What is the treatment for bronchiolitis?

Treatment of Bronchiolitis

Bronchiolitis treatment is primarily supportive care with oxygen supplementation (only if SpO₂ persistently <90%) and hydration management—bronchodilators, corticosteroids, antibiotics, and ribavirin should NOT be used routinely. 1, 2

Core Management: What TO Do

Oxygen Therapy

• Administer supplemental oxygen only if SpO₂ persistently falls below 90% in previously healthy infants 1, 2
• Maintain SpO₂ ≥90% with adequate supplemental oxygen 1
• Discontinue oxygen when SpO₂ ≥90%, infant feeds well, and has minimal respiratory distress 1
• Avoid continuous pulse oximetry in stable infants—serial clinical assessments are more important than continuous monitoring 2

Hydration and Nutrition

• Assess ability to feed and hydrate orally 1
• Continue oral feeding if infant feeds well without respiratory compromise 2
• When respiratory rate exceeds 60-70 breaths/minute, feeding may be compromised and aspiration risk increases—consider IV or nasogastric hydration 2
• Use isotonic fluids if IV hydration needed, as infants may develop SIADH and are at risk for hyponatremia with hypotonic fluids 2

Airway Clearance

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

Breastfeeding

• Continue breastfeeding if possible—breastfed infants have shorter hospital stays, less severe illness, and 72% reduction in hospitalization risk 2

What NOT To Do: Avoid These Interventions

Bronchodilators

• Do NOT use bronchodilators routinely 3, 1, 2
• A carefully monitored trial of α-adrenergic or β-adrenergic medication may be considered, but should only be continued if there is documented positive clinical response 3, 1
• If no clinical response is observed (improvements in wheezing, respiratory rate, respiratory effort, oxygen saturation), discontinue treatment 3
• Anticholinergic agents (ipratropium) should not be used, either alone or in combination with β-adrenergic agents 3

Corticosteroids

• Do NOT use corticosteroids routinely 3, 1, 2
• Meta-analyses of nearly 1,200 children showed no significant benefit in length of stay or clinical scores 3
• Both systemic and inhaled corticosteroids lack evidence of benefit 3

Antibiotics

• Use antibacterial medications ONLY with specific indications of coexisting bacterial infection 3, 1, 2
• Serious bacterial infection (SBI) rates are very low (0%-3.7%) in bronchiolitis patients 3
• When SBI is present, it is more likely to be UTI than bacteremia or meningitis 3
• Fever alone does not justify antibiotics—risk of SBI in febrile infants with bronchiolitis is <1% 2
• Bacterial pneumonia without consolidation is unusual in bronchiolitis 3
• Acute otitis media may coexist (present in 50-62% of cases) and should be treated if documented, but prophylactic antibiotics are not indicated 3

Ribavirin

• Do NOT use ribavirin routinely 3
• May be considered only in highly selected situations: documented RSV bronchiolitis with severe disease OR high-risk patients (immunocompromised and/or hemodynamically significant cardiopulmonary disease) 3
• Marginal benefit at best, with cumbersome delivery, potential health risks to caregivers, and high cost 3

Diagnostic Testing

• Do NOT routinely order chest radiographs, viral testing, or laboratory studies—bronchiolitis is a clinical diagnosis 3, 1, 2
• Approximately 25% of hospitalized infants have radiographic atelectasis or infiltrates, often misinterpreted as bacterial infection 3

Chest Physiotherapy

• Avoid chest physiotherapy—no evidence of benefit 2

Risk Stratification: Who Needs Closer Monitoring

High-Risk Infants Requiring Close Monitoring

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

Assessment Parameters

• Count respiratory rate over a full minute—tachypnea ≥70 breaths/minute indicates increased severity risk 2
• Assess work of breathing: nasal flaring, grunting, intercostal/subcostal retractions 2
• High-risk infants may have abnormal baseline oxygenation and require close monitoring during oxygen weaning 2

Clinical Pitfalls to Avoid

• Do NOT treat based solely on pulse oximetry readings without clinical correlation—transient desaturations can occur in healthy infants 2
• Do NOT overlook feeding difficulties—aspiration risk increases significantly when respiratory rate exceeds 60-70 breaths/minute 2
• Do NOT misinterpret radiographic findings—atelectasis and infiltrates are common and do not indicate bacterial infection requiring antibiotics 3
• Continuous pulse oximetry may lead to less careful clinical monitoring in stable infants 2

Expected Clinical Course

• Symptoms (cough, congestion, wheezing) typically last 2-3 weeks—this is normal and does not indicate treatment failure 2
• Most infections are self-limited with improvement within several days 4

Prevention Strategies

• Hand hygiene is the most important step in preventing nosocomial spread of RSV—alcohol-based disinfectants are preferred 1
• Avoid tobacco smoke exposure—significantly increases severity and hospitalization risk 1, 2
• Consider palivizumab prophylaxis for high-risk infants: 5 monthly doses (15 mg/kg per dose IM), typically starting November or December 1
• Limit visitor exposure during respiratory virus season 2