What is the treatment for bronchiolitis?

Bronchiolitis Treatment

Bronchiolitis treatment is primarily supportive care—maintain hydration, provide supplemental oxygen only if SpO₂ persistently falls below 90%, and avoid routine use of bronchodilators, corticosteroids, antibiotics, chest physiotherapy, and diagnostic testing. 1, 2

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, 2

• Assess risk factors for severe disease including age <12 weeks, prematurity (<35 weeks gestation), underlying cardiopulmonary disease (bronchopulmonary dysplasia, hemodynamically significant congenital heart disease), or immunodeficiency. 1, 2

• Evaluate respiratory status by counting respiratory rate over a full minute (tachypnea ≥60-70 breaths/minute indicates increased severity and feeding compromise), and assess work of breathing by looking for nasal flaring, grunting, and intercostal/subcostal retractions. 3

Supportive Care: What TO Do

Hydration Management

• Assess hydration status and ability to take fluids orally—infants who feed well without respiratory compromise should continue oral feeding. 1, 2

• When respiratory rate exceeds 60-70 breaths/minute, feeding may be compromised and aspiration risk increases—consider IV or nasogastric hydration at this threshold. 3

• 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. 3

Oxygen Therapy

• Administer supplemental oxygen only if SpO₂ persistently falls below 90% in previously healthy infants, with a goal of maintaining SpO₂ ≥90%. 1, 2

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

• Infants with hemodynamically significant heart or lung disease and premature infants require close monitoring during oxygen weaning. 1, 2

• Avoid continuous pulse oximetry in stable infants, as it may lead to less careful clinical monitoring—serial clinical assessments are more important than continuous monitoring. 3

Airway Clearance

• Use gentle nasal suctioning only as needed for symptomatic relief—avoid deep suctioning, as it is associated with longer hospital stays in infants 2-12 months of age. 3

What NOT To Do: Avoid These Interventions

Pharmacologic Interventions to Avoid

• Do not use bronchodilators routinely—they lack evidence of benefit in bronchiolitis. 1, 2 A carefully monitored trial of α-adrenergic or β-adrenergic medication is an option, but should be continued only if there is a documented positive clinical response using an objective means of evaluation. 1

• Do not use corticosteroids routinely—they lack evidence of benefit. 1, 2

• Do not use antibiotics routinely—use antibacterial medications only when there are specific indications of coexisting bacterial infection (such as acute otitis media or documented bacterial pneumonia). 1, 2 The risk of serious bacterial infection in febrile infants with bronchiolitis is <1%, so fever alone does not justify antibiotics. 3

• Do not use ribavirin routinely in children with bronchiolitis. 1

Other Interventions to Avoid

• Do not perform chest physiotherapy routinely—it lacks evidence of benefit. 1, 2

• Do not order routine diagnostic tests—chest radiographs, viral testing, and laboratory studies are not indicated in typical presentations. 1, 2

Prevention Strategies

Palivizumab Prophylaxis for High-Risk Infants

• Administer palivizumab prophylaxis to high-risk infants: those with prematurity (<35 weeks gestation) or hemodynamically significant congenital heart disease. 1, 4

• Give palivizumab in 5 monthly doses at 15 mg/kg per dose intramuscularly, usually beginning in November or December during RSV season. 1, 4

• Palivizumab reduced RSV hospitalization by 55% in premature infants and those with bronchopulmonary dysplasia, and by 45% in children with congenital heart disease. 4

Infection Control and Environmental Measures

• Hand decontamination 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

• Use alcohol-based rubs for hand decontamination (preferred) or hand-washing with antimicrobial soap. 1, 2

• Infants should not be exposed to passive smoking—tobacco smoke significantly increases severity and hospitalization risk. 1, 2

• Recommend breastfeeding to decrease risk of lower respiratory tract disease—breastfed infants have shorter hospital stays, less severe illness, and a 72% reduction in hospitalization risk for respiratory diseases. 1, 3

Clinical Pitfalls to Avoid

• Do not treat based solely on pulse oximetry readings without clinical correlation—transient desaturations can occur in healthy infants, and 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

• Do not overlook feeding difficulties—aspiration risk increases significantly when respiratory rate exceeds 60-70 breaths/minute. 3

• Educate families that symptoms (cough, congestion, wheezing) are expected to last 2-3 weeks—this is normal and does not indicate treatment failure. 3