Management of Bronchiolitis
Bronchiolitis is managed primarily with supportive care alone—do not routinely use bronchodilators, corticosteroids, antibiotics, chest physiotherapy, or diagnostic testing in otherwise healthy infants. 1, 2
Diagnosis and Initial Assessment
Make the diagnosis clinically based on history and physical examination without routine laboratory tests, viral testing, or chest radiographs 1, 2, 3
Identify high-risk patients who require closer monitoring and lower thresholds for intervention: 1, 2, 4
- Age less than 12 weeks
- History of prematurity (especially <35 weeks gestation)
- Underlying cardiopulmonary disease (hemodynamically significant heart disease, bronchopulmonary dysplasia)
- Immunodeficiency
Supportive Care (The Cornerstone of Management)
Hydration and Nutrition
- Assess the child's ability to feed and hydrate orally as the first priority 1, 2
- Provide intravenous or nasogastric hydration if the infant cannot maintain adequate oral intake 2, 3, 5
- Nasal suctioning facilitates breathing and feeding 4
Oxygen Therapy
- Administer supplemental oxygen only if SpO₂ falls persistently below 90% in previously healthy infants 1, 2, 5
- Maintain SpO₂ at or above 90% with adequate supplemental oxygen 1, 2
- Discontinue oxygen when SpO₂ ≥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/lung disease) require close monitoring during oxygen weaning 1, 2
Positioning
- Elevate the head of the bed slightly to facilitate breathing 4
What NOT to Do (Common Pitfalls)
Bronchodilators
- Do not use bronchodilators routinely (including albuterol, nebulized epinephrine) 1, 2, 3, 5
- 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, 2
Corticosteroids
Antibiotics
- Use antibiotics only when specific indications of coexisting bacterial infection exist 1, 2, 5
- Treat bacterial infections the same way as in the absence of bronchiolitis 1
Other Non-Beneficial Therapies
- Do not perform chest physiotherapy routinely 1, 2
- Do not routinely order chest radiographs or viral testing 1, 2, 3
- Hypertonic saline is not recommended for routine use 3, 5
Hospitalization Criteria
Admit infants with: 4
- Moderate to severe respiratory distress
- Difficulty feeding or dehydration
- Apnea episodes
Prevention Strategies
Palivizumab Prophylaxis
- Consider palivizumab for high-risk infants: premature infants (<35 weeks gestation) or those with congenital heart disease 1, 2
- Administer 5 monthly doses at 15 mg/kg intramuscularly, typically starting in November or December 1, 2
Infection Control
- Hand hygiene is the most important preventive measure for nosocomial RSV spread 1, 2
- Use alcohol-based hand rubs before and after patient contact, after touching objects near the patient, and after removing gloves 1, 2
- Educate family members and personnel on hand sanitation 1
General Prevention
- Avoid exposure to passive smoking 1, 2
- Recommend breastfeeding to decrease risk of lower respiratory tract disease 1, 2
Post-Bronchiolitis Management
- Most children are symptom-free by 21 days; the disease is self-limited with median duration of 8-15 days 4
- Do not use asthma medications for persistent cough post-bronchiolitis unless there is additional evidence of asthma 4
- Do not use hypertonic saline for persistent cough after bronchiolitis 4
Important Caveat
These guidelines apply to pediatric viral bronchiolitis only—adult bronchiolitis is a fundamentally different disease requiring cause-specific treatment including prolonged antibiotics for bacterial disease or corticosteroids for toxic/antigenic exposures 6