What is the management of infectious bronchiolitis?

Management of Infectious Bronchiolitis

Supportive care is the cornerstone of bronchiolitis management, and clinicians should NOT routinely use bronchodilators, corticosteroids, antibiotics, chest physiotherapy, or routine diagnostic testing. 1, 2, 3

Diagnosis and Initial Assessment

• Diagnose bronchiolitis clinically based on history and physical examination alone—do not routinely order chest radiographs, viral testing, or laboratory studies in typical presentations. 1, 3

• Identify high-risk patients requiring closer monitoring: infants less than 12 weeks old, history of prematurity (≤35 weeks gestation), underlying cardiopulmonary disease (including bronchopulmonary dysplasia or hemodynamically significant congenital heart disease), or immunodeficiency. 1, 3

Supportive Care Interventions

Hydration and Nutrition

• Assess the child's ability to feed and hydrate orally as the first priority—this is the most critical initial evaluation. 2, 3

• Provide intravenous or nasogastric fluids for infants who cannot feed safely due to respiratory distress. 2, 4

Oxygen Therapy

• Administer supplemental oxygen only if SpO₂ falls persistently below 90% in previously healthy infants, maintaining SpO₂ at or above 90%. 1, 2, 3

• Discontinue oxygen when SpO₂ ≥90%, the infant is feeding well, and has minimal respiratory distress. 1, 2, 3

• Continuous SpO₂ monitoring is not routinely needed as the child's clinical course improves. 1, 3

• Close monitoring during oxygen weaning is mandatory for infants with hemodynamically significant heart or lung disease and premature infants. 1, 3

Therapies NOT Recommended

Bronchodilators

• Do NOT routinely administer albuterol or other bronchodilators—studies using pulmonary function tests show no effect among hospitalized infants with bronchiolitis. 1, 2, 3

• A carefully monitored trial of α-adrenergic or β-adrenergic medication may be considered as an option, but should only be continued if there is documented positive clinical response using objective evaluation. 1, 3

• Nebulized epinephrine has only transient effects and is not recommended for routine outpatient use, though it may provide short-term benefit in monitored settings. 1, 5

Corticosteroids

• Corticosteroids should NOT be used routinely—multiple high-quality trials demonstrate no benefit in bronchiolitis treatment. 1, 2, 3

Antibiotics

• Antibiotics should only be used when there are specific indications of coexisting bacterial infection (such as acute otitis media or urinary tract infection), not for bronchiolitis itself. 1, 2, 3

• Routine antibacterial therapy shows no benefit and contributes to antibiotic resistance. 2

Other Non-Recommended Therapies

• Chest physiotherapy should NOT be used routinely—Cochrane Review found no clinical benefit using vibration, percussion, or passive expiratory techniques. 1, 2, 3

• Ribavirin should not be used routinely in children with bronchiolitis. 1

Hypertonic Saline Considerations

• Nebulized 3% hypertonic saline may reduce hospital length of stay by approximately 1 day in settings where average length of stay exceeds 3 days, but this benefit may not be generalizable to U.S. hospitals where average length of stay is 2.4 days. 1

• The evidence suggests hypertonic saline is safe and may improve symptoms after 24 hours of use, but more recent trials have attenuated the summary estimate of effect on length of stay. 1

Prevention Strategies

Palivizumab Prophylaxis

• Administer palivizumab prophylaxis to high-risk infants: those with history of prematurity (≤35 weeks gestation) who are ≤6 months old at RSV season onset, infants with bronchopulmonary dysplasia requiring medical treatment within previous 6 months who are ≤24 months old, or those with hemodynamically significant congenital heart disease who are ≤24 months old. 1, 3, 6

• Dosing: 15 mg/kg intramuscularly monthly for 5 doses, typically beginning in November or December throughout RSV season. 1, 3, 6

• Children undergoing cardiopulmonary bypass should receive an additional dose as soon as possible after the procedure, as serum levels decrease after bypass. 6

Infection Control

• Hand hygiene with alcohol-based disinfectants is the most important step in preventing nosocomial spread of RSV—decontaminate hands before and after direct patient contact, after contact with inanimate objects near the patient, and after removing gloves. 1, 2, 3

• Educate personnel and family members on hand sanitation. 1

General Prevention

• Infants should not be exposed to passive smoking. 1, 3

• Breastfeeding is recommended to decrease risk of lower respiratory tract disease. 1, 3

Important Caveats

Common pitfall: Discharging an infant after observing response to epinephrine in the emergency department raises concerns for subsequent progression of illness, as the effect is transient and home administration is not routine practice. 1

Note on adult bronchiolitis: The pediatric viral bronchiolitis guidelines do NOT apply to adults—adult bronchiolitis requires cause-specific treatment tailored to underlying etiology, with infectious bacterial bronchiolitis requiring prolonged antibiotic therapy and toxic/antigenic exposure requiring cessation of the offending agent plus corticosteroids for those with physiologic impairment. 2, 7