What are the diagnostic criteria and treatment guidelines for acute bronchiolitis in pediatric patients?

Diagnostic Criteria and Treatment Guidelines for Acute Bronchiolitis in Pediatric Patients

Diagnosis

Bronchiolitis is a clinical diagnosis based on history and physical examination alone—do not routinely order laboratory tests, chest radiographs, or viral testing. 1, 2

Clinical Presentation Required for Diagnosis

• Viral upper respiratory prodrome (rhinorrhea, congestion, sneezing) followed by lower respiratory tract signs in children under 2 years of age 1, 2
• Lower respiratory signs: tachypnea, wheezing, rales, and cough 1, 2
• Increased respiratory effort: grunting, nasal flaring, intercostal and/or subcostal retractions 1, 2

Critical History Elements to Assess

• Effects on feeding and hydration status—this determines need for hospitalization 1, 2
• Mental status changes (lethargy or irritability) 2
• Respiratory rate counted for full 60 seconds—tachypnea ≥70 breaths/minute suggests increased risk of severe disease 2
• Serial observations over time are necessary as the disease state varies 2

Risk Factors for Severe Disease (Require Closer Monitoring)

• Age <12 weeks 1, 2
• History of prematurity (especially <35 weeks gestation) 1, 2
• Hemodynamically significant congenital heart disease 1, 2
• Chronic lung disease (bronchopulmonary dysplasia) 1, 2
• Immunodeficiency 1, 2
• In utero smoke exposure 1, 2

When NOT to Order Tests

Do not routinely obtain chest radiographs, laboratory studies, or RSV testing in typical bronchiolitis—these tests do not alter management, increase costs, and may lead to inappropriate antibiotic prescribing. 1, 2 Reserve chest radiography only for severe respiratory distress requiring ICU admission or suspected airway complications like pneumothorax. 1

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Treatment Guidelines

The cornerstone of bronchiolitis management is supportive care only—supplemental oxygen when indicated, hydration support, and gentle nasal suctioning. 3, 4

Oxygen Therapy (The Primary Intervention)

• Administer supplemental oxygen ONLY if SpO2 falls persistently below 90% in previously healthy infants 1, 3
• Maintain SpO2 at or above 90% with adequate supplemental oxygen 1, 3
• Discontinue oxygen when SpO2 ≥90%, infant feeds well, and has minimal respiratory distress 1
• Avoid continuous pulse oximetry in stable infants—it may lead to less careful clinical monitoring; serial clinical assessments are more important 3
• High-risk infants (premature, congenital heart disease, chronic lung disease) require close monitoring during oxygen weaning 1

Hydration and Nutrition

• Assess hydration status and ability to take fluids orally 1, 3
• Reserve IV or nasogastric fluids for infants who cannot maintain adequate oral intake 3, 4

Airway Clearance

• Gentle nasal suctioning may provide temporary relief 3
• Avoid deep suctioning—it is associated with longer hospital stays in infants 2-12 months of age 3

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What NOT to Do (Evidence-Based Avoidance)

Bronchodilators: Do NOT Use Routinely

• Do not administer albuterol (or salbutamol) routinely—bronchodilators do not improve oxygen saturation, disease resolution, need for hospitalization, or length of stay 1, 3
• A carefully monitored trial of bronchodilators is an option only if continued based on documented positive clinical response using objective evaluation 1
• The potential adverse effects (tachycardia, tremors) and cost outweigh any benefits 1

Corticosteroids: Do NOT Use Routinely

• Do not use corticosteroid medications routinely—they lack evidence of benefit 1, 3

Antibiotics: Use Only with Specific Bacterial Indications

• Do not use antibacterial medications unless specific indications of bacterial coinfection exist 1, 3
• The risk of serious bacterial infection in infants with bronchiolitis is <1% 3
• Fever alone does not justify antibiotics 3
• When bacterial infection is present, treat it the same as in the absence of bronchiolitis 1

Other Therapies to Avoid

• Do not use ribavirin routinely 1
• Do not use chest physiotherapy routinely 1, 4

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Prevention and Infection Control

Palivizumab Prophylaxis (For High-Risk Infants Only)

• Administer palivizumab prophylaxis for infants with history of prematurity (<35 weeks gestation) or congenital heart disease 1
• Give 5 monthly doses at 15 mg/kg per dose intramuscularly, usually beginning in November or December 1
• If breakthrough RSV infection occurs during prophylaxis, discontinue palivizumab—very low likelihood of second RSV infection in the same year 1

Infection Control Measures

• Hand decontamination is the most important step in preventing nosocomial spread of RSV 1
• Decontaminate hands before and after direct patient contact, after contact with inanimate objects near the patient, and after removing gloves 1
• Alcohol-based rubs are preferred; alternative is antimicrobial soap 1
• Educate personnel and family members on hand sanitation 1

General Prevention

• Infants should not be exposed to passive smoking 1
• Breastfeeding is recommended to decrease risk of lower respiratory tract disease 1

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Common Pitfalls to Avoid

• Do not over-rely on continuous pulse oximetry—it can lead to unnecessary interventions and prolonged hospitalization in stable infants 3
• Do not order chest radiographs routinely—atelectasis is common and does not change management; radiography increases antibiotic prescribing without improving outcomes 1
• Do not confuse viral bronchiolitis with bacterial pneumonia—fever and tachypnea alone do not indicate bacterial infection 3
• Recognize that PCR assay results may detect prolonged viral shedding from previous illness, particularly with rhinovirus, and should be interpreted cautiously 1