Approach
Treatment strategies are largely supportive, with a focus on ensuring adequate oxygenation, ventilation, nutrition, and hydration. No available treatment shortens the course of bronchiolitis or hastens the resolution of symptoms.[8]
High-risk infants include those with a history of prematurity, age <6 months at the start of respiratory syncytial virus (RSV) season, chronic lung disease, complex congenital heart disease, or immune deficiency.[1][15][16][17][18][45][81] These patients require closer observation and are frequently admitted to the hospital.
Treatment strategies depend on the severity of the illness.[114]
For adults, management is typically limited to supportive care, with supplemental oxygen, bronchodilators, intravenous fluids, and antipyretics as required and guided by the individual clinical scenario. Antiviral therapy is sometimes considered for patients with RSV following solid organ or hematopoietic stem cell transplantation (HSCT) to prevent progression to lower respiratory tract involvement, although definitive evidence of efficacy is scarce.[29][115][116][117]
Hospitalization and supportive care
Mild illness
Patients have no hypoxemia and can feed adequately.
For most infants, RSV disease is usually mild and self-limited, and can be treated in the outpatient setting. Outpatient care requires diligent follow-up to ensure that the patient is not deteriorating.
High-risk infants (e.g., history of prematurity, age <6 months at start of RSV season, chronic lung disease, complex congenital heart disease, or immune deficiency) may require hospital admission.
Treatment is largely supportive and about providing adequate nutritional support. Infants are obligate nose breathers, and nasal obstruction is a frequent problem. Simple nasal toilet with saline drops and a suction bulb can significantly improve the work of breathing.
Symptomatic therapy for healthy adults is usually sufficient, as the disease is typically confined to the upper respiratory tract and is self-limited.
Moderate illness
Signs of moderate illness in infants include hypoxemia (oxygen saturations <90% to 92%), tachypnea, increased work of breathing (nasal flaring, intercostal retractions, head bobbing), inadequate feeding, and dehydration.
Patients should be admitted for further care and observation.[2]
Hypoxemia should be treated with warm, humidified oxygen through a nasal cannula or mask.
High-flow nasal cannula (HFNC) therapy is safe; however, there is no clear evidence that initiating support with HFNC is more effective than standard oxygen therapy with a mask, either in shortening hospital length-of-stay or preventing ICU admissions (although studies have been conflicting).[118] HFNC should be limited to infants who have failed standard oxygen therapy.[118]
Careful attention should be given to prompt correction of any dehydration and reestablishing adequate nutrition. Infants with poor feeding or significantly elevated work of breathing or respiratory rate should be fed by nasogastric or nasojejunal tube, or receive intravenous fluids.[2]
Adults who are older, immune deficient, or have comorbidities may have moderate illness and should be managed with supportive care while addressing exacerbations of underlying illnesses.
Severe illness
Infants with refractory hypoxemia, progressive respiratory distress, or frank respiratory failure should be transferred to the pediatric intensive care unit.
These patients often improve with noninvasive mechanical ventilation such as nasal continuous positive airway pressure or noninvasive ventilation, but may require endotracheal intubation with mechanical ventilation.[119] These modalities are associated with significantly decreased RSV-associated mortality.[120]
Hypoxemia should be treated with warm, humidified oxygen through a nasal cannula or mask.
Rehydration and nutrition can be accomplished by enteral or parenteral routes, depending on the degree of disease severity and other clinical considerations. In the UK, the National Institute for Health and Care Excellence recommends giving fluids by nasogastric or orogastric tube in babies and children with bronchiolitis if they cannot take enough fluid by mouth. Alternatively, it recommends intravenous isotonic fluids to babies and children who do not tolerate nasogastric or orogastric fluids or have impending respiratory failure.[51]
Adults who are older, immune deficient, or have comorbidities may progress to severe illness, requiring intensive care unit admission with respiratory support and intravenous and nutritional support.
Adjunctive therapies
Bronchodilators
Bronchodilators (e.g., albuterol and ipratropium) should not be used routinely in the management of bronchiolitis.[2][51]
Bronchodilators may be of benefit for patients with asthma, COPD, or severe disease.
