Management of RSV Bronchiolitis
RSV bronchiolitis management is primarily supportive care—maintain hydration, provide supplemental oxygen only if SpO2 persistently falls below 90%, and avoid routine use of bronchodilators, corticosteroids, or antibiotics. 1, 2
Initial Assessment and Risk Stratification
Diagnosis is clinical based on history and physical examination alone—do not routinely order chest radiographs, viral testing, or laboratory studies. 1, 2 The classic presentation includes rhinorrhea, congestion, cough, tachypnea, retractions, and wheezing following a 4-6 day incubation period. 3
Identify High-Risk Infants Requiring Closer Monitoring:
- Age <12 weeks (particularly <3 months) 1, 2, 4
- Premature birth (<35 weeks gestation) 1
- Chronic lung disease/bronchopulmonary dysplasia 1
- Hemodynamically significant congenital heart disease 1
- Immunodeficiency 2
These infants have abnormal baseline oxygenation and inability to cope with pulmonary inflammation, resulting in more severe and prolonged hypoxia. 1
Oxygen Therapy
Administer supplemental oxygen ONLY if SpO2 persistently falls below 90%, with a goal of maintaining SpO2 ≥90%. 1, 2 Before initiating oxygen therapy, verify the accuracy of the pulse oximetry reading by repositioning the probe and repeating the measurement, as poorly placed probes and motion artifact cause false readings. 1
Critical pitfall: 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 Avoid continuous pulse oximetry in stable infants, as it may lead to less careful clinical monitoring and unnecessary interventions. 2
Oxygen may be discontinued when SpO2 is ≥90%, the infant is feeding well, and has minimal respiratory distress. 2
Hydration and Nutrition Management
Assess respiratory rate over a full minute—this is critical for feeding decisions. 2
Feeding Algorithm:
- Continue oral feeding if respiratory rate <60 breaths/minute with minimal nasal flaring or retractions 2
- Transition to IV or nasogastric fluids if respiratory rate ≥60-70 breaths/minute, as aspiration risk increases significantly at this threshold 2
When providing IV fluids, use isotonic fluids specifically, as infants with bronchiolitis frequently develop syndrome of inappropriate antidiuretic hormone (SIADH) secretion, placing them at risk for hyponatremia with hypotonic fluids. 2
Common pitfall: Do not continue oral feeding based solely on oxygen saturation—an infant may have adequate SpO2 but still have tachypnea >60-70 breaths/minute that makes feeding unsafe. 2
Airway Clearance
Use gentle nasal suctioning only as needed for symptomatic relief. 2 Deep suctioning should be avoided, as it is associated with longer hospital stays in infants 2-12 months of age. 2 Chest physiotherapy should not be used due to lack of evidence of benefit. 2
What NOT to Do: Ineffective Therapies
Bronchodilators
Do not use bronchodilators routinely—they lack evidence of benefit. 1, 2 A carefully monitored trial may be considered, but should only be continued if there is a documented positive clinical response. 2
Corticosteroids
Do not use corticosteroids routinely—meta-analyses have shown no significant benefit in length of stay or clinical scores. 1, 2
Antibiotics
Use antibacterial medications only with specific indications of bacterial coinfection (such as acute otitis media or documented bacterial pneumonia), as the risk of serious bacterial infection in infants with bronchiolitis is <1%. 1, 2 Fever alone does not justify antibiotics. 2
Approximately 25% of hospitalized infants have radiographic atelectasis or infiltrates, often misinterpreted as bacterial infection—this does not warrant antibiotic therapy. 2
Ribavirin
Do not use ribavirin routinely. 2 It may be considered only in highly selected situations such as documented RSV bronchiolitis with severe disease in immunocompromised patients, but drug toxicity and minimal clinical benefit preclude routine use. 5
Prevention with Palivizumab Prophylaxis
Indications for Palivizumab (per FDA label and AAP guidelines):
Infants born ≤28 weeks gestation: Benefit from prophylaxis during their first RSV season, whenever that occurs during the first 12 months of life. 1, 6, 7
Infants born 29-32 weeks gestation: Benefit most from prophylaxis up to 6 months of age. 1, 6
Chronic lung disease/BPD: Infants <24 months with BPD requiring medical treatment (supplemental oxygen, bronchodilator, diuretic, or corticosteroid therapy) within 6 months before RSV season. 1, 7
Hemodynamically significant congenital heart disease: Infants <24 months at the beginning of RSV season. 1, 7 Mortality rates for CHD patients hospitalized with RSV are approximately 24 times higher compared to those without RSV infection. 8
Dosing and Administration:
Palivizumab should be administered at 15 mg/kg per dose intramuscularly, given monthly for 5 doses throughout the RSV season (typically November through April in the northern hemisphere). 1, 6, 7 The first dose should be administered before RSV season starts. 6, 7
Once initiated, prophylaxis should continue throughout the entire RSV season and not stop when the infant reaches 6 or 12 months of age. 1, 6
Special consideration: Children undergoing cardiopulmonary bypass should receive an additional dose of palivizumab as soon as possible after the procedure (even if sooner than a month from the previous dose), as serum levels are decreased after bypass. 7
Palivizumab reduces hospitalization risk by approximately 45-55% in high-risk infants. 7
Contraindication:
Severe allergic reaction to palivizumab (including anaphylaxis, severe rash, hives, swelling of lips/tongue/face, difficulty breathing, bluish skin color, or unresponsiveness). 7
Additional Prevention Strategies
Hand hygiene is the single most important step in preventing RSV transmission—use alcohol-based hand rubs before and after direct contact with the infant, after contact with objects near the infant, and after removing gloves. 6
Avoid tobacco smoke exposure completely, as it significantly increases RSV infection risk and hospitalization rates. 6, 9
Continue breastfeeding, as breastfed infants have shorter hospital stays, less severe illness, and a 72% reduction in hospitalization risk for respiratory diseases. 2, 6
Limit exposure to crowds and group childcare during RSV season, as RSV can survive on hard surfaces for ≥6 hours. 6, 9
Expected Clinical Course
Symptoms of bronchiolitis (cough, congestion, wheezing) are expected to last 2-3 weeks—this is normal and does not indicate treatment failure. 2 Most episodes are self-limited, though some children have increased risk of asthma later in life. 3