Pediatric Bronchiolitis Treatment & Management

  • Author: Lucian Kenneth DeNicola, MS, MD, FAAP, FCCM; Chief Editor: Russell W Steele, MD   more...
 
Updated: Mar 26, 2012
 

Medical Care

Despite the prominent role that inflammation plays in the pathogenesis of airway obstruction, corticosteroids have not proven beneficial in improving the clinical status of patients with bronchiolitis in a large, controlled multi-institutional study.[89] Beta-agonists and ipratropium bromide, an aerosolized anticholinergic agent, have not shown effectiveness in the management of infants with respiratory syncytial virus (RSV) and wheezing.[90, 91, 92, 93, 94]

Although numerous medications and interventions have been used to treat bronchiolitis, at present, only oxygen appreciably improves the condition of young children with bronchiolitis.[95] Medical therapies used to treat bronchiolitis in infants and young children are controversial. Efficacy in infants is difficult to determine because it can be a function of the pharmacologic agent, the route of administration, the clinical status of the patient, or the adequacy of the outcome measure used to demonstrate an effect. Recombinant human DNAse also had no clinical effects in infants who were not receiving ventilation.[96] Newer immunotherapies are being introduced to both treat the acute disease and prevent sequelae.[97, 98, 99, 100]

Bronchodilators

A meta-analysis reviewed 15 randomized placebo-controlled trials of inhaled albuterol treatment in bronchiolitis.[90] It concluded that albuterol produces only modest short-term improvement in clinical features of mild or moderately severe bronchiolitis, primarily through making the child more alert.

A meta-analysis of 9 clinical trials noted that conclusive analysis for the efficacy of beta2-agonist therapy for bronchiolitis remains unavailable, and that the routine use of beta2-agonist therapy for bronchiolitis is not supported.[91] A 2000 Cochrane review of the use of bronchodilators for bronchiolitis further confirmed the lack of direct evidence of a sustained benefit.[101] A 2010 Cochrane review found that bronchodilators do not improve oxygen saturation, shorten hospital stay, decrease the need for hospitalization, or reduce the length of illness at home.[102]

One study compared nebulized albuterol with normal saline in an age-matched and severity-matched trial of 52 infants over 72 hours of treatment.[92] Nebulized albuterol did not improve recovery or attenuate severity, as indicated by improvement in oxygen saturation, length of stay, or clinical score. Two randomized studies using albuterol, ipratropium, and both medications combined versus normal saline found no improvement with medications.[93, 103] In a prospective nonrandomized study, inhaled albuterol failed to significantly improve the respiratory status of infants with RSV-induced respiratory failure whether they had an obstructive or restrictive pulmonary dysfunction.[104]

Only a single, nonrandomized study of 25 ventilated young infants (13 of whom were premature and/or had preexisting cardiopulmonary disease) with RSV bronchiolitis demonstrated a statistically significant increase in maximum volume functional residual capacity (Vmax FRC) with aerosolized albuterol; however, in 3 of these infants, respiratory function worsened.[105]

Although initial evidence suggested that nebulized racemic epinephrine reduced symptoms and length of hospital stay,[106, 107, 108] subsequent studies have not supported the use of epinephrine.[109, 110, 111] A randomized, double-blind, placebo-controlled study of 62 somewhat older children (aged, 6 wk to 2 y; mean age, 6.4 mo) compared aerosolized racemic epinephrine with salbutamol. Racemic epinephrine resulted in significant improvement in wheezing and respiratory distress score on day 2 but did not shorten hospitalization or total duration of illness.[112] However, in a randomized placebo-controlled trial of albuterol and epinephrine in equipotent doses, neither drug reduced the need for oxygen nor reduced length of stay.[113] Additionally, neither drug reduced the quantity of oxygen required nor reduced clinical respiratory scores.[113, 114]

In an editorial, Wohl and Chernick, both highly respected experts on bronchiolitis, speculated that inhaled epinephrine may relieve symptoms by acting as a nasal decongestant, and similar nose drops may help to relieve symptoms.[115] A follow-up letter to the editor asks for a controlled study to end the speculation.