Bronchodilators may transiently improve oxygen saturation and work of breathing, but have not been shown to decrease hospital admissions, length of stay, or length of oxygen therapy.[121][122][123][124] [
]
Nebulized hypertonic saline
Nebulized hypertonic saline is of potential benefit in reducing symptoms of mild or moderate bronchiolitis in the hospital setting.[125] Given the relatively long period of use required to achieve improvement, nebulized hypertonic saline is not recommended for use in the emergency department.[2][126][127]
Ribavirin ± intravenous immune globulin (IVIG)
Ribavirin is not recommended for routine use in children with bronchiolitis.[8][107]
Ribavirin is a synthetic nucleoside analog with in vitro activity against RSV. In practice, however, its benefit is less certain.[8]
Several factors complicate the use of ribavirin: it is expensive; it must be given early in the course of infection for best effect; it may present a risk to those who give it, as it is a potential teratogen when administered by nebulization.
Oral ribavirin has been used in immune deficient adults (predominantly transplant recipients and cancer patients with severe RSV disease), although it is not approved for this indication.[128] Its early use in adult bone marrow transplant patients has reduced morbidity and mortality in this patient subset.[129]
IVIG may be added to inhaled ribavirin for immune deficient patients at high risk for progression to severe lower respiratory tract disease.[128][129] IVIG with oral ribavirin has also been studied in immune deficient patients.[130]
Studies with aerosolized ribavirin therapy demonstrated a small increase in oxygen saturation in small clinical trials; however, a decrease in the need for mechanical ventilation or a decrease in the length of stay was not shown. Because of limited evidence for a clinically relevant benefit, potential toxic effects, and high cost, routine use of aerosolized ribavirin is not recommended.[8]
Antibiotics
Routine administration of empiric antibiotic therapy to infants with RSV bronchiolitis is not recommended, because the risk of concomitant bacterial infection is very low (0.2%).[8] [
]
Antibiotics should be administered to those with confirmed or strongly suspected bacterial infections.[2][8]
For infants with severe RSV bronchiolitis who require intubation, the risk of bacterial pneumonia is significantly higher (26%). These infants may benefit from initiation of antibiotics pending culture results.[2][107][131][132]
Corticosteroids
Corticosteroids are not effective in the routine management of RSV infection and do not appear to reduce subsequent recurrent wheeze or asthma.[2][133][134][135][136] [
]
In addition, their use in patients with bronchiolitis indicate that they do not reduce hospital admissions and do not reduce length of stay for inpatients.[8]
The American Academy of Pediatrics guidelines recommend against the routine use of corticosteroids for this condition.[2]
Corticosteroids may be beneficial in patients with atopy, asthma, or chronic lung disease.
Less effective or ineffective therapies
Chest physical therapy has not been shown to improve outcomes, and its use is discouraged.[2][110] In the UK, the National Institute for Health and Care Excellence does not recommend chest physical therapy on babies and children with bronchiolitis. However, a chest physical therapy assessment in babies and children who have relevant comorbidities where there may be additional difficulty clearing secretions (e.g., spinal muscular atrophy, severe tracheomalacia) may be warranted.[51]
Nasal suctioning is widely utilized for infants with bronchiolitis as supportive management, but there is a lack of evidence demonstrating risk or benefit of this intervention.[137] The American Academy of Pediatrics does not make a recommendation about suction due to insufficient data but suggests that the routine use of "deep" suctioning may not be beneficial.[2] In the UK, the National Institute for Health and Care Excellence does not recommend routinely performing upper airway suctioning in babies or children with bronchiolitis but suggest that it could be considered for those with respiratory distress or feeding difficulties due to upper airway secretions.[51]
Mucolytic therapy with nebulized recombinant human DNase, acetylcysteine, or carbocysteine has not been effective.[138][139]
Surfactant therapy for intubated patients has not been effective.
Helium-oxygen (heliox) mixtures have also shown no benefit in regards to the rate of intubation, rate of emergency department discharge, or length of treatment for respiratory distress in the management of bronchiolitis in infants.[140] [
]
Montelukast has not been proven effective in the treatment of RSV infection, or in the reduction of post-bronchiolitis wheezing.[141] [
]
Evidence is lacking for the safety and effectiveness of magnesium sulfate in children ≤2 years with bronchiolitis.[142]
Use of this content is subject to our disclaimer