Management of Bronchiolitis

Diagnostic Approach

The American Academy of Pediatrics recommends that bronchiolitis should be diagnosed based on history and physical examination; routine laboratory and radiologic studies are not recommended 1, 2
Assessment of risk factors for severe disease is essential, including age less than 12 weeks, history of prematurity, underlying cardiopulmonary disease, or immunodeficiency 1, 3
Pulse oximetry should be used to assess oxygenation status, but continuous monitoring is not needed once the clinical course improves 3, 4
Chest radiography should be reserved only for cases with severe respiratory distress warranting ICU admission or when complications such as pneumothorax are suspected 5
Viral testing is not routinely recommended except in cases where a patient receiving monthly palivizumab prophylaxis is hospitalized with bronchiolitis 5

Supplemental oxygen is indicated if SpO2 falls persistently below 90% in previously healthy infants 1, 3
Oxygen may be discontinued when SpO2 is at or above 90%, the infant is feeding well, and has minimal respiratory distress 3, 6
Infants with hemodynamically significant heart or lung disease and premature infants require closer monitoring during oxygen weaning 3, 4
Assessment of hydration status and ability to take fluids orally is crucial 3, 4
Intravenous fluids should be provided for infants who cannot feed safely due to respiratory distress 4
Monitor for possible fluid retention related to production of antidiuretic hormone in patients with bronchiolitis 4
Bronchodilators (albuterol/salbutamol) should not be routinely administered 2, 5
If a trial of bronchodilator is attempted, it should be continued only if there is a documented positive clinical response using objective evaluation 1, 3
Corticosteroid medications should not be used routinely 1, 5
Ribavirin should not be used routinely 1, 3
Antibacterial medications should only be used when there are specific indications of bacterial coinfection 1, 4
Chest physiotherapy is not recommended for routine management 3, 7

Hand decontamination is the most important step in preventing nosocomial spread of RSV 3
Alcohol-based rubs are preferred for hand decontamination 3
Educate personnel and family members on hand sanitation 3

Palivizumab prophylaxis should be administered to infants with a history of prematurity (less than 35 weeks' gestation) or with congenital heart disease 3
More specifically, palivizumab should be given during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease of prematurity (defined as preterm infants <32 weeks 0 days' gestation who require >21% oxygen for at least the first 28 days of life) 2
When given, prophylaxis with palivizumab should be administered in 5 monthly doses, usually beginning in November or December, at a dose of 15 mg/kg per dose administered intramuscularly 3
Advise parents to avoid exposing infants to passive smoking 3
Recommend breastfeeding to decrease a child's risk of having lower respiratory tract disease 3
Patients with risk factors (prematurity, cardiopulmonary disease, immunodeficiency) may have more severe disease course 1, 3

Overuse of diagnostic testing (chest X-rays, viral testing) that does not change management 1, 5
Routine use of bronchodilators without documented benefit 2, 5
Unnecessary use of corticosteroids 1, 5
Inappropriate use of antibiotics without evidence of bacterial infection 1, 4
Inadequate assessment of hydration status 3, 4
Failure to identify high-risk patients who may need more intensive monitoring 1, 3