Bronchiolitis Medication

Updated: Mar 25, 2018
  • Author: Nizar F Maraqa, MD, FAAP; Chief Editor: Russell W Steele, MD  more...
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Medication

Medication Summary

Although numerous medications have been used to treat bronchiolitis (eg, oxygen, bronchodilators, immunoglobulins, antibiotics, antivirals, nasal decongestants, and corticosteroids), only oxygen has demonstrably improved the condition of young children with bronchiolitis.

Oxygen decreases the work of breathing, thus delaying the onset of respiratory muscle fatigue and allowing other therapies to work.

Humidified oxygen is administered via nasal cannula, mask, head box, or tent to maintain transcutaneous oxygen saturations above 92%. A nasal cannula is preferred because it is effective and minimally intrusive and allows full access to the child.

Heliox has been used in patients with acute asthma. It may be a beneficial addition to conventional therapy in critically ill children with respiratory syncytial virus (RSV) bronchiolitis. However, further clinical studies are required to assess its efficacy of this therapy. Heliox may be useful in intubated patients whose condition is not responding to conventional treatment.

Medical therapies used to treat bronchiolitis in pediatric patients are controversial. Healthy children with bronchiolitis usually have limited disease. These patients usually do well with supportive care only.

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Alpha/Beta Agonists

Class Summary

Bronchodilators are among the most common therapies for bronchiolitis; studies have reported that their use ranges from approximately 50% of cases to more than 90%. They act by decreasing muscle tone in both small and large airways in the lungs, thus increasing ventilation. Most controlled studies have failed to show a benefit in terms of oxygen saturation, rate of hospitalization, or length of hospital stay, but some studies have demonstrated an improvement in short-term surrogate measures.

Epinephrine racemic (Adrenalin, Twinject, EpiPen 2-Pak)

Epinephrine stimulates alpha-adrenergic, beta1-adrenergic, and beta2-adrenergic receptors, resulting in bronchodilatation, increased peripheral vascular resistance, hypertension, increased chronotropic cardiac activity, and positive inotropic effects.

Nebulized epinephrine (0.1 mL/kg) is more efficacious than albuterol in infants with acute bronchiolitis. Randomized controlled trials comparing nebulized racemic epinephrine with placebo found more improvement in the epinephrine-treated group in oxygenation and clinical signs, presumably because of reduction in airway and perhaps nasal mucosal edema. Morbidity and length of stay did not improve.

Albuterol (Proventil, Ventolin)

Albuterol is a beta agonist used to treat bronchospasm refractory to epinephrine. It simulates adenyl cyclase to convert adenosine triphosphate (ATP) to cyclic adenosine monophosphate (cAMP) and causes bronchodilation. Albuterol relaxes bronchial smooth muscle by acting on beta2 receptors but has little effect on cardiac muscle contractility. It may inhibit airway microvascular leakage.

The frequency may be increased. Institute a regular schedule in patients receiving anticholinergic drugs who remain symptomatic. Albuterol is available as a liquid for nebulizers, metered-dose inhalers (MDIs), and dry-powder inhalers.

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Monoclonal Antibodies

Class Summary

Specific immunoglobulin products with anti-RSV activity have been developed for prophylaxis of high-risk patients against RSV infection.

Palivizumab (Synagis)

Palivizumab is a humanized monoclonal antibody directed against the F (fusion) protein of RSV. Given monthly through the RSV season, it has been demonstrated to decrease chances of RSV hospitalization in premature babies who are at increased risk for severe RSV-related illness.

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Antibiotics, Other

Class Summary

Viruses are the primary etiologic agents in bronchiolitis; therefore, routine administration of antibiotics has not been shown to influence the course of this disease. Although rapid diagnostic techniques are available to identify RSV as a causative agent in bronchiolitis, they are not readily available for other viruses. In small, acutely ill infants, clinically excluding the existence of secondary bacterial invasion may be difficult. Administration of broad-spectrum antibiotics in critically ill infants is often justified until culture results prove to be negative.

Ampicillin

Ampicillin has bactericidal activity against susceptible organisms. It is an alternative to amoxicillin when the patient is unable to take medication orally

Ceftriaxone (Rocephin)

Ceftriaxone is a safe and effective third-generation cephalosporin used for initial antimicrobial coverage of critically ill infants until culture results are known. It covers a wide range of gram-positive and gram-negative organisms but is not a first-line drug for Staphylococcus or Pseudomonas. It does not cover Listeria, an important pathogen in infants younger than 6 weeks; for this age group, add ampicillin.

Cefotaxime (Claforan)

Cefotaxime is a safe and effective third-generation cephalosporin used for initial antimicrobial coverage of critically ill infants until culture results are known. It covers a wide range of gram-positive and gram-negative organisms but is not a first-line drug for Staphylococcus or Pseudomonas. It does not cover Listeria, an important pathogen in infants younger than 6 weeks; for this age group, add ampicillin.

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Antiviral, Other

Class Summary

Ribavirin is licensed by the US Food and Drug Administration (FDA) for the management of RSV bronchiolitis and pneumonia. It has a broad spectrum of antiviral activity in vitro, inhibiting replication of RSV as well as influenza, parainfluenza, adenovirus, measles, Lassa fever, and Hantaan viruses. In adults, ribavirin can be used for the treatment of other infections, including hepatitis C.

Ribavirin (Virazole)

Ribavirin (1-beta-D-ribofuranosyl-1,2,4-triazole-3-carboxamide) is a synthetic nucleoside analogue that resembles guanosine and inosine. It is believed to act by interfering with expression of messenger RNA and inhibiting viral protein synthesis. Ribavirin appears safe but is expensive. Its efficiency and effectiveness have not been clearly demonstrated in large, randomized, placebo-controlled trials. At present, routine use of ribavirin cannot be recommended.

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Decongestant, Intranasal

Class Summary

No controlled studies on the use of nasal decongestants in bronchiolitis have been performed. Aerosolized racemic epinephrine may be primarily beneficial as a nasal decongestant.

Oxymetazoline (Afrin, 12 Hour Nasal Relief)

Oxymetazoline is applied directly to mucous membranes, where it stimulates alpha-adrenergic receptors and causes vasoconstriction. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation.

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Corticosteroids

Class Summary

Clinical trials demonstrate that corticosteroids have no benefit in the treatment of bronchiolitis and thus should not be used routinely. However, one study (with a treatment group of 8 patients) showed some clinical improvement with dexamethasone plus albuterol. A subsequent double-blind, placebo-controlled trial of the same agents revealed no difference from placebo. Nebulized steroid treatment has not been proven efficacious. Steroid treatment has not been shown to decrease the long-term incidence of wheezing or asthma after RSV infection.

Prednisone

Prednisone blocks release of inflammatory mediators by inhibiting phospholipase A2. It may be useful in patients who have either asthma or bronchiolitis with asthmatic qualities.

Methylprednisolone (Medrol, Solu-Medrol, A-Methapred)

Methylprednisolone blocks release of inflammatory mediators by inhibiting phospholipase A2. It may be useful in patients who have either asthma or bronchiolitis with asthmatic qualities.

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