What are the management strategies for bronchiolitis?

Management of Bronchiolitis

Bronchiolitis management is primarily supportive care only—supplemental oxygen when SpO2 persistently falls below 90%, hydration support, and gentle nasal suctioning—while avoiding all routine pharmacologic interventions including bronchodilators, corticosteroids, and antibiotics. 1

Diagnosis and Initial Assessment

• Bronchiolitis is a clinical diagnosis based on history and physical examination alone, without requiring routine chest radiographs, viral testing, or laboratory studies 1, 2
• Assess respiratory rate over a full minute (tachypnea ≥70 breaths/minute indicates increased severity risk) and work of breathing (nasal flaring, grunting, intercostal/subcostal retractions) 1
• Identify high-risk infants requiring closer monitoring: age <12 weeks, history of prematurity, hemodynamically significant congenital heart disease, chronic lung disease, or immunodeficiency 1, 2

Oxygen Therapy

• Administer supplemental oxygen only if SpO2 persistently falls below 90% in previously healthy infants, with a goal of maintaining SpO2 at or above 90% 3, 1
• Otherwise healthy infants with SpO2 ≥90% at sea level while breathing room air gain little benefit from supplemental oxygen, particularly without respiratory distress or feeding difficulties 3, 1
• Oxygen may be discontinued when SpO2 is ≥90%, the infant is feeding well, and has minimal respiratory distress 3, 2
• Infants with hemodynamically significant heart or lung disease and premature infants require close monitoring during oxygen weaning 3, 2
• Use standard oxygen delivery as the primary approach 1

Hydration and Nutrition Management

• Assess hydration status and ability to take fluids orally 1, 2
• Infants who feed well without respiratory compromise should continue oral feeding 1
• When respiratory rate exceeds 60-70 breaths per minute, feeding may be compromised and aspiration risk increases—consider IV or nasogastric hydration 1
• Use isotonic fluids if IV hydration is needed, as infants with bronchiolitis may develop syndrome of inappropriate antidiuretic hormone (SIADH) secretion and are at risk for hyponatremia with hypotonic fluids 1
• Continue breastfeeding if possible, as breastfed infants have shorter hospital stays and less severe illness 1

Airway Clearance

• Use gentle nasal suctioning only as needed for symptomatic relief 1, 2
• Avoid deep suctioning, as it is associated with longer hospital stays in infants 2-12 months of age 1
• Do not use chest physiotherapy, as it lacks evidence of benefit 1

What NOT to Do: Avoiding Non-Evidence-Based Interventions

• Do not use bronchodilators routinely for infants with bronchiolitis, as they lack evidence of benefit 1, 2
• Do not use corticosteroids routinely for infants with bronchiolitis, as they lack evidence of benefit 1, 2
• Use antibacterial medications only with specific indications of bacterial coinfection (such as acute otitis media or documented bacterial pneumonia), as the risk of serious bacterial infection in infants with bronchiolitis is <1% 1, 2
• Fever alone does not justify antibiotics 1
• Do not order routine chest radiographs, viral testing, or laboratory studies 1, 2

Monitoring Strategies

• Serial clinical assessments are more important than continuous monitoring in stable infants 1
• Avoid continuous pulse oximetry in stable infants, as it may lead to less careful clinical monitoring 1, 2
• Do not treat based solely on pulse oximetry readings without clinical correlation, as transient desaturations can occur in healthy infants 3, 1

Prevention for High-Risk Infants

• Consider palivizumab prophylaxis for high-risk infants (history of prematurity ≤35 weeks gestational age and ≤6 months old at RSV season start, bronchopulmonary dysplasia requiring treatment within 6 months and ≤24 months old, or hemodynamically significant congenital heart disease and ≤24 months old) 2, 4
• Administer palivizumab at 15 mg/kg intramuscularly in 5 monthly doses, typically starting in November or December 2, 4
• Children undergoing cardiopulmonary bypass should receive an additional dose as soon as possible after the procedure, then continue monthly dosing 4
• Promote hand hygiene with alcohol-based disinfectants to prevent nosocomial RSV spread 2
• Avoid tobacco smoke exposure and limit visitor exposure during respiratory virus season 1, 2

Critical Clinical Pitfalls to Avoid

• Do not overlook feeding difficulties—aspiration risk increases significantly when respiratory rate exceeds 60-70 breaths/minute 1
• Before instituting oxygen therapy, verify the accuracy of pulse oximetry readings by repositioning the probe, as poorly placed probes and motion artifact lead to inaccurate measurements 3
• Consider maintaining higher SpO2 targets in children with fever, acidosis, or hemoglobinopathies, as these conditions shift the oxyhemoglobin dissociation curve 3
• Symptoms such as cough, congestion, and wheezing are expected to last 2-3 weeks, which is normal and does not indicate treatment failure 1