Bronchiolitis

Key Features

Essentials of Diagnosis

• Clinical syndrome characterized by one or more of the following findings:

  • Coughing

  • Tachypnea

  • Labored breathing

  • Hypoxia

• Irritability, poor feeding, vomiting

• Wheezing and crackles on chest auscultation

General Considerations

• Most common serious acute respiratory illness in infants and young children

• Between 1% and 3% of infants with bronchiolitis require hospitalization, especially during the winter months

• Respiratory syncytial virus (RSV) is by far the most common viral cause

• Parainfluenza, human metapneumovirus, influenza, and adenovirus, are less common causes during early infancy

Clinical Findings

• Fever (1–2 days)

• Rhinorrhea

• Cough

• Wheezing

• Tachypnea

• Respiratory distress

• Breathing pattern is shallow, with rapid respirations

Diagnosis

Laboratory Findings

• Nasal wash

  • Can be used to identify the causative pathogen

  • Not necessary to make the diagnosis

• Peripheral white blood cell count may be normal or show a mild lymphocytosis

Imaging

• Chest radiographs are not indicated in children who

  • Have bilateral, symmetrical findings on examination

  • Are not in significant respiratory distress

  • Do not have elevated temperature

• Chest radiographic findings are generally nonspecific and typically include

  • Hyperinflation

  • Peribronchial cuffing

  • Increased interstitial markings

  • Subsegmental atelectasis

Treatment

• Mst children are treated as outpatients

• However, hospitalization is required in infected children with

  • Hypoxemia on room air

  • History of apnea

  • Moderate tachypnea with feeding difficulties

  • Marked respiratory distress with retractions

• Supportive strategies used during hospitalization

  • Frequent suctioning

  • Administration of adequate fluids to maintain hydration

• Supplemental oxygen should be administered if hypoxemia is present

• Antibiotics not necessary unless there is evidence of an associated bacterial pneumonia

• Bronchodilators and corticosteroids

  • Have not been shown to change the severity or the length of the illness

  • Not recommended

• High-risk patients with RSV bronchiolitis may need to be hospitalized and treated with ribavirin

Outcome

Prevention

• The most effective preventions against RSV infection are proper handwashing techniques and reducing exposure to potential environmental risk factors.

• Prophylaxis with a monoclonal antibody (palivizumab) is effective in reducing the rate of hospitalization and associated morbidity in high-risk premature infants and those with chronic cardiopulmonary conditions.

• Patients at risk for life-threatening RSV infections should receive prophylactic therapy

  • Children younger than 24 months whose gestational age is < 35 weeks

  • Children younger than 24 months with other severe pulmonary conditions, congenital heart disease, neuromuscular disease, or significant immunocompromise

Complications

• Bacterial superinfection is a rare complication of viral pneumonia

• Bronchiolitis due to RSV infection contributes substantially to morbidity and mortality in children with underlying medical disorders

Prognosis

• Very good for most infants

• Mortality rate has decreased substantially due to improved supportive care and prophylaxis with palivizumab

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