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.

Pharmacological therapy

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

Oxygen therapy

• Oxygen therapy must be used if a oxygen hemoglobin saturation falls below 90% in previously healthy patients.
• It is recommended to closely monitor hemoglobin oxygen saturation is necessary if the patient's clinical status is not improving.
• It is strongly recommended that high risk patients (hemodynamically significant hear or lung disease and/or premature children) be closely monitored for hemoglobin oxygenation saturation when the oxygen therapy is gradually reduced.

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

Fluid therapy

• Hydration and ingestion capacity of oral fluids must be evaluated in order to determine the need of intravenous hydration.
• Fluid therapy should be restricted to patients who present 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.

Respiratory physical therapy

• 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.

Prevention

Recommendations for the prevention of bronchiolitis are based on the 2006 American Academy of Pediatrics Practice Guidelines for the Diagnosis and Management of Bronchiolitis.

Palivizumab prophylaxis

Recommendations are based on the 2009 AAP Modified Recomendations for Use of Palivizumab for Prevention of Respiratory Syncytial Virus Infections.

• Prophylaxis is recommended in selected patients with high risk of severe bronchiolitis:

• Patients younger than 2 years of age who required medical therapy for chronic lung disease 6 months or less before the RSV season.

with chronic lung disease.

• Patients younger than 2 years of age with congenital heart disease.

• Infants who are receiving congestive heart failure treatment.
• Cyanotic heart disease.
• Moderate to severe pulmonary hypertention.

• Hystory of prematurity.

• Prophylaxis is recommended in premature infants with less than 32 weeks of gestation with or without chronic lung disease of prematurity.
• For patients born with 28 weeks of gestation or less, prophylaxis is recommended for their first RSV season disregarding the age of the patient. If the prophylaxis is started, it should continue through all the RSV season.
• For patients born with 29 to 32 weeks of gestation, prophylaxis is recommended for patients are born 6 months or less before the RSV season. If the prophylaxis is started, it should continue through all the RSV season.
• For patients bor with 32 to 35 weeks of gestation, prophylaxis ir recommended in patients who are born 3 months before the RSV season or during the RSV season and 1 of the following risk factors which may require hospitalization due to bronchiolitis:

• Infants with school-aged sbilings.
• Infants who attend to child care centers.

• Infants who have either congenital abnormalities of the airway or neuromuscular disease that compromises handling of respiratory secretions.

References

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