What is the management of bronchiolitis?

Management of Bronchiolitis

Bronchiolitis management is primarily supportive care, focusing on oxygen supplementation only when SpO2 falls persistently below 90%, hydration support, and gentle nasal suctioning, while avoiding bronchodilators, corticosteroids, and routine antibiotics. 1, 2

Initial Assessment and Risk Stratification

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

High-Risk Infants Requiring Closer Monitoring:

• Age less than 12 weeks 1, 2, 3
• History of prematurity 1, 2, 3
• Hemodynamically significant congenital heart disease 1, 2, 3
• Chronic lung disease or bronchopulmonary dysplasia 2, 3
• Immunodeficiency 1, 2, 3

Severity Assessment:

• 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

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%. 4, 1, 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 4, 1, 2
• Discontinue oxygen when SpO2 is ≥90%, the infant is feeding well, and has minimal respiratory distress 1, 2, 3
• Infants with hemodynamically significant heart or lung disease and premature infants require close monitoring during oxygen weaning 4, 3

Monitoring Pitfall:

Avoid continuous pulse oximetry in stable infants—serial clinical assessments are more important than continuous monitoring, as continuous oximetry may lead to less careful clinical evaluation. 1, 2

Hydration and Feeding Management

Assess hydration status and ability to take fluids orally—infants who feed well without respiratory compromise should continue oral feeding. 1, 2, 3

Critical Threshold:

When respiratory rate exceeds 60-70 breaths per minute, feeding may be compromised and aspiration risk increases significantly—consider IV or nasogastric tube hydration at this threshold. 2

Fluid Selection:

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. 4, 2, 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. 1, 2

Do not use chest physiotherapy, as it lacks evidence of benefit. 4, 1, 2

What NOT to Do: Avoiding Harmful or Ineffective Interventions

Bronchodilators:

Do not use bronchodilators (albuterol) routinely—they lack evidence of benefit in bronchiolitis. 1, 2, 5

• The American Academy of Pediatrics recommends against routine use, but may consider a carefully monitored trial, which should only be continued if there is a documented positive clinical response 1, 3

Corticosteroids:

Do not use corticosteroids routinely—meta-analyses show no significant benefit in length of stay or clinical scores. 1, 2, 3

Antibiotics:

Do not use antibiotics routinely—the risk of serious bacterial infection in infants with bronchiolitis is less than 1%, and fever alone does not justify antibiotics. 1, 2

• Use antibacterial medications only with specific indications of bacterial coinfection such as acute otitis media or documented bacterial pneumonia 1, 2, 3

Ribavirin:

Ribavirin should not be used routinely, but may be considered in highly selected situations, such as documented RSV bronchiolitis with severe disease in high-risk patients (immunosuppressed, severe cardiopulmonary disease). 1, 6

• The vast majority of infants and children with RSV infection have disease that is mild, self-limited, and does not require hospitalization or antiviral treatment 6

Diagnostic Testing:

Do not routinely order chest radiographs—approximately 25% of hospitalized infants have radiographic atelectasis or infiltrates, often misinterpreted as bacterial infection. 1, 5

Prevention Strategies

Palivizumab prophylaxis is recommended for high-risk infants, with 5 monthly doses (15 mg/kg IM) starting November/December, to reduce the risk of hospitalization due to RSV infection. 2, 3

Additional Prevention Measures:

• Promote breastfeeding—breastfed infants have shorter hospital stays, less severe illness, and a 72% reduction in hospitalization risk for respiratory diseases 1, 2
• 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
• Hand hygiene and handwashing reduce transmission 2, 3

Expected Disease Course

Symptoms of bronchiolitis, such as cough, congestion, and wheezing, are expected to last 2-3 weeks, which is normal and does not indicate treatment failure. 1, 2