Bronchiolitis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Bronchiolitis Microchapters
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Overveiw

There is no effective specific treatment for bronchiolitis. Therapy is principally supportive. Frequent small feeds are encouraged to maintain good urine output, and sometimes oxygen may be required to maintain blood oxygen levels. In severe cases the infant may need to be fed via a nasogastric tube or it may even need intravenous fluids. In extreme cases, mechanical ventilation (for example, using continuous positive airway pressure (CPAP) might be necessary.

Pharmacotherapy

Bronchodialators

• There is no evidence that supports the routine use of bronchodialators for bronchiolitis, nontheless, clinical score improvements have been shown in some patients treated with albuterol and recemous adrenaline nebulizations.
• Benefits were observed in outpatient trials, bronchodialators did not reduce the length of stay or duration of illness.
• Avoid the use of anticholinergic agents or leukotrien inhibitors as there is no evidence that proves their benefit.

Corticosteroids

• The use of corticosteroids should be avoided as clinical trials have shown no benefit in the length of stay, blood oxygen saturation level, respirtatory rate and revist or readmission.

Antiviral therapy

• Rivavirin should not be used regularly for the treatment of bronchiolitis.
• Patients with severe disease or risk of severe disease (immunocompromised patients and patients with hemodynamicaly significant cardiopulmonary disease) may benefit from the use of ribavirin.

Atibiotics

• RCT showed no benefit in antibiotic treatment for brochiolitis if there is no concomitant bacterial infection.
• Antibiotics should only be used when bronchiolitis is associated with a bacterial infection.
• UTI are the most common cause of severe bacterial infections in patients with bronchiolitis. The treatment for bacterial infections should nod differ in patients with brochiolitis than in those without brochiolitis.
• Acute otitis media is a common infection associated with brochiolitis. Though RSV can cause AOM, clinical findings are ussually simillar to those in bacterial infections, therefore the infection should be treated as a bacterial infection. Clinical trials have demonstrated that the common etiologic pathoges are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. The pathogen based antibiotic treatment for AOM is shown below.

Bacterial AOM pathogen based treatment   ▸  Streptococcus pneumoniae   ▸  Haemophilus influenzae   ▸  Moraxella catarrhalis

Acute Pharmacotherapies

Bronchodilator drugs such as salbutamol/albuterol or ipratropium are no longer recommended, but many clinicians offer a trial dose to see if there is any benefit (especially if there is a family history of asthma, since it can be difficult to clinically distinguish bronchiolitis from a viral-induced wheeze). Racemic epinephrine is another drug that is sometimes given.

Ribavirin is an antiviral drug which has a controversial role in treating RSV infection. There is no proven benefit but it is used sometimes for infants with pre-existing lung, heart or immune disease. Antibiotics are often given in case of a bacterial infection complicating bronchiolitis, but have no effect on the underlying viral infection.

Corticosteroids have no proven benefit in bronchiolitis treatment and are not advised.

There is some interest in the use of hypertonic saline in bronchiolitis. Initially recommended for use in cystic fibrosis patients, it is speculated to increase hydration of secretions, thus facilitating their removal.

References

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