What is the management approach for bronchiolitis?

Management of Bronchiolitis

Bronchiolitis management is primarily supportive care—avoid bronchodilators, corticosteroids, and antibiotics routinely, as they provide no benefit; focus on maintaining hydration, providing oxygen only when SpO2 persistently falls below 90%, and gentle nasal suctioning as needed. 1, 2

Diagnosis and Initial Assessment

Make the diagnosis clinically based on history and physical examination alone—do not routinely order chest radiographs, viral testing, or laboratory studies. 1, 2

• Count respiratory rate over a full minute; tachypnea ≥70 breaths/minute indicates increased severity risk 2
• Assess work of breathing by looking for nasal flaring, grunting, and intercostal/subcostal retractions 2
• Identify high-risk infants requiring closer monitoring: age <12 weeks, history of prematurity (<35 weeks gestation), hemodynamically significant congenital heart disease, chronic lung disease/bronchopulmonary dysplasia, or immunodeficiency 1, 2

Common pitfall: Approximately 25% of hospitalized infants have radiographic atelectasis or infiltrates that are often misinterpreted as bacterial infection, leading to unnecessary antibiotic use 2

Supportive Care: What TO Do

Hydration Management

• Assess hydration status and ability to take fluids orally as a strong priority 1, 2
• Infants who feed well without respiratory compromise should continue oral feeding 2, 3
• When respiratory rate exceeds 60-70 breaths/minute, feeding becomes compromised and aspiration risk increases significantly—consider IV or nasogastric tube hydration at this threshold 2, 3
• Use isotonic fluids if IV hydration is needed, as infants with bronchiolitis may develop SIADH and are at risk for hyponatremia with hypotonic fluids 2, 3

Oxygen Therapy

• Administer supplemental oxygen only if SpO2 persistently falls below 90% in previously healthy infants 1, 2
• Maintain SpO2 at or above 90% using standard oxygen delivery methods 2, 3
• 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 2, 3
• Discontinue oxygen when SpO2 is ≥90%, the infant is feeding well, and has minimal respiratory distress 1, 2
• High-risk infants (hemodynamically significant heart or lung disease, premature infants) require close monitoring during oxygen weaning 1, 2

Critical pitfall: Continuous pulse oximetry may lead to less careful clinical assessment—serial clinical evaluations are more important than continuous monitoring in stable infants 2

Airway Clearance

• Use gentle nasal suctioning only as needed for symptomatic relief and temporary relief 2, 3
• Avoid deep suctioning, as it is associated with longer hospital stays in infants 2-12 months of age 2, 3
• Do not use chest physiotherapy routinely—it lacks evidence of benefit 1, 2

What NOT To Do: Avoiding Ineffective Interventions

Bronchodilators

• Do not use bronchodilators (albuterol) routinely in bronchiolitis management—they lack evidence of benefit 1, 2
• A carefully monitored trial of α-adrenergic or β-adrenergic medication is an option, but should only be continued if there is a documented positive clinical response using objective evaluation 1, 3

Corticosteroids

• Do not use corticosteroids routinely—meta-analyses show no significant benefit in length of stay or clinical scores 1, 2

Antibiotics

• Do not use antibacterial medications routinely—the risk of serious bacterial infection in infants with bronchiolitis is less than 1% 2, 3
• Fever alone does not justify antibiotics 2, 3
• Use antibacterial medications only with specific indications of bacterial coinfection such as acute otitis media or documented bacterial pneumonia 1, 2

Ribavirin

• Do not use ribavirin routinely in children with bronchiolitis 1

Diagnostic Testing

• Do not routinely order chest radiographs, viral testing, or laboratory studies—bronchiolitis is a clinical diagnosis 1, 2

Prevention Strategies

RSV Prophylaxis

• Administer palivizumab prophylaxis for high-risk infants with history of prematurity (<35 weeks gestation) or hemodynamically significant congenital heart disease 1, 3
• Give 5 monthly doses at 15 mg/kg per dose intramuscularly, usually beginning in November or December 1, 3

General Prevention

• Promote breastfeeding—breastfed infants have shorter hospital stays, less severe illness, and a 72% reduction in hospitalization risk for respiratory diseases 2, 3
• Avoid tobacco smoke exposure, as it significantly increases severity and hospitalization risk 2, 3
• Limit visitor exposure during respiratory virus season to help prevent RSV transmission 2, 3
• Hand decontamination before and after direct patient contact is the most important step in preventing nosocomial spread of RSV; alcohol-based rubs are preferred 1, 4

Expected Disease Course

• Symptoms of bronchiolitis (cough, congestion, wheezing) are expected to last 2-3 weeks, which is normal and does not indicate treatment failure 2, 3