Bronchiolitis Management

Evaluation

Clinical Decision  

Indications for Hospitalization

• Apnea, cyanosis, hypoxia, severe dyspnea, moderate to severe chest retractions, nasal flaring, grunting
• Infants at high risk of respiratory distress:
  • History of prematurity
  • With congenital heart disease
  • With chronic lung disease
  • With underlying immunodeficiency or neuromuscular disorders
  • Younger than 3 months of age
  • With Down syndrome
• Infants with arterial oxygen saturation (SaO₂) <92%
• Dehydration
• Age <4 to 6 months
• Poor feeding or inadequate oral fluid intake
• Lethargy

Pharmacological therapy

Pharmacological therapy depends on the underlying etiology of the disease.  

Inhaled Bronchodilator  

Inhaled bronchodilator may be considered in patients with strong family history of allergy, atopy, or asthma. There is no definite evidence to support their routine use. It is not recommended for patients <6 months old. However, it may produce modest short-term improvement in clinical features. A trial may be considered with further therapy based on the presence of a documented clinical response in a particular patient (ie improved wheezing, respiratory rate, respiratory effort, SaO₂). It should be discontinued if there is no significant improvement within 15 to 30 minutes after trial inhalation therapy.

Epinephrine  

Epinephrine is no longer considered a treatment option for infants and children with bronchiolitis. Several studies have concluded that use of nebulized Epinephrine is not beneficial and does not improve the length of stay of hospitalized pediatric patients when compared to Salbutamol and placebo.  

Ipratropium  

Ipratropium is not recommended but may be considered as trial treatment for the symptoms of acute bronchiolitis in an emergency setting. It is discontinued if there is no treatment response.

Salbutamol/Albuterol  

Salbutamol/Albutarol is not recommended in infants and children diagnosed with bronchiolitis. The adverse effects in studies outweigh the benefits of administration of Albuterol in infants with bronchiolitis.  

Nebulized Saline Solution  

Nebulized saline solution is recommended for admitted patients, to be nebulized alone or with bronchodilators, in repeated doses. Some studies show a decrease in the length of hospital stay. It should not be given in emergency room settings.

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Nonpharmacological

Parental Education  

Parents are educated in basic pathophysiology and expected clinical course of bronchiolitis. They are also educated in proper suctioning and airway maintenance techniques. Other respiratory care therapies (eg chest physiotherapy, cool mist therapy and aerosol therapy) are generally not helpful and therefore not recommended. Deep and improper suctioning has been associated with longer hospital stay. Information is provided on signs of progressing disease which would necessitate calling healthcare providers including increase in respiratory rate and accessory muscle use for respiration, worsening general appearance, and inability to maintain an acceptable hydration status. Propping up the patient at an angle of 10 to 30 degrees may ease breathing difficulty. Lastly, parents are informed that symptoms of bronchiolitis (eg cough) usually resolve within 3 weeks from diagnosis.  

Hydration and Nutrition Therapy  

It must be noted that bronchiolitis patients usually feed poorly and are dehydrated. If the patient only has mild to moderate respiratory distress, small frequent feedings may be attempted. Nasogastric tube feeding may be tried in patients who refuse to feed or have difficulty sucking due to tachypnea. This may be employed to decompress the dilated stomach. IV fluids are administered to infants with severe respiratory distress, cyanosis, and apnea. For patients with swallowing difficulties, feeds should be mashed or thickened prior to feeding.

Supplemental Oxygen (O₂)  

It must be noted that adequate oxygenation is achieved at a SaO₂ between 92-94%. Supplemental humidified O₂ should be started when the SaO₂ is consistently <90%, with signs of hypoxia, increased work of breathing, and/or increased fatigue with feeding. One may choose not to administer supplemental O₂ if the child’s SaO₂ is >90%. SaO₂ should be maintained at ≥95% in patients with moderate symptoms of bronchiolitis and >95% in patients with severe symptoms or signs of bronchiolitis. Respiratory failure may be imminent when SaO₂ remains low despite inspired O₂ level of >40% or when CO₂ levels are rising. Weaning off O₂ supplementation may be considered when SaO₂ is consistently >94%.  The patient is observed for at least 4 hours after cessation of O₂ supplementation. 

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