What is the treatment approach for pediatric patients with bronchitis?

Treatment for Pediatric Bronchitis

Critical Clarification: Bronchitis vs. Bronchiolitis

The term "bronchitis" in children requires immediate clarification, as acute viral bronchiolitis and acute bronchitis are fundamentally different diseases requiring distinct management approaches. 1 Most cases in infants and young children presenting with lower respiratory tract symptoms are actually bronchiolitis, not bronchitis. 2, 3

---

Management of Bronchiolitis (Most Common Scenario)

Core Treatment Principle

The cornerstone of bronchiolitis management is supportive care alone—oxygen supplementation when SpO2 <90%, hydration support, and gentle nasal suctioning—while avoiding all routine pharmacologic interventions. 3, 1

Diagnosis

• Bronchiolitis is a clinical diagnosis based on history and physical examination alone 3, 4
• Do not routinely order chest radiographs, viral testing, or laboratory studies 3, 4, 1
• Characterized by rhinitis, cough progressing to tachypnea, wheezing, rales, and increased work of breathing in infants 1-23 months 2

Oxygen Therapy

• Administer supplemental oxygen only if SpO2 persistently falls below 90% 2, 3, 4
• Maintain SpO2 ≥90% with standard oxygen delivery 3, 1
• Otherwise healthy infants with SpO2 ≥90% gain little benefit from supplemental oxygen 3
• Discontinue oxygen when SpO2 ≥90%, infant feeds well, and has minimal respiratory distress 3, 4

Hydration and Feeding

• Assess hydration status and ability to take fluids orally 3, 4
• Continue oral feeding if infant feeds well without respiratory compromise 3
• When respiratory rate exceeds 60-70 breaths/minute, feeding may be compromised and aspiration risk increases significantly 3, 1
• Use IV or nasogastric hydration only when oral intake is inadequate 3, 4
• Use isotonic fluids if IV hydration needed, as infants may develop SIADH and are at risk for hyponatremia with hypotonic fluids 3

Airway Clearance

• Use gentle nasal suctioning only as needed for symptomatic relief 3, 4
• Avoid deep suctioning, as it is associated with longer hospital stays 3
• Do not use chest physiotherapy, as it lacks evidence of benefit 3

---

What NOT to Do (Critical)

Pharmacologic Interventions to Avoid

• Do not routinely use bronchodilators (albuterol, nebulized epinephrine)—they lack evidence of benefit 2, 3, 4, 1
• Do not routinely use corticosteroids—they lack evidence of benefit 2, 3, 4, 1
• Do not routinely use antibiotics—the risk of serious bacterial infection in infants with bronchiolitis is <1% 3, 1
• Use antibacterial medications only with specific indications of bacterial coinfection (acute otitis media, documented bacterial pneumonia) 3, 4, 1
• Fever alone does not justify antibiotics 3, 1

Monitoring Pitfalls

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

---

Risk Stratification and Special Populations

High-Risk Infants Requiring Closer Monitoring

• Age <12 weeks 3, 1
• History of prematurity 3, 1
• Hemodynamically significant congenital heart disease 2, 3, 1
• Chronic lung disease (bronchopulmonary dysplasia) 2, 3, 1
• Immunodeficiency 3, 1

These infants may have abnormal baseline oxygenation and require close monitoring during oxygen weaning 3, 4

---

Management of Chronic/Recurrent Bronchitis (Bronchiectasis)

When to Consider Bronchiectasis

If a child has recurrent respiratory exacerbations or chronic wet/productive cough post-bronchiolitis, manage according to pediatric chronic cough guidelines 1

Treatment Approach for Bronchiectasis

• For acute respiratory exacerbations, use a 14-day course of appropriate systemic antibiotics 2
• Empiric antibiotic of choice is amoxicillin-clavulanate, but tailor based on airway cultures 2
• For recurrent exacerbations (>1 hospitalized or ≥3 non-hospitalized in 12 months), use long-term macrolide antibiotics for at least 6 months 2
• Teach and provide regular airway clearance techniques individualized to age and development 2
• For new P. aeruginosa detection, initiate eradication therapy promptly 2

Preventive Interventions

• Early identification and treatment of inhaled foreign bodies 2, 1
• Preventing recurrent protracted bacterial bronchitis 2, 1
• Treating primary immunodeficiency disorders 2, 1
• Optimizing nutrition including vitamin D status 2
• Encouraging ongoing exercise 2
• Full immunization including pneumococcal and seasonal influenza vaccines 2

---

Prevention Strategies

• Palivizumab prophylaxis for high-risk infants: 5 monthly doses (15 mg/kg IM) starting November/December 2, 4
• Indications: infants <32 weeks gestation requiring >21% oxygen for ≥28 days, or hemodynamically significant heart disease 2
• Promote breastfeeding—reduces hospitalization risk by 72% 3
• Avoid tobacco smoke exposure 3, 4
• Hand hygiene with alcohol-based disinfectants to prevent nosocomial RSV spread 4