Background
Bronchiolitis is a viral infection. Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis.
In North America, RSV season is November to April. Most cases occur from December to March.
RSV is rarely associated with a bacterial superimposition.
Diagnosis
H&P: Assess hydration status (UOP, oral secretions, cap refill, etc).
Risk factors:
DDx:
Common presentation:
Diagnostic tests (not routinely indicated): Flu (A &B), RSV, CXR, CBC, CMP. Consider ABG.
CXR is not routinely indicated except when there are focal lung findings.
Treatment
-Bronchiolitis is self-limiting and requires only supportive care (fluids, antipyretics, nasal bulb suction, etc.)
-Nasal suctioning via bulb or neo sucker to clear the upper airway.
-Saline drops in the nose and nasal suctioning PRN.
-Supplemental oxygen for oxygen saturation < 90%
-Encourage PO intake.
-Strict I&Os and daily weights.
-If a patient with a history of asthma, atopy, or allergy is in respiratory distress, a single trial of inhaled epinephrine or albuterol is reasonable.
Patients hospitalized ≥ 3 days (AFP 2017).
-Nebulized Hypertonic saline (3% or 7% solution). Give 4ml q2h for 3 doses followed by 4ml q4h for 5 doses, followed by 4ml q6h till discharge.
Prevention with Palivizumab when indicated (up to 5 monthly doses).
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Treatments that are not routinely recommended are: Antibiotics, Bronchodilators, Chest physiotherapy, Epinephrine, Excessive nasal suction of secretions, Systemic or inhaled corticosteroids, and Nebulized hypertonic saline (when the hospital stay is shorter than 3 days).
No pharmacologic treatment shortens the course of viral bronchiolitis in a young child.
Deep suction (beyond the nasopharynx) is not recommended.
A single trial of inhaled epinephrine or albuterol for respiratory distress may be considered, but only if there is a history of asthma, atopy, or allergy.”
Emerging evidence
1. High flow oxygen in infants with bronchiolitis, RCT
“Among infants with bronchiolitis who were treated outside an ICU, those who received high-flow oxygen therapy had significantly lower rates of escalation of care due to treatment failure than those in the group that received standard oxygen therapy.”
N Engl J Med 2018; 378:1121-1131. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis.
Reference / Further Reading
Pediatrics 2014;133(3):e730-e737. https://www.ncbi.nlm.nih.gov/pubmed/24534398
Pediatrics 2014;134(5):e1474-e1502. Clinical practice guideline: The diagnosis, management, and prevention of bronchiolitis.
Am Fam Physician 2017;95(2):94-99. Respiratory syncytial virus bronchiolitis in children.
N Engl J Med 2016;374(1):62-72. Viral bronchiolitis in children.