In a systematic review and metaanalysis of steroids and bronchodilators for acute bronchiolitis in the first 2 years of life, Harling and colleagues found the majority (83%) of 48 studies to have either high or unclear bias.[116] The evidence only shows effectiveness and superiority of adrenaline for most clinically relevant outcomes among outpatients with acute bronchiolitis. This is largely based on a multicenter, double-blind, placebo-controlled trial that randomized 800 infants (6 weeks to 12 months of age) to 4 treatment arms (nebulized epinephrine and oral dexamethasone, nebulized epinephrine and oral placebo, nebulized placebo and oral dexamethasone, and nebulized placebo and oral placebo).[117] In this large trial, the combination of nebulized epinephrine and oral dexamethasone may reduce risk of admission within 7 days of emergency room visit.

In a double-blind study, Livni et al found no significant differences between inhaled epinephrine and nasal decongestant in hospitalized infants with acute bronchiolitis regarding length of hospitalization, need for oxygen supplementation, or intravenous fluids and clinical score. They concluded that nasal decongestant is as effective as inhaled epinephrine in acute bronchiolitis.[118] Multiple authors have recommended instillation of saline nose drops prior to feeding. Instillation of the lowest concentration of nasal decongestant drops 2-3 times a day for no more than 3 days in hospitalized infants could be evaluated for its benefits.

Because using bronchodilators in bronchiolitis lacks efficacy, administering a beta-agonist on a trial basis to older patients with bronchiolitis and a personal or family history of asthma and assessing the clinical response in 10-15 minutes is reasonable. If improvement in retractions, respiratory rate, and wheezing is noted, scheduled aerosol treatments may be continued, with additional treatments administered as needed. If little or no sustained response is noted, cease bronchodilator therapy because it contributes to agitation and ventilation-perfusion ratio mismatching.

Anti-inflammatory agents

The belief that corticosteroids can prevent or reduce the major pathology of inflammation and edema of the bronchiolar mucosa is tempting. Various studies have failed to conclusively define a beneficial role for routine use of glucocorticoids in the treatment of infants with bronchiolitis.[89, 119, 120, 121, 122, 123, 124, 125] Additionally, a Cochrane Review that included 13 trials of 1198 children aged 0-30 months failed to demonstrate improvement in length of stay, clinical score, hospital admission rates, or readmission rates for either systemic or inhaled corticosteroids administered in hospital or in the emergency department.[126] Despite these findings Weinberger refers to several small studies that suggest that high-dose systemic steroids early in the course of bronchiolitis may be effective in preventing the progression of inflammation or, at least, in modifying the course.[127]

Similarly, the mast cell inhibitor cromoglycate had no beneficial effects.[128] One study suggested that montelukast, a Cys-LT receptor antagonist, may reduce postbronchiolitis reactive airway disease, but this intervention cannot be recommended at this time.[129]

Chest physiotherapy

Medical therapy seems to be disappointing for bronchiolitis, but chest physiotherapy cannot be recommended either. Three clinical trials of unventilated hospitalized infants compared vibration and percussion techniques in postural drainage positions with no intervention.[130] No differences were reported in length of hospital stay, oxygen requirements, or improvement in the severity of clinical score in infants with bronchiolitis.

A 2012 Cochrane review, which included 9 studies of children under 2 years of age with acute bronchiolitis, confirmed that chest physiotherapy does not improve the severity of the disease, improve respiratory parameters, reduce the length of hospital stay, or reduce oxygen requirements in nonventilated hospitalized patients. Chest physiotherapy modalities (vibration and percussion or forced expiratory techniques) have shown equally negative results.[131]

Given the lack of evidence-based support for medicinal interventions for the treatment of bronchiolitis, admission rates and the treatment of bronchiolitis widely varies, particularly in emergency departments.[132, 133] In a Canadian study, children evaluated in general emergency departments were admitted twice as often as those observed in pediatric emergency departments, controlling for age, gender, estimated family income, medical comorbidity, and clinical severity.[134]

A survey of members of the Emergency Medicine section of the American Academy of Pediatrics (AAP) found that 96% recommended bronchodilators and 8% recommended steroids.[135] Twice as many pediatric emergency physicians would admit a child with an oxygen saturation of 92% versus 94%, as measured with pulse oximetry (SpO2), although a respiratory rate of 50 breaths per minute versus 65 breaths per minute made little difference in admission rate. A study of 30 large children's hospitals in the United States found that 45% of patients received steroids and 25% received systemic antibiotics. Factors that contributed to longer stays included use of antibiotics, steroids, and bronchodilators. Undergoing chest radiography was a significant predictor of antibiotic administration.[136]

These differences from recommendations and between practices have led to a call for national guidelines for the treatment of bronchiolitis. In 2006, the AAP, in conjunction with the American Academy of Family Physicians, the American College of Chest Physicians, and the American Thoracic Society, published recommendations.[135] These recommendations were as follows:

