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Pediatrics, Bronchiolitis: Treatment & Medication
Updated: Jun 23, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Prehospital care consists of cardiorespiratory monitoring, positioning to facilitate respiratory efforts (ie, upright posture), administration of oxygen, and possibly a trial of bronchodilators.
Emergency Department Care
- General supportive measures are the mainstay of treatment for patients with bronchiolitis.
- Patients should be made as comfortable as possible (held in a parent's arms or sitting in the position of comfort).
- Cardiorespiratory monitoring is essential.
- Pulse oximetry is a helpful tool, as hypoxia is common.
- Humidified oxygen should be administered if the oxygen saturation is less than 94% on room air.
- The ability to maintain adequate hydration should be assessed by observing patient oral intake. Many dyspneic infants have difficulty taking a bottle.
- Fever and tachypnea increase insensible fluid losses.
- Early effort should be made to isolate or cohort patients confirmed or likely to have RSV infection, especially from other patients at risk for severe disease.
- Antibiotics are not indicated unless bacterial infection is suggested (eg, toxic appearance, hyperpyrexia, consolidation or focal lobar infiltrates on chest radiograph, leukocytosis, positive bacterial cultures).1
- Concomitant otitis media is common and may be treated with oral antibiotics.
Consultations
Early consultation with a pediatrician is advisable when the need for admission is anticipated. Intensive care consultation should be sought for patients who are severely ill.
Medication
Adrenergic agents
The use of bronchodilators is controversial. These agents relieve reversible bronchospasm by relaxing smooth muscles of the bronchi. Meta-analyses of clinical studies show little or no benefit from treatment with inhaled beta-adrenergic agents (with or without ipratropium bromide). These are plagued by the heterogeneous methods of the studies included. Empiric treatment with beta-agonists seems to be the standard of care. Such treatment is most reasonable in the child with documented improvement after initial treatment with bronchodilators. Drugs and dosages are the same as those for asthma. Nebulized epinephrine may occasionally be useful.
Albuterol (Proventil, Ventolin, Salbutamol)
Beta-agonist for bronchospasm refractory to epinephrine. Relaxes bronchial smooth muscle by action on beta2-receptors with little effect on cardiac muscle contractility. May inhibit airway microvascular leakage. Administered by nebulizer or metered dose inhaler (MDI).
Adult
Nebulizer: 5 mg/mL; 5 mg q15-20min for 3 doses, or continuous nebulization
MDI: 90 mcg/actuation; 4-8 inhalations q20min up to 4 h, then 2-4 inhalations q1-4h; use with a spacer device
Pediatric
Nebulizer: (5 mg/mL) 0.15 mg/kg (2.5-5 mg) q15-20min for 3 doses, then 0.15-0.3 mg/kg q1-4h prn or 0.5 mg/kg/h continuous nebulization
MDI: 90 mcg/actuation; 4-8 inhalations q20min up to 4 h, then q1-4h prn; use with a spacer device
Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation by albuterol; cardiovascular effects may increase with MAOIs, inhaled anesthetics, TCAs, and sympathomimetic agents
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, diabetes mellitus, and cardiovascular disorders; decreased serum potassium may occur
Epinephrine (Adrenalin) or racemic epinephrine (microNefrin)
No proven advantage over inhaled beta2-agonists exists.
Adult
Epinephrine: 0.3-0.5 mg/kg (ie, 0.3-0.5 mL of 1:1000 [1 mg/mL]) solution SC q20min up to 3 doses
Pediatric
Epinephrine: 0.01 mL (ie, 0.01 mL/kg of 1:1000 solution [1 mg/mL]) SC q15-20min, not to exceed 0.3 mL/dose
Racemic epinephrine:
<2 years: 0.25 mL of 2.25% solution via nebulizer diluted in 3 mL NS
>2 years: 0.5 mL of 2.25% solution via nebulizer diluted in 3 mL NS
Increases toxicity of beta-blocking and alpha-blocking agents and that of halogenated inhalational anesthetics
Documented hypersensitivity; cardiac arrhythmias or angle-closure glaucoma; local anesthesia in areas such as fingers or toes because vasoconstriction may produce sloughing of tissue; not to use during labor (may delay second stage of labor)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in elderly patients, prostatic hypertrophy, hypertension, cardiovascular disease, diabetes mellitus, hyperthyroidism, and cerebrovascular insufficiency; rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac arrhythmias
Corticosteroids
Clinical trials demonstrate that corticosteroids have no benefit in the treatment of bronchiolitis, and thus they should not be used routinely. However, one study (with a treatment group of 8 patients) showed some clinical improvement with the combination of dexamethasone and salbutamol. A larger and more recent double-blind, placebo-controlled trial of the same agents revealed no difference from placebo.
