What is the recommended management for a young child diagnosed with acute bronchiolitis?

Acute Bronchiolitis: Diagnosis and Management

Diagnosis

Bronchiolitis is a clinical diagnosis based on history and physical examination alone—do not routinely order chest radiographs, viral testing, or laboratory studies. 1, 2

• Bronchiolitis is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm, most commonly caused by viral lower respiratory tract infection in infants 3
• Count respiratory rate over a full minute—tachypnea ≥70 breaths/minute indicates increased severity risk 1
• Assess work of breathing by looking for nasal flaring, grunting, and intercostal/subcostal retractions 1, 2
• Approximately 25% of hospitalized infants have radiographic atelectasis or infiltrates, often misinterpreted as bacterial infection 1

Core Management: Supportive Care Only

The American Academy of Pediatrics recommends supportive care as the sole treatment approach, with oxygen supplementation reserved for specific indications and avoidance of all routine pharmacologic interventions. 1, 4

Oxygen Therapy

• Administer supplemental oxygen only if SpO2 persistently falls below 90%, and maintain SpO2 at or above 90% using standard oxygen delivery methods 1, 2
• 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 1, 2
• Discontinue oxygen when SpO2 is ≥90%, the infant is feeding well, and has minimal respiratory distress 1, 2
• Avoid continuous pulse oximetry in stable infants, as it may lead to less careful clinical monitoring—serial clinical assessments are more important 1

Hydration Management

• Infants who feed well without respiratory compromise should continue oral feeding 1, 2
• When respiratory rate exceeds 60-70 breaths per minute, transition from oral feeding to IV or nasogastric fluids due to significantly increased aspiration risk 1, 2
• Use isotonic fluids only 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 1, 2

Airway Clearance

• Use gentle nasal suctioning only as needed for symptomatic relief and temporary relief 1, 2
• 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 1, 2

What NOT to Do: Avoiding Harmful Interventions

Bronchodilators, corticosteroids, and routine antibiotics should not be used in bronchiolitis management. 1, 2

Bronchodilators

• Do not use bronchodilators (albuterol) routinely—they lack evidence of benefit in bronchiolitis 1, 2
• The FDA label for albuterol indicates use for bronchospasm or asthma, not bronchiolitis 5

Corticosteroids

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

Antibiotics

• The risk of serious bacterial infection in infants with bronchiolitis is less than 1%—fever alone does not justify antibiotics 1, 2, 4
• Use antibacterial medications only with specific indications of bacterial coinfection such as acute otitis media or documented bacterial pneumonia 1, 2

Risk Stratification

High-risk infants require closer monitoring and may have abnormal baseline oxygenation. 1, 2

High-risk categories include:

• Age <12 weeks 1, 2, 4
• History of prematurity 1, 2, 4
• Hemodynamically significant congenital heart disease 1, 2, 4
• Chronic lung disease or bronchopulmonary dysplasia 1, 2, 4
• Immunodeficiency 1, 2, 4

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
• 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 1, 2
• Limit visitor exposure during respiratory virus season and emphasize hand hygiene to help prevent RSV transmission 1, 2

Expected Disease Course and Parent Education

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

Critical Pitfalls to Avoid

• Do not treat based solely on pulse oximetry readings without clinical correlation, as transient desaturations can occur in healthy infants 1, 4
• Do not overlook feeding difficulties—an infant may have adequate SpO2 but still have tachypnea >60-70 breaths/minute that makes feeding unsafe 1, 4
• Do not continue oral feeding based solely on oxygen saturation 1