What is the recommended management of acute bronchitis in a pediatric patient?

Treatment of Acute Bronchitis in Children

Acute bronchitis in children is managed with supportive care only—no antibiotics, bronchodilators, or corticosteroids should be routinely used. The cornerstone of management is maintaining adequate hydration, oxygenation when needed, and nasal clearance of secretions 1, 2.

Critical Distinction: Bronchitis vs. Bronchiolitis

The term "bronchitis" in pediatrics typically refers to acute viral bronchiolitis in infants and young children under 2 years of age, which is distinct from bacterial bronchitis 1, 2. This is a clinical diagnosis based solely on history and physical examination—no routine chest radiographs, viral testing, or laboratory studies should be ordered 1, 2.

Key Diagnostic Features:

• Age 1-24 months with prodrome of upper respiratory symptoms 2
• Progression to lower respiratory tract signs: tachypnea, wheezing, crackles on auscultation, increased work of breathing 3, 1
• Respiratory rate >70 breaths/minute indicates increased severity risk 1
• Work of breathing indicators: nasal flaring, grunting, intercostal/subcostal retractions 1

Supportive Care Management

Oxygen Therapy

• Administer supplemental oxygen ONLY if SpO2 persistently falls below 90% 3, 1, 2
• Goal: maintain SpO2 ≥90% with standard oxygen delivery 1
• Discontinue oxygen when SpO2 ≥90%, infant feeds well, and has minimal respiratory distress 1
• Avoid continuous pulse oximetry in stable infants—serial clinical assessments are more important 1

Hydration and Feeding

• Continue oral feeding if respiratory rate <60 breaths/minute with minimal nasal flaring or retractions 3
• Transition to IV or nasogastric fluids if respiratory rate ≥60-70 breaths/minute, as aspiration risk increases significantly at this threshold 3, 1
• Use isotonic fluids specifically, as infants with bronchiolitis frequently develop SIADH, placing them at risk for hyponatremia with hypotonic fluids 1

Airway Clearance

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

What NOT to Do: Avoid Non-Evidence-Based Interventions

Bronchodilators

• Should not be used routinely 1, 4, 5
• May be considered in highly selected situations with documented positive clinical response, but this is not standard practice 1

Corticosteroids

• Should not be used routinely, as meta-analyses have shown no significant benefit in length of stay or clinical scores 1, 4, 5

Antibiotics

• Should only be used with specific indications of bacterial coinfection, such as acute otitis media or documented bacterial pneumonia 1, 4
• Fever alone does not justify antibiotics, as the risk of serious bacterial infection in febrile infants with bronchiolitis is <1% 1

Other Ineffective Therapies

• Hypertonic saline is not recommended for acute bronchiolitis 6, 1
• Ribavirin, interferon, vitamin A, anticholinergics, and mist therapy have not demonstrated measurable clinical effect 7

High-Risk Infants Requiring Closer Monitoring

Identify infants at increased risk for severe disease and complications 3, 1, 2:

• Age <12 weeks (higher risk of apnea and severe disease) 3, 1, 2
• History of prematurity, especially <32 weeks gestation 3, 1, 2
• Hemodynamically significant congenital heart disease 3, 1, 2
• Chronic lung disease of prematurity requiring oxygen >21% during first 28 days of life 3, 1
• Primary immunodeficiency 3, 1

Criteria for Hospitalization

Admit if any of the following are present 3:

• Moderate to severe respiratory distress 3
• Difficulty feeding or dehydration 3
• Apnea 3
• SpO2 persistently <90% 1

Natural History and Expected Course

• Bronchiolitis is self-limiting in most children, with a duration of 8-15 days on average 3, 2
• 90% of infants are cough-free by day 21 3, 2

Management of Chronic Cough Post-Bronchiolitis (>4 Weeks)

If cough persists beyond 4 weeks, follow CHEST pediatric chronic cough guidelines 6:

For Wet or Productive Cough:

• Evaluate for cough pointers (e.g., coughing with feeding, digital clubbing) 6
• Consider 2 weeks of antibiotics targeted to common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) based on local antibiotic sensitivities in children with wet cough without specific cough pointers 6
• Early identification and treatment of protracted bacterial bronchitis can prevent development of bronchiectasis 3

What NOT to Use for Chronic Cough Post-Bronchiolitis:

• Do not use asthma medications unless other evidence of asthma is present (recurrent wheeze and/or dyspnea responsive to beta-2 agonists) 6, 3
• Do not use inhaled osmotic agents (hypertonic saline) 6, 3

Prevention Strategies

• Hand hygiene is the most important step in preventing nosocomial spread of RSV, with alcohol-based disinfectants preferred 1
• Avoid tobacco smoke exposure, as it significantly increases severity and hospitalization risk 1, 2
• Promote breastfeeding—breastfed infants have shorter hospital stays, less severe illness, and a 72% reduction in hospitalization risk 1, 2
• Limit visitor exposure during respiratory virus season 1, 2
• Palivizumab prophylaxis should be considered for high-risk infants (5 monthly doses of 15 mg/kg intramuscularly, typically starting November/December) 1, 2

Critical Pitfalls to Avoid

• 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 1
• Do not overlook feeding difficulties, as aspiration risk increases significantly when respiratory rate exceeds 60-70 breaths/minute 3, 1
• Do not treat based solely on pulse oximetry readings without clinical correlation, as transient desaturations can occur in healthy infants 1
• Do not use hypotonic fluids for IV hydration due to SIADH risk 1

Special Consideration: Recurrent Episodes

Children with recurrent episodes of "bronchiolitis" after the first year of life likely do not have viral bronchiolitis, but rather recurrent wheezing or asthma, and should not receive treatment for acute bronchiolitis 3. These children require evaluation for asthma and should be managed accordingly.