  • Diagnosis and severity should be based on history and physical findings and not on laboratory and radiologic findings. Risk factors should be assessed when making decisions about evaluation and management.
  • Bronchodilators should not be routinely used. If a trial of an alpha-adrenergic or beta-adrenergic medication is an option, they should be continued only if a positive (and continued) response is documented.
  • Corticosteroids should not routinely be used.
  • Ribavirin should not be used.
  • Antibacterials should be used only upon proven coexistence of bacterial infection.
  • Assess hydration and the ability to take oral fluids.
  • Supplemental oxygen should be supplied for SpO2 less than 90%; saturation measurement is otherwise unnecessary.
  • Palivizumab prophylaxis should be administered to selective children.
  • Hand decontamination prevents nosocomial spread.
  • Infants should not be exposed to secondary smoking, and breastfeeding is recommended.
  • Clinicians should inquire about use of complementary and alternative medicine (CAM) therapies.

Researchers at Cincinnati Children's Hospital found that bronchiolitis admissions were increasing so that patients could receive bronchodilator therapy. In 1997, the hospital instituted evidence-based point-of-care algorithms and rules based on guideline recommendations on the overuse of therapies for bronchiolitis and reviewed them in 2001, 2005, and 2006. Their guidelines discouraged etiologic testing because the treatment is directed at the syndrome rather than the etiologic cause, reduced the use of chest radiography (because opacities [atelectasis] are unlikely to change for 7-9 d and are not influenced by antibiotics or chest physiotherapy), and discouraged the use of steroids and bronchodilators unless clear and sustained improvement was noted 20 minutes after aerosol administration.[137]

After introduction of the guidelines, decreases were seen in admissions (29%), length of stay (17%), nasopharyngeal washings for RSV antigen (52%), chest radiography(20%), all respiratory therapies (30%), beta-agonist administrations (51%), cost of all services (37%), and cost of respiratory therapy services (77%).[138] Research shows these changes continued in the 3-year and 4-year follow-up investigations.[139]

Hospital care

Indications for hospital admission include the following:[6, 8, 140]

  • Persistent resting SpO2 below 92% in room air prior to beta-agonist trial (Increased reliance on pulse oximetry has contributed to an increase in hospitalizations for bronchiolitis over the past 2 decades.)[141]
  • Inability to maintain oral hydration in patients younger than 6 months
  • Markedly elevated respiratory rate (>70 breaths per min)
  • History of chronic cardiorespiratory disease including significant asthma
  • Dyspnea and intercostal retractions, indicating respiratory distress
  • Desaturation in 40% oxygen (3-4 L/min oxygen), cyanosis
  • Extrapulmonary symptoms
  • Parent unable to care for child at home
  • Apnea and acidosis are indicators for pediatric ICU (PICU) referral.

Administer supplemental humidified oxygen to maintain transcutaneous saturation above 92%. Unger and Cunningham found that oxygen supplementation is the prime determinant of length of hospitalization.[142]

Infants with bronchiolitis are mildly dehydrated because of decreased fluid intake and increased fluid losses from fever and tachypnea. The goal of fluid therapy is to replace deficits and to provide maintenance requirements. Avoid excessive fluid administration because this may promote interstitial edema formation, particularly if a component of inappropriate antidiuretic hormone release is present.[143] Oral therapy is preferred.

Administer saline nose drops and perform nasal and oral suctioning. Carefully monitor the patient for apnea. Pay attention to temperature regulation in small infants.[144] Nebulized hypertonic saline have been used for treating hospitalized, as well as ambulatory, children with viral bronchiolitis with variable success.[145, 146] In a prospective, double-blinded, multicenter trial, the use of nebulized 3% hypertonic saline was a safe, inexpensive, and effective treatment for moderately ill, hospitalized infants with viral bronchiolitis.[147]

Al-Ansari et al reported results from a randomized, double-blind trial of 187 infants younger than 18 months with acute bronchiolitis.[148] Nebulization with 5% hypertonic saline was found to be safe and superior to 0.9% saline, and possibly superior to 3% hypertonic saline, for ambulatory, early treatment of bronchiolitis. A multicenter trial with a larger sample size may help in determining the clinical benefits of this therapy.

