Diagnosis is generally achieved based on smoking history and chest CT findings without requiring biopsy 2

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
• This includes occupational/environmental inhalation exposures and novel forms like vaping-related lung injury 2

Constrictive (Obliterative) Bronchiolitis

• Associated with airflow obstruction 2
• Seen in transplant recipients (bronchiolitis obliterans syndrome), post-inhalation exposures, and other contexts 2
• Treatment depends on underlying cause; for transplant-related cases, immunosuppression adjustment is typically required 2

Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH)

• Can cause progressive airflow obstruction related to constrictive bronchiolitis ("DIPNECH syndrome") 2
• Increasingly recognized entity requiring specialized management 2

Common Pitfalls

Do not apply pediatric bronchiolitis treatment paradigms to adults—the supportive care approach (no bronchodilators, no corticosteroids, no antibiotics) recommended for viral pediatric bronchiolitis 3, 4, 1 is inappropriate for adult disease, which often requires targeted pharmacologic intervention based on etiology. 1

Do not assume all adult bronchiolitis is infectious—a broad differential including occupational exposures, medications, aspiration, and systemic diseases must be considered. 2 Diffuse aspiration bronchiolitis is often unsuspected and confused for interstitial lung disease. 2