Bronchiolitis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2]

The primary mode of treatment for bronchiolitis is supportive management. Supportive therapy includes frequent, small feeding and oxygen therapy. In severe cases, infants may require intravenous fluids and food via a nasogastric tube. In severe cases, mechanical ventilation or the use of continuous positive airway pressure (CPAP) might be necessary. Prophylaxis is indicated in infants with hemodynamically significant heart disease and preterm infants who require >21% oxygen for at least the first 28 days of life. The drug of choice for prophylaxis is palivizumab.

Recommendations for the treatment of bronchiolitis are based on the 2006 American Academy of Pediatrics Practice Guidelines for the Diagnosis and Management of Bronchiolitis.^[1][2]

• Indications for prophylaxis:
  • The first year of life during RSV season in infants with hemodynamically significant heart disease.
  • The first year of life during RSV season in preterm infants < 32 weeks 0 days gestation who require > 21% oxygen for at least the first 28 days of life.
• Preferred regimen: Palivizumab 15 mg/kg IM monthly for 5 months.

• Supplemental oxygen therapy must be used to maintain oxygen saturation above (SpO₂) 90% in patients with previous normal SpO₂.

• Infants with persistent respiratory distress who do not respond to supplemental oxygen therapy should be treated with nasal continuous positive airway pressure (CPAP) or tracheal intubation.^[3]

• It is recommended to closely monitor SpO₂ if the patient’s clinical status does not improve.
• It is strongly recommended to closely monitor SpO₂ while gradually decreasing oxygen therapy in high-risk patients (congenital heart disease with significant hemodynamic changes, chronic lung disease, or premature infants).

• There is no evidence that supports the routine use of bronchodilators for bronchiolitis.

• Several clinical trials have been performed to assess the efficacy of albuterol treatment, which did not demonstrate significant changes in the course of the disease.
• The use of racemic epinephrine has not been demonstrated to be effective for the long term improvement of the disease; however, one RCT showed improvement in the SpO₂ in the first hour after nebulization.^[4]
• One study proved that nebulized l-epinephrine is more effective than albuterol to prevent hospitalization in patients with bronchiolitis.^[5]

• Benefits were observed only in outpatient trials, the use of Bronchodilators did not show improvements in hospitalized patients regarding the length of stay or duration of the illness.
• Avoid the use of anticholinergic agents or leukotriene inhibitors, as there is no evidence that proves their benefit.

• Regular use of corticosteroids (either systemic or inhaled) is not recommended, as clinical trials have shown no benefit in the length of stay, blood oxygen saturation level, respiratory rate or revisit and readmission.
• Special cases, such as patients with family history of asthma or atopy and/or previous atopic dermatitis, could benefit from the use of corticosteroid therapy.^[3]

• Ribavirin should not be used regularly for the treatment of bronchiolitis. Several RCTs (randomized control trials) have demonstrated that the use of ribavirin does not improve the course of the disease or reduce the need for oxygen therapy or length of stay.
• Patients with severe disease or risk of severe disease (immunocompromised patients and patients with congenital heart disease with significant hemodynamic changes or chronic lung disease) may benefit from the use of ribavirin.

• Randomized clinical trials (RCT) showed no benefit in antibiotic treatment for bronchiolitis if there is no concomitant bacterial infection.
• Urinary tract infection and acute otitis media (AOM) are the most common causes of secondary bacterial infections in patients with bronchiolitis. The treatment for bacterial infections should not differ in patients with bronchiolitis than in those without bronchiolitis.
• Acute otitis media is a common infection associated with bronchiolitis. Though RSV can cause AOM, clinical findings are usually similar to those in bacterial infections; therefore it should be managed as a bacterial infection. Click here for a complete therapeutic approach to AOM.

• Hydration and ingestion capacity of oral fluids must be evaluated in order to determine the need for intravenous hydration.
• Fluid therapy should be restricted to patients who present with signs of severe respiratory distress (60-70 breaths per minute, intercostal retraction, sternal retraction and/or prolonged expiratory wheezing), as these patients will have increased risk of food aspiration.
• Fever and tachypnea increase the insensible losses; therefore, IV fluid therapy must be calculated accordingly.^[3]

• It has been demonstrated that the use of respiratory physical therapy doesn’t improve clinical signs or symptoms in patients with bronchiolitis.
• Nasal clearance could produce temporary relief; however, deep pharynx aspiration has not shown efficacy in relieving signs and symptoms.

• Nebulized hypertonic saline (HS) may reduce the length of stay among inpatients (see Forest plot).^[6] However, the quality of evidence is low due to the imprecision of results and the substantial heterogeneity or inconsistency of results.

• Nebulized hypertonic saline may reduce the rate of admission among outpatients according to a systematic review. In this review, the relative risk reduction from hypertonic saline was 0.77. In populations similar to those in this review which had a rate of admission of 25% without treatment, the number needed to treat is 14. However, the quality of evidence is low due to imprecision of results and likely publication bias. (see Forest plot)^[7]

• Shown below is the Forest plot depicting the different trials that evaluated the administration of nebulized hypertonic saline solution for the reduction of length of stay in acute bronchiolitis among children.

• 
  Shown below is the Forest plot depicting the different trials that evaluated the administration of nebulized hypertonic saline solution for the reduction of the rate of hospitalization in acute bronchiolitis among children.

• Pulmonary surfactant has been proven to contain protein components A and D, which enhance the elimination of viruses and bacteria by the immune system.^[3]
• Protein D is related to the production of free radicals by the macrophages in the alveoli.
• A meta-analysis demonstrated a significant reduction in duration of ICU stay and in the need for mechanical ventilation with the use of surfactant against a placebo or non-surfactant in patients using mechanical ventilators due to viral bronchiolitis.^[8]

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