Infants with bronchiolitis and recurrent apnea or increased work of breathing with respiratory failure occasionally require mechanical ventilation. Treat these patients supportively, providing adequate oxygen, ventilation, and hydration. Continuous positive airway pressure (CPAP) and intermittent mandatory ventilation (IMV) with positive end-expiratory pressure (PEEP) have been successfully used to treat these infants.[149, 150, 151, 152] Negative pressure ventilation has been used successfully, with reduced need for endotracheal intubation and shortened lengths of stay. The typical approach in patients who require ventilation using IMV and PEEP is to ventilate at rates slow enough to allow adequate emptying during exhalation.

In addition, a short inspiratory time optimizes ventilation to more compliant lung units without over distending more obstructed ones. Aggressive weaning over the first 2-3 days is not warranted and is usually unsuccessful. Once the illness subsides, weaning can proceed quickly. Infants with progressive hypoxemia unresponsive to conventional ventilation may respond to high-frequency ventilation or extracorporeal membrane oxygenation.[90, 153]

Several studies have looked into use of surfactant and nitric oxide in cases of severe respiratory distress; however, the results were inconclusive to support routine use in bronchiolitis.[154, 155, 156] Heliox is a mixture of oxygen (20-30%) and helium (70-80%) that has lower viscosity than air. It has been used successfully in cases of airway obstruction, croup, airway surgery, and asthma to reduce respiratory effort during the period of airway compromise. Several studies have shown improved respiratory distress scores in patients on heliox breathing and may obviate the need for intubation when heliox is combined with nasal continuous positive airway pressure.[157, 158, 159, 160, 161, 162, 163] A meta-analysis of several small studies suggests that surfactant therapy may shorten the duration of ICU stay in children ventilated for bronchiolitis.

Tie et al found that in selected children with acute bronchiolitis, home oxygen therapy may be a feasible alternative to traditional hospital oxygen therapy.[164] In a prospective pilot study, 44 children aged 3-24 months old who still required oxygen supplementation 24 hours after admission to the hospital were randomly assigned to receive oxygen supplementation at home with support from "hospital in the home" or to continue oxygen supplementation in the hospital. Children in the home oxygen group spent almost 2 days less in a hospital bed than those managed as traditional inpatients (p = 0.001). No difference in clinical outcome was noted between the groups.

Discharge criteria widely varies from one institution to another, as reported by Weiss and Annamalai.[165] Discharge criteria primarily rests with (1) the ability of the caretaker to manage the infant's nasal congestion, (2) improvement in respiratory distress as evidenced by respiratory rate less than 60-70 breaths per minute and resting oxygen saturation above 92% without supplemental oxygen, (3) adequate oral intake, and (4) education and confidence of the caretaker.[165, 166]

Next

Consultations

When a healthy infant presents with a history, physical examination findings, and course consistent with uncomplicated bronchiolitis, no consultations are necessary; however, refer infants with comorbidities, atypical histories, or critical conditions to a pediatrician, preferably at a center that can provide a spectrum of pediatric subspecialists in critical care, pulmonology, and infectious disease.

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Diet

Although young infants have the unique ability to breathe and swallow simultaneously, risk of aspiration is significant when the respiratory rate is above 60 breaths per minute. Fever and hyperpnea may contribute to excessive fluid losses. For these reasons, infants who are hospitalized with bronchiolitis require careful fluid monitoring and provision of nasogastric or intravenous fluids when hyperpnea precludes safe oral feeding.

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Contributor Information and Disclosures
Author

Lucian Kenneth DeNicola, MS, MD, FAAP, FCCM  Professor, Department of Pediatrics, University of Florida Health Science Center at Jacksonville

Lucian Kenneth DeNicola, MS, MD, FAAP, FCCM is a member of the following medical societies: American Academy of Pediatrics, American College of Critical Care Medicine, Florida Medical Association, Florida Pediatric Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Nizar F Maraqa, MD  Assistant Professor of Pediatrics, Pediatric Infectious Diseases, University of Florida College of Medicine at Jacksonville

Nizar F Maraqa, MD, is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Haidee T Custodio, MD  Assistant Professor, Department of Pediatrics, Division of Pediatric Infectious Diseases, University of South Alabama College of Medicine

Haidee T Custodio, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

David Jaimovich, MD  Chief Medical Officer, Joint Commission International and Joint Commission Resources

David Jaimovich, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Mark R Schleiss, MD  American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

The authors gratefully acknowledge Michael Gayle, MBBS, FRCPC, FAAP, FCCM, for his participation in the original production of this review in 2001.

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A chest radiography revealing lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions in a 16-day-old infant with severe bronchiolitis.
 
 
 
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