Bronchiolitis is a diagnosis frequently made in the setting of the emergency department and a major cause of illness in infants and children less then 2 years of age. It is most commonly a result of viral infection, typically respiratory syncytial virus (RSV) and is more common in winter months.  It is characterized by upper airway symptoms including rhinorrhea, congestion, or fevers, followed by lower respiratory infection and inflammation, with resultant wheezing or rales.

Severity assessment

Bronchiolitis is designated as severe based on the presence of any of the following conditions:

1. Persistently increased respiratory effort on serial examinations separated by at least 15 min. This can include tachypnea, nasal flaring, grunting, intercostal, subcostal, or suprasternal retractions or accessory muscle use
2. Hypoxemia of O2 saturation <95%
3. Apnea
4. Respiratory failure

Absence of any of these signs/symptoms is generally considered non-severe bronchiolitis.  Risk factors for developing severe disease include age less than 12 weeks, a history of prematurity, underlying cardiopulmonary disease, or immunodeficiency.

Treatment of Non-severe Bronchiolitis

The main mode of treatment of non-severe bronchiolitis is supportive care. The majority of patients in this category can be managed in an outpatient setting.  Supportive care includes maintaining adequate hydration, relief of nasal congestion or obstruction, and monitoring for worsening symptoms or signs of disease progression. If infants are immune competent, pharmacologic intervention is not recommended.  Clinicians should not administer albuterol (or salbutamol) to infants and children with a diagnosis of bronchiolitis. Epinephrine, nebulized hypertonic saline, or systemic or inhaled corticosteroids should not be administered as well. These have shown no proven benefit and have their own risk of adverse effect and increase cost of care needlessly.  

Treatment of Severe Bronchiolitis

Treatment in severe bronchiolitis is similar to that of non-severe bronchiolitis but frequently requires treatment in the emergency department or inpatient setting.  Mainstay of treatment is still supportive care. Emergency department care involves respiratory status stabilization and ensuring appropriate hydration. Uptodate does not routinely recommend the use of inhaled bronchodilators, nebulized hypertonic saline, or corticosteroids. However, children with severe disease or respiratory failure generally were excluded from trials evaluating inhaled bronchodilators in children with bronchiolitis, and a one time trial may be warranted per Uptodate. According to the AAFP, they also do not recommend use of bronchodilators (albuterol, salbutamol), epinephrine, or corticosteroids. More intensive ventilatory support such as high-flow nasal cannula or intubation and mechanical ventilation may be required.

Authors:
Kara Finegan, DO
Peer reviewed and edited by Michael Witt, MD