Approach to Acute Bronchiolitis

Bronchiolitis remains one of the most common presentations to the health care system but there is a trend toward reduction in unnecessary treatment and hospitalization due to the revised recommendations provided through the 2014 AAP clinical practice guidelines.

A couple of key points follow. All are moderate to strong recommendations based on the practice guideline. Both the hospitalist and emergency services have adopted and incorporated the recommendations into clinical pathways based on the guidelines.

  • Diagnosis is