Plint et al found the combined used of dexamethasone and epinephrine for infants with bronchiolitis treated in the emergency department may significantly reduce hospital admissions. In this multicenter, double-blind trial, 800 infants with bronchiolitis were assigned to 1 of 4 treatment groups (nebulized epinephrine and oral dexamethasone, nebulized epinephrine and oral placebo, nebulized placebo and oral dexamethasone, or nebulized placebo and oral placebo). Only infants in the epinephrine and dexamethasone group were significantly less likely to be admitted to the hospital within 7 days of treatment compared with placebo (unadjusted analysis P=0.02; adjustment for multiple comparisons was insignificant P=0.07).3
Nebulized steroid treatment has not been proven efficacious.
A subsequent study of prednisolone treatment of inpatients appeared to show a small benefit in a subgroup of 14 intubated patients. Corticosteroids may be useful in patients with history of reactive airway disease.
Steroid treatment has not been shown to decrease the long-term incidence of wheezing or asthma after RSV infection.
Prednisone (Deltasone)
Blocks release of inflammatory mediators by inhibition of phospholipase A2. May be useful in patients with asthma or in bronchiolitis with asthmatic qualities.
Adult
60 mg PO initial, then 40-60 mg qd for 5-10 d; taper for longer period
Pediatric
2 mg/kg PO initially, then 1 mg/kg/d qd or divided bid; not to exceed 60 mg/d for 3-10 d; taper for longer periods
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; fungal, viral, connective tissue, or tubercular skin infections; peptic ulcer disease; hepatic dysfunction; GI disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Methylprednisolone (Medrol, Solu-Medrol)
Blocks release of inflammatory mediators by inhibition of phospholipase A2. May be useful in patients with asthma or in bronchiolitis with asthmatic qualities.
Adult
60-80 mg IV
Pediatric
2 mg/kg PO initial, then 1 mg/kg/d qd/bid; not to exceed 60 mg/d for 3-10 d; taper for longer periods; 0.5-2 mg/kg IV q6h
Coadministration with digoxin, may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use
Nucleoside analog
These agents inhibit viral replication by inhibiting DNA and RNA synthesis.
Ribavirin (Virazole)
May be used for inpatients who have, or who are at high risk for, severe RSV infection. In early trials, 3-7 d of ribavirin therapy produced significant reduction in mortality, length of hospitalization, and duration of mechanical ventilation. However, recent studies demonstrate no clinical benefit. Furthermore, this therapy is very expensive. Use of aerosolized ribavirin in mechanically ventilated patients requires administration by physicians and support staff familiar with this mode of administration and the specific ventilator.
Adult
Pediatric
20 mg/mL initial solution, with continuous aerosol administration of 12-18 h/d for 3-7 d
Zidovudine effects are decreased when administered concurrently with ribavirin
Documented hypersensitivity
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Monitor closely patients with COPD and asthma for deterioration of respiratory function; sudden deterioration of respiratory function associated with aerosolized ribavirin in infants
More on Pediatrics, Bronchiolitis |
| Overview: Pediatrics, Bronchiolitis |
| Differential Diagnoses & Workup: Pediatrics, Bronchiolitis |
 Treatment & Medication: Pediatrics, Bronchiolitis |
| Follow-up: Pediatrics, Bronchiolitis |
| References |
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References
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Further Reading
Keywords
upper respiratory tract infection, URI, respiratory syncytial virus, RSV, rhinorrhea, tachypnea, bronchiolitis, asthma, lower respiratory tract infection, infection of the small airways, viral infection of the small airways, bronchioles, adenovirus, parainfluenza virus, Mycoplasma pneumoniae, M pneumoniae, rhinovirus, enterovirus, influenza virus, Chlamydia pneumoniae, C pneumoniae, infection of bronchiolar respiratory cells, infection of ciliated epithelial cells, peribronchiolar lymphocytic infiltrate
