What is the treatment for bronchiolitis?

Treatment of Bronchiolitis

Supportive care is the only proven treatment for pediatric viral bronchiolitis, and bronchodilators, corticosteroids, antibiotics, and chest physiotherapy should NOT be used routinely. 1, 2

Core Management Principles

The American Academy of Pediatrics establishes that bronchiolitis management centers entirely on supportive measures, with most pharmacologic interventions showing no benefit and potentially causing harm 1, 2. This represents a fundamental shift away from aggressive interventions that dominated earlier practice.

Hydration and Feeding

• Assess oral feeding ability as the first priority - infants who can feed safely without respiratory compromise should continue oral feeding 1, 2
• Provide IV or nasogastric fluids only when respiratory rate exceeds 60-70 breaths/minute, as aspiration risk increases significantly at this threshold 2
• 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
• Continue breastfeeding whenever possible, as it reduces hospitalization risk by 72% and shortens hospital stays 2

Oxygen Therapy

• Administer supplemental oxygen ONLY if SpO₂ falls persistently below 90% in previously healthy infants 3, 1, 2
• Maintain SpO₂ at or above 90% with adequate supplemental oxygen 3, 1
• Discontinue oxygen when SpO₂ ≥90%, the infant feeds well, and has minimal respiratory distress 1, 2
• Otherwise healthy infants with SpO₂ ≥90% at sea level gain little benefit from supplemental oxygen, particularly without respiratory distress or feeding difficulties 3, 2

Critical caveat: High-risk infants (age <12 weeks, prematurity, hemodynamically significant heart disease, chronic lung disease, immunodeficiency) require close monitoring during oxygen weaning and may have abnormal baseline oxygenation 3, 2

Airway Clearance

• Use gentle nasal suctioning only as needed for symptomatic relief 2
• Avoid deep suctioning, as it is associated with longer hospital stays in infants 2-12 months of age 2
• Do NOT use chest physiotherapy routinely - Cochrane Review found no clinical benefit using vibration, percussion, or passive expiratory techniques 1, 2

What NOT to Do: Ineffective Interventions

Bronchodilators

• Do NOT routinely administer albuterol or other bronchodilators - studies using pulmonary function tests show no effect among hospitalized infants with bronchiolitis 1, 2
• A carefully monitored trial may be considered, but should only be continued if there is documented positive clinical response 2

Corticosteroids

• Corticosteroids should NOT be used routinely - multiple high-quality trials and meta-analyses demonstrate no benefit in length of stay or clinical scores 1, 2

Antibiotics

• Use antibiotics ONLY with specific indications of coexisting bacterial infection (acute otitis media, documented bacterial pneumonia) 1, 2
• Routine antibacterial therapy shows no benefit and contributes to antibiotic resistance 1
• The risk of serious bacterial infection in infants with bronchiolitis is <1%, even with fever 2

Diagnostic Testing

• Do NOT routinely order chest radiographs, viral testing, or laboratory studies - bronchiolitis is a clinical diagnosis based on history and physical examination alone 2
• Approximately 25% of hospitalized infants have radiographic atelectasis or infiltrates often misinterpreted as bacterial infection 2

Monitoring Approach

• Avoid continuous pulse oximetry in stable infants - it may lead to less careful clinical monitoring, and serial clinical assessments are more important 2
• Do NOT treat based solely on pulse oximetry readings without clinical correlation, as transient desaturations can occur in healthy infants 2
• Assess respiratory rate by counting over a full minute, with tachypnea ≥70 breaths/minute indicating increased severity risk 2
• Evaluate work of breathing by looking for nasal flaring, grunting, and intercostal/subcostal retractions 2

Prevention Strategies

• Hand hygiene with alcohol-based disinfectants is the most important step in preventing nosocomial spread of respiratory viruses 1
• Consider palivizumab prophylaxis for high-risk infants (premature birth, chronic lung disease of prematurity) to prevent RSV infection 1
• Avoid tobacco smoke exposure, as it significantly increases severity and hospitalization risk 2

Expected Clinical Course

• Symptoms (cough, congestion, wheezing) typically last 2-3 weeks, which is normal and does NOT indicate treatment failure 2

Adult Bronchiolitis (Fundamentally Different Disease)

Adult bronchiolitis requires cause-specific treatment tailored to the underlying etiology - pediatric treatment paradigms should NOT be applied 4. Infectious bacterial bronchiolitis requires prolonged antibiotic therapy, while toxic/antigenic exposure or drug-related bronchiolitis necessitates cessation of the offending agent plus corticosteroids for those with physiologic impairment 1, 4. Comprehensive evaluation including spirometry, HRCT with expiratory cuts, and often bronchoscopy or surgical lung biopsy is mandatory before treatment 1, 4.