Bronchiolitis Treatment & Management

  • Author: John Udeani, MD, FAAEM; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: Jun 9, 2011
 

Medical Care

Most cases of bronchiolitis result from a viral pathogen such as RSV, parainfluenza virus, influenza virus, or adenovirus. Approximately 123,000 infants are hospitalized each year for bronchiolitis. Of the total number of hospitalizations from 1980-1996 involving lower respiratory tract illnesses in infants younger than 1 year, the proportion of infants hospitalized for bronchiolitis more than doubled, from 22.2% to 47.4%. RSV is responsible for most admissions involving bronchiolitis. Eighty-one percent of all children hospitalized for bronchiolitis are younger than 1 year; 57% are younger than 6 months. RSV infection accounts for 500 deaths each year.

In many children, RSV bronchiolitis is a self-limited disease and can be safely managed in an outpatient setting. However, disease manifestation can be variable, and risk factors for severe disease include preexisting cardiac or pulmonary disease, premature birth, very young age (< 2-3 mo), nosocomial RSV infection, and, in some studies, low socioeconomic status.

Despite the increasing hospitalization rate, controversy still exists regarding the optimal treatment of these patients. As a result, the use of management tools among physicians and between hospitals varies greatly. The use of clinical practice guidelines can standardize care, reduce admissions, manage resources better, and shorten the length of hospital stays without increasing re-admission rates or decreasing family satisfaction.

Management is primarily supportive and should focus on therapies that improve oxygenation and hydration. Management strategies to consider include the following:

  • Importantly, carefully assess clinical respiratory status and the severity of disease.
  • Measure the oxygen saturation level. Use supplemental humidified oxygen, if necessary, to maintain adequate oxygen saturation.
  • Consider bronchodilator therapy to relax bronchial smooth muscle. Although this treatment is common, no convincing evidence supports it as routine practice. Consider continuing bronchodilator therapy in patients who demonstrate clinical improvement.
  • Maintain adequate hydration. Parenteral therapy may be necessary in patients who are unable to take fluids by mouth or who have a respiratory rate of greater than 70 respirations per minute. Patients with apneic episodes should have access to intravenous hydration.
  • Institute respiratory and contact isolation precautions to prevent nosocomial transmission.
  • Confirm the viral etiology based on rapid antigen testing of the nasopharyngeal aspirate. Positive viral antigen test results indicate that a concomitant serious bacterial infection is unlikely and are strongly indicative to the physician to withhold empiric antibiotic drugs.
  • In previously healthy children with viral bronchiolitis, a chest radiograph, CBC count, or blood culture is not necessary. However, give careful consideration to these tests in persons with severe disease or a very ill appearance, preexisting cardiac or pulmonary disease, a markedly elevated temperature, or other risk factors for more severe disease.
  • A few children at risk for acute respiratory failure may require monitoring of the blood carbon dioxide level.
  • Decide whether the patient should be treated in an inpatient or outpatient setting.
  • Raltson and Roohi reported in 2008 that nasal phenylephrine was not effective treatment in infants hospitalized for bronchiolitis.[16]
  • For outpatients, review discharge instructions carefully and arrange for appropriate follow-up with the primary care physician.
  • Electronic cardiac and respiratory monitoring is required for some patients (persons who are very sick, are very young, or are having apneic episodes). This monitoring should be discontinued in a timely manner when it is no longer necessary.
  • Determine whether an infant with bronchiolitis should be admitted. For hospitalized patients, the length of stay averages 2-3 days, with a re-admission rate of 1-4%. Infants with bronchiolitis at increased risk should be considered for admission. Conditions for increased risk include the following:
    • Congenital heart disease, especially if associated with cyanosis or pulmonary hypertension
    • Chronic lung disease, especially if the patient is on supplemental oxygen
    • Prematurity
    • Age younger than 3 months, when severe disease is most common
    • Oxygen saturation level of 92% or less
    • Respiratory rate of greater than 70-80 respirations per minute
    • Difficulty feeding due to respiratory distress
    • Less serious conditions (eg, neuromuscular disease, history of recurrent aspiration, congenital anomaly of the airway, myasthenia gravis, immunodeficiency state)
  • Determine which patients need to be admitted to the ICU. Criteria for ICU admission vary greatly among physicians. ICU admission is uncommon for previously healthy infants who present with bronchiolitis (1.8% of 542 patients in one study). Patients with the following conditions should be evaluated for PICU admission:
    • Worsening hypoxemia or hypercapnia
    • Apnea
    • Worsening respiratory distress
    • Worsening mental status
  • Determine criteria for patient discharge. The median duration of cough, poor sleeping and irritability, wheezing, and poor feeding is 7-12 days. Further research is needed to clarify safe endpoints for discharge. Criteria currently in use include the following:
    • Clinical improvement
    • Oral intake adequate to maintain hydration status
    • No apnea in preceding 24 hours in infants younger than 6 months or preceding 48 hours in patients older than 6 months
    • Acceptable oxygen saturation for more than one day, either on room air or from stable oxygen therapy of less than 0.5 L/min by nasal canula
    • Respiratory rate less than 80 respirations per minute
    • When appropriate, home oxygen therapy arranged and patient or parents educated in its use
    • Follow-up arranged with primary care physician
  • The following guidelines may be helpful:
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

