The treatment of bronchiolitis in infants and young children

Abstract

Bronchiolitis is swelling and mucus buildup in the smallest air passages in the lungs (bronchioles) usually due to a viral infection (RSV, adenovirus, influenza, Parainfluenza). Bronchiolitis usually affects children under the age of 2, with a peak in the age of 3 - 6 months. It is a common, and sometimes severe illness. Risk factors for bronchiolitis include: exposure to cigarette smoke at an age younger than 6 months old, living in crowded conditions, not being breastfed, and prematurity. Sometimes, no treatment is necessary. The basic management of typical bronchiolitis is anchored in the provision of therapies that assures the patient is clinically stable, well oxygenated, and well hydrated. The main benefits of hospitalization of infants with acute bronchiolitis are the careful clinical monitoring, maintenance of a patent’s airway (through positioning, suctioning, and mucus clearance) and adequate hydration, and parental education. It is recommended to consider monitoring the cardiac and respiratory rate in hospitalized patients during the acute stage of bronchiolitis when the risk of apnea and/or bradycardia is greatest: premature infants, infants with underlying chronic conditions predisposing to apnea, infants with a witnessed episode of apnea, and infants less than three months of age who contract RSV. It is recommended to administer supplemental oxygen when the saturation is less than 91% and consider weaning oxygen when the saturation is higher than 94%. Systemic corticosteroids and inhaled bronchodilators are widely used by clinicians caring for infants with bronchiolitis. Clinical practice guidelines have recommended against their routine use, although there may be some instances where they will be useful: in older patients (> 12 months) with asthma risk factors (parental history of asthma, in utero exposure to parental smoking, and repeated wheezing before age 1) and any history of wheezing. It is recommended that a single trial inhalation using epinephrine or albuterol is to be considered on an individual basis. Nebulized racemic epinephrine demonstrates better shortterm improvement in pulmonary physiology. Combined treatment of systemic glucocorticoids (dexamethasone) and bronchodilators (epinephrine) may significantly reduce hospital admissions. It is recommended the infant be suctioned, when clinically indicated before feedings, as needed, prior to each inhalation therapy and normal saline nose drops may be used prior to suctioning. Current guidelines do not recommend routine chest physiotherapy in the management of bronchiolitis. Infants with this severe disease may need supportive care for respiratory failure and dehydration, such as mechanical ventilation and supplemental fluid therapy. Treatment for severe bronchiolitis may include: humidified oxygen therapy, chest physical therapy, bronchodilator medications: Ventolin, Salbutamol, Epinephrine (Adrenalin), anti-viral medication from bronchiolitis: ribavirin, palivizumab, antibiotics for associated otitis media, suspected bacterial pneumonia, and mechanical ventilation. It is recommended that the family be educated on the following topics regarding the care of a child with bronchiolitis: to call their primary care provider if the following signs of worsening clinical status are observed: increasing respiratory rate and/or work of breathing as indicated by use of the accessory muscle, inability to maintain adequate hydration, or worsening general appearance. Therapies NOT Routinely Recommended: It is recommended that scheduled or serial inhalation therapies not be used routinely nor repeated if there is no measured improvement in the clinical outcome after a trial inhalation. Hypertonic saline inhalations are not to be given for the routine treatment of bronchiolitis due to inconsistent evidence regarding its effectiveness. It is recommended at this time that the following drugs not be used in the treatment of bronchiolitis: antibodies (immunoglobulins), Montelukast, Recombinant human deoxyribonuclease (rhDNase), antihistamines, oral decongestants, and nasal vasoconstrictors. Antibiotics are not recommended unless bacterial infection is suggested (e.g., toxic appearance, hyperpyrexia, consolidation or focal lobar infiltrates on chest radiograph, leukocytosis, positive bacterial cultures).