Fall 2025 Newsletter II: Acute Bronchiolitis
Overview
- Acute Bronchiolitis is the leading cause of hospitalization in infants and young children, most commonly affecting those under 2 years of age.
- Respiratory syncytial virus (RSV) if the predominant pathogen, but other viruses including rhinovirus, human metapneumovirus, influenza, parainfluenza, and adenovirus can also be responsible.
- The American Academy of Pediatrics provides evidence-based recommendations to guide the management of bronchiolitis in emergency and urgent care settings.
- AAP Clinical Practice Guideline: “The Diagnosis, Management, and Prevention of Bronchiolitis”.
Diagnosis
Clinical Diagnosis is Key
- History – Typically presents with upper respiratory symptoms (rhinorrhea, cough, congestion) progressing to lower respiratory signs
- Physical Exam – Findings may include tachypnea, nasal flaring, retractions, wheezing, crackles, and hypoxemia.
- Age – Most common in infants < 12 months but occurs up to 2-3 years.
- Risk factors for severe disease: Age < 12 weeks
- History of prematurity
- Cardiopulmonary disease
- Immunodeficiency
Routine Testing is Not Recommended
- No routine chest X-ray – Imaging is not indicated unless severe disease, diagnostic uncertainty, or suspicion for complications (pneumonia, pneumothorax).
- No routine viral testing – RSV and other viral testing do not change management in most cases. Testing if considering treatment of influenza or room assignments with admission.
- No routine blood or urine testing – Not indicated unless concern for sepsis or other diagnoses.
Treatment
Supportive Care is Mainstay
- Oxygen – Administer if SpO2 persistently < 90%. • Hydration – Encourage oral fluids if able; use nasogastric or IV fluids if unable to maintain hydration due to respiratory distress or fatigue.
- Nasal Suctioning – Especially before feeds, can improve intake and comfort
Treatment
Medications Generally Not Recommended
- Bronchodilators (albuterol, salbutamol) - Not recommended for routine use. May consider a monitored trial in select cases with strong atopic history or recurrent wheezing but discontinue if no clear benefit.
- Corticosteroids and Antivirals - Not recommended for routine use.
- Antibiotics - Not indicated unless there is evidence of secondary bacterial infection.
- Hypertonic Saline Nebulization - Not recommended in the emergency or acute care setting.
- Chest physiotherapy, heliox, racemic epinephrine and leukotriene modifiers - Not recommended.
Prevention
Infection Control
- Hand hygiene - Rigorous handwashing for staff, patients, and families.
- Contact precautions: - Use gloves and gowns for direct patient contact.
- Cohorting - Grouping RSV positive patients may be considered during outbreaks.
Immunoprophylaxis
- The AAP recommends RSV immunization (Nirsevimab) for the following: o Infants < 8 months of age born during or entering their first RSV season if:
- Children up to 2 years with underlying high-risk diagnosis.
Education
- Caregiver counseling - Emphasize the self-limited nature of bronchiolitis, home care, expected course (usually 7–10 days, with peak severity at days 3–5), and signs of respiratory distress or dehydration that warrant return to care.
Disposition
Admission Criteria
- Persistent hypoxemia (SpO₂ <90% on room air)
- Severe respiratory distress (marked retractions, grunting, apnea)
- Inability to maintain hydration orally
- Underlying high-risk conditions (prematurity, chronic cardiopulmonary disease, immunodeficiency)
- Social concerns (inadequate home support, unreliable follow-up)
Discharge Criteria
- Stable on room air (SpO₂ ≥90%)
- Adequate oral intake
- Caregivers able to recognize and respond to worsening symptoms