John Udeani, MD, FAAEM  Assistant Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science, University of California, Los Angeles, David Geffen School of Medicine

John Udeani, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Charles I Ojielo, MD  Assistant Professor of Medicine, Rush Medical College; Consulting Staff, Resident Education Coordinator, Department of Pulmonary and Critical Care Medicine, John H Stroger Hospital of Cook County/Rush University Medical Center

Charles I Ojielo, MD is a member of the following medical societies: American College of Physicians, American Medical Association, and American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP  Professor of Genomics and Personalized Medicine Research, Internal Medicine, and Pediatrics, Associate Director, Center for Genomics and Personalized Medicine Research, Director of Research, Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University School of Medicine

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society, and Sigma Xi

Disclosure: See below for list of all activities None None

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H  Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California Keck School of Medicine

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Osler Society, American Thoracic Society, New York Academy of Medicine, and Royal Society of Medicine

Disclosure: Nothing to disclose.

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

References

  1. Epler GR, Colby TV, McLoud TC, Carrington CB, Gaensler EA. Bronchiolitis obliterans organizing pneumonia. N Engl J Med. Jan 17 1985;312(3):152-8. [Medline].

  2. Shay DK, Holman RC, Newman RD, Liu LL, Stout JW, Anderson LJ. Bronchiolitis-associated hospitalizations among US children, 1980-1996. JAMA. Oct 20 1999;282(15):1440-6. [Medline].

  3. Rudan I, Tomaskovic L, Boschi-Pinto C, Campbell H. Global estimate of the incidence of clinical pneumonia among children under five years of age. Bull World Health Organ. Dec 2004;82(12):895-903. [Medline].

  4. [Best Evidence] Koehoorn M, Karr CJ, Demers PA, Lencar C, Tamburic L, Brauer M. Descriptive epidemiological features of bronchiolitis in a population-based cohort. Pediatrics. Dec 2008;122(6):1196-203. [Medline].

  5. Bradley JP, Bacharier LB, Bonfiglio J, et al. Severity of respiratory syncytial virus bronchiolitis is affected by cigarette smoke exposure and atopy. Pediatrics. Jan 2005;115(1):e7-14. [Medline].

  6. La Via WV, Grant SW, Stutman HR, Marks MI. Clinical profile of pediatric patients hospitalized with respiratory syncytial virus infection. Clin Pediatr (Phila). Aug 1993;32(8):450-4. [Medline].

  7. Saijo M, Ishii T, Kokubo M, Murono K, Takimoto M, Fujita K. White blood cell count, C-reactive protein and erythrocyte sedimentation rate in respiratory syncytial virus infection of the lower respiratory tract. Acta Paediatr Jpn. Dec 1996;38(6):596-600. [Medline].

  8. Vieira RA, Diniz EM, Vaz FA. Clinical and laboratory study of newborns with lower respiratory tract infection due to respiratory viruses. J Matern Fetal Neonatal Med. May 2003;13(5):341-50. [Medline].

  9. Kuppermann N, Bank DE, Walton EA, Senac MO Jr, McCaslin I. Risks for bacteremia and urinary tract infections in young febrile children with bronchiolitis. Arch Pediatr Adolesc Med. Dec 1997;151(12):1207-14. [Medline].

  10. Liebelt EL, Qi K, Harvey K. Diagnostic testing for serious bacterial infections in infants aged 90 days or younger with bronchiolitis. Arch Pediatr Adolesc Med. May 1999;153(5):525-30. [Medline].

  11. Antonow JA, Hansen K, McKinstry CA, Byington CL. Sepsis evaluations in hospitalized infants with bronchiolitis. Pediatr Infect Dis J. Mar 1998;17(3):231-6. [Medline].

  12. Bloomfield P, Dalton D, Karleka A, Kesson A, Duncan G, Isaacs D. Bacteraemia and antibiotic use in respiratory syncytial virus infections. Arch Dis Child. Apr 2004;89(4):363-7. [Medline].

  13. Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J Paediatr Child Health. Aug 1990;26(4):209-11. [Medline].

  14. Shaw KN, Bell LM, Sherman NH. Outpatient assessment of infants with bronchiolitis. Am J Dis Child. Feb 1991;145(2):151-5. [Medline].

  15. Friis B, Eiken M, Hornsleth A, Jensen A. Chest X-ray appearances in pneumonia and bronchiolitis. Correlation to virological diagnosis and secretory bacterial findings. Acta Paediatr Scand. Feb 1990;79(2):219-25. [Medline].

  16. [Best Evidence] Ralston S, Roohi M. A randomized, controlled trial of nasal phenylephrine in infants hospitalized for bronchiolitis. J Pediatr. Dec 2008;153(6):795-8. [Medline].

  17. [Guideline] American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. Oct 2006;118(4):1774-93. [Medline].

  18. [Guideline] Brown KK. Chronic cough due to nonbronchiectatic suppurative airway disease (bronchiolitis): ACCP evidence-based clinical practice guidelines. Chest. Jan 2006;129(1 Suppl):132S-137S. [Medline].

  19. [Best Evidence] Amirav I, Luder AS, Kruger N, et al. A double-blind, placebo-controlled, randomized trial of montelukast for acute bronchiolitis. Pediatrics. Dec 2008;122(6):e1249-55. [Medline].

  20. Menon K, Sutcliffe T, Klassen TP. A randomized trial comparing the efficacy of epinephrine with salbutamol in the treatment of acute bronchiolitis. J Pediatr. Jun 1995;126(6):1004-7. [Medline].

  21. Wainwright C, Altamirano L, Cheney M, et al. A multicenter, randomized, double-blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med. Jul 3 2003;349(1):27-35. [Medline].

  22. Hartling L, Fernandes RM, Bialy L, et al. Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis. BMJ. Apr 6 2011;342:d1714. [Medline]. [Full Text].

  23. Corneli HM, Zorc JJ, Mahajan P, et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med. Jul 26 2007;357(4):331-9. [Medline].

  24. Adcock PM, Sanders CL, Marshall GS. Standardizing the care of bronchiolitis. Arch Pediatr Adolesc Med. Aug 1998;152(8):739-44. [Medline].

  25. American Thoracic Society (ATS) and the European Respiratory Society (ERS). American Thoracic Society. Idiopathic pulmonary fibrosis: diagnosis and treatment. International consensus statement. American Thoracic Society (ATS), and the European Respiratory Society (ERS). Am J Respir Crit Care Med. Feb 2000;161(2 Pt 1):646-64. [Medline].

  26. Becroft DM. Bronchiolitis obliterans, bronchiectasis, and other sequelae of adenovirus type 21 infection in young children. J Clin Pathol. Feb 1971;24(1):72-82. [Medline].

  27. Bordley WC, Viswanathan M, King VJ, et al. Diagnosis and testing in bronchiolitis: a systematic review. Arch Pediatr Adolesc Med. Feb 2004;158(2):119-26. [Medline].

  28. Brand PL, Vaessen-Verberne AA. Differences in management of bronchiolitis between hospitals in The Netherlands. Dutch Paediatric Respiratory Society. Eur J Pediatr. May 2000;159(5):343-7. [Medline].

  29. Brooks AM, McBride JT, McConnochie KM, Aviram M, Long C, Hall CB. Predicting deterioration in previously healthy infants hospitalized with respiratory syncytial virus infection. Pediatrics. Sep 1999;104(3 Pt 1):463-7. [Medline].

  30. Brown L, Shaw T, Wittlake WA. Does leucocytosis identify bacterial infections in febrile neonates presenting to the emergency department?. Emerg Med J. Apr 2005;22(4):256-9. [Medline].

  31. Byington CL, Castillo H, Gerber K, et al. The effect of rapid respiratory viral diagnostic testing on antibiotic use in a children's hospital. Arch Pediatr Adolesc Med. Dec 2002;156(12):1230-4. [Medline].

  32. Byington CL, Enriquez FR, Hoff C, et al. Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections. Pediatrics. Jun 2004;113(6):1662-6. [Medline].

  33. Cade A, Brownlee KG, Conway SP, et al. Randomised placebo controlled trial of nebulised corticosteroids in acute respiratory syncytial viral bronchiolitis. Arch Dis Child. Feb 2000;82(2):126-30. [Medline].

  34. Carlsen KH, Orstavik I, Halvorsen K. Viral infections of the respiratory tract in hospitalized children. A study from Oslo during a 90 months' period. Acta Paediatr Scand. Jan 1983;72(1):53-8. [Medline].

  35. Castro M, Schechtman KB, Halstead J, Bloomberg G. Risk factors for asthma morbidity and mortality in a large metropolitan city. J Asthma. Dec 2001;38(8):625-35. [Medline].

  36. Christakis DA, Cowan CA, Garrison MM, Molteni R, Marcuse E, Zerr DM. Variation in inpatient diagnostic testing and management of bronchiolitis. Pediatrics. Apr 2005;115(4):878-84. [Medline].

  37. Colby TV. Bronchiolitis. Pathologic considerations. Am J Clin Pathol. Jan 1998;109(1):101-9. [Medline].

  38. De Boeck K. Respiratory Syncytial virus: Clinical Aspects and epidemiology. Monaldi Arch Chest Dis. 1996;51:210-213.

  39. Downham MA, Scott R, Sims DG, Webb JK, Gardner PS. Breast-feeding protects against respiratory syncytial virus infections. Br Med J. Jul 31 1976;2(6030):274-6. [Medline].

  40. Duttweiler L, Nadal D, Frey B. Pulmonary and systemic bacterial co-infections in severe RSV bronchiolitis. Arch Dis Child. Dec 2004;89(12):1155-7. [Medline].

  41. Edelson PJ. Respiratory syncytial virus pneumonia. In: Pediatric Emergency Casebook. 3. New York, NY: World Health Communications; 1985:1-15.

  42. Fernandez JA, Tapia L, Palomino MA, Larranaga C, Pena M, Jaramillo H. Plasma interferon-gamma, interleukin-10 and soluble markers of immune activation in infants with primary adenovirus (ADV) and respiratory syncytial virus (RSV) infection. Eur Cytokine Netw. Jan-Mar 2005;16(1):35-40. [Medline].

  43. Field CM, Connolly JH, Murtagh G, Slattery CM, Turkington EE. Antibiotic treatment of epidemic bronchiolitis--a double-blind trial. Br Med J. Jan 8 1966;1(5479):83-5. [Medline].

  44. Flores G, Horwitz RI. Efficacy of beta2-agonists in bronchiolitis: a reappraisal and meta-analysis. Pediatrics. Aug 1997;100(2 Pt 1):233-9. [Medline].

  45. Fox GF, Everard ML, Marsh MJ, Milner AD. Randomised controlled trial of budesonide for the prevention of post-bronchiolitis wheezing. Arch Dis Child. Apr 1999;80(4):343-7. [Medline].

  46. Gurkan F, Kiral A, Dagli E, Karakoc F. The effect of passive smoking on the development of respiratory syncytial virus bronchiolitis. Eur J Epidemiol. May 2000;16(5):465-8. [Medline].

  47. Hall CB. Respiratory syncytial virus. In: Feigen RD, Cherry JC, eds. Textbook of Pediatric Infectious Disease. Philadelphia, Pa: WB Saunders; 1992:1653-75.

  48. Hall CB, Powell KR, Schnabel KC, Gala CL, Pincus PH. Risk of secondary bacterial infection in infants hospitalized with respiratory syncytial viral infection. J Pediatr. Aug 1988;113(2):266-71. [Medline].

  49. Henderson FW, Clyde WA Jr, Collier AM, et al. The etiologic and epidemiologic spectrum of bronchiolitis in pediatric practice. J Pediatr. Aug 1979;95(2):183-90. [Medline].

  50. Kellner JD, Ohlsson A, Gadomski AM, Wang EE. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2000;CD001266. [Medline].

  51. King VJ, Viswanathan M, Bordley WC, et al. Pharmacologic treatment of bronchiolitis in infants and children: a systematic review. Arch Pediatr Adolesc Med. Feb 2004;158(2):127-37. [Medline].

  52. Kini NM, Robbins JM, Kirschbaum MS, Frisbee SJ, Kotagal UR. Inpatient care for uncomplicated bronchiolitis: comparison with Milliman and Robertson guidelines. Arch Pediatr Adolesc Med. Dec 2001;155(12):1323-7. [Medline].

  53. Kou M, Mayer TA. Pediatric Asthma and Bronchiolitis. In: Tintinalli J, Kelen G, Stspczynski J. Emergency Medicine: A Comprehensive Study Guide. 5th ed. New York, NY: McGraw-Hill; 1999:821-4.

  54. Lanari M, Giovannini M, Giuffre L, et al. Prevalence of respiratory syncytial virus infection in Italian infants hospitalized for acute lower respiratory tract infections, and association between respiratory syncytial virus infection risk factors and disease severity. Pediatr Pulmonol. Jun 2002;33(6):458-65. [Medline].

  55. Law BJ, Wang EE, MacDonald N, et al. Does ribavirin impact on the hospital course of children with respiratory syncytial virus (RSV) infection? An analysis using the pediatric investigators collaborative network on infections in Canada (PICNIC) RSV database. Pediatrics. Mar 1997;99(3):E7. [Medline].

  56. Leer JA Jr, Green JL, Heimlich EM, et al. Corticosteroid treatment in bronchiolitis. A controlled, collaborative study in 297 infants and children. Am J Dis Child. May 1969;117(5):495-503. [Medline].

  57. Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics. Jun 2004;113(6):1728-34. [Medline].

  58. Lugo RA, Nahata MC. Pathogenesis and treatment of bronchiolitis. Clin Pharm. Feb 1993;12(2):95-116. [Medline].

  59. Mallory MD, Shay DK, Garrett J, Bordley WC. Bronchiolitis management preferences and the influence of pulse oximetry and respiratory rate on the decision to admit. Pediatrics. Jan 2003;111(1):e45-51. [Medline].

  60. Meissner HC. Uncertainty in the management of viral lower respiratory tract disease. Pediatrics. Oct 2001;108(4):1000-3. [Medline].

  61. Njoku DB, Kliegman RM. Atypical extrapulmonary presentations of severe respiratory syncytial virus infection requiring intensive care. Clin Pediatr (Phila). Aug 1993;32(8):455-60. [Medline].

  62. Numa AH, Williams GD, Dakin CJ. The effect of nebulized epinephrine on respiratory mechanics and gas exchange in bronchiolitis. Am J Respir Crit Care Med. Jul 1 2001;164(1):86-91. [Medline].

  63. Panitch HB, Callahan CW Jr, Schidlow DV. Bronchiolitis in children. Clin Chest Med. Dec 1993;14(4):715-31. [Medline].

  64. Perlstein PH, Kotagal UR, Bolling C, et al. Evaluation of an evidence-based guideline for bronchiolitis. Pediatrics. Dec 1999;104(6):1334-41. [Medline].

  65. Perlstein PH, Kotagal UR, Schoettker PJ, et al. Sustaining the implementation of an evidence-based guideline for bronchiolitis. Arch Pediatr Adolesc Med. Oct 2000;154(10):1001-7. [Medline].

  66. Plint AC, Johnson DW, Wiebe N, et al. Practice variation among pediatric emergency departments in the treatment of bronchiolitis. Acad Emerg Med. Apr 2004;11(4):353-60. [Medline].

  67. Prendiville A, Green S, Silverman M. Ipratropium bromide and airways function in wheezy infants. Arch Dis Child. Apr 1987;62(4):397-400. [Medline].

  68. Purcell K, Fergie J. Concurrent serious bacterial infections in 2396 infants and children hospitalized with respiratory syncytial virus lower respiratory tract infections. Arch Pediatr Adolesc Med. Apr 2002;156(4):322-4. [Medline].

  69. Ryu JH, Myers JL, Swensen SJ. Bronchiolar disorders. Am J Respir Crit Care Med. Dec 1 2003;168(11):1277-92. [Medline].

  70. S Simila, O Linna, P Lanning, E Heikkinen and M Ala-Houhala. Chronic lung damage caused by adenovirus type 7: a ten-year follow-up study.Chest. 1981 Aug;80(2):127-31. Chest. Aug 1981;80(2):127-31.

  71. Sanchez I, De Koster J, Powell RE, Wolstein R, Chernick V. Effect of racemic epinephrine and salbutamol on clinical score and pulmonary mechanics in infants with bronchiolitis. J Pediatr. Jan 1993;122(1):145-51. [Medline].

  72. Schroeder AR, Marmor AK, Pantell RH, Newman TB. Impact of pulse oximetry and oxygen therapy on length of stay in bronchiolitis hospitalizations. Arch Pediatr Adolesc Med. Jun 2004;158(6):527-30. [Medline].

  73. Singh SP, Barrett EG, Kalra R, et al. Prenatal cigarette smoke decreases lung cAMP and increases airway hyperresponsiveness. Am J Respir Crit Care Med. Aug 1 2003;168(3):342-7. [Medline].

  74. Smith RA. Background and mechanism of action of ribavirin. In: Smith RA, Knight V, Smith JA. Clinical Applications of Ribavirin. Vol 1. Orlando, Fla: Academic Press; 1984:1-18.

  75. Swingler GH, Hussey GD, Zwarenstein M. Duration of illness in ambulatory children diagnosed with bronchiolitis. Arch Pediatr Adolesc Med. Oct 2000;154(10):997-1000. [Medline].

  76. Titus MO, Wright SW. Prevalence of serious bacterial infections in febrile infants with respiratory syncytial virus infection. Pediatrics. Aug 2003;112(2):282-4. [Medline].

  77. Todd J, Bertoch D, Dolan S. Use of a large national database for comparative evaluation of the effect of a bronchiolitis/viral pneumonia clinical care guideline on patient outcome and resource utilization. Arch Pediatr Adolesc Med. Nov 2002;156(11):1086-90. [Medline].

  78. van Woensel JB, van Aalderen WM, de Weerd W, et al. Dexamethasone for treatment of patients mechanically ventilated for lower respiratory tract infection caused by respiratory syncytial virus. Thorax. May 2003;58(5):383-7. [Medline].

  79. Wainwright C, Altamirano L, Cheney M, et al. A multicenter, randomized, double-blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med. Jul 3 2003;349(1):27-35. [Medline].

  80. Welliver RC, Wong DT, Sun M, Middleton E Jr, Vaughan RS, Ogra PL. The development of respiratory syncytial virus-specific IgE and the release of histamine in nasopharyngeal secretions after infection. N Engl J Med. Oct 8 1981;305(15):841-6. [Medline].

  81. Wennergren G, Kristjánsson S. Relationship between respiratory syncytial virus bronchiolitis and future obstructive airway diseases. Eur Respir J. Dec 2001;18(6):1044-58. [Medline].

  82. Williams BG, Gouws E, Boschi-Pinto C, Bryce J, Dye C. Estimates of world-wide distribution of child deaths from acute respiratory infections. Lancet Infect Dis. Jan 2002;2(1):25-32. [Medline].

  83. Wohl ME, Chernick V. Treatment of acute bronchiolitis. N Engl J Med. Jul 3 2003;349(1):82-3. [Medline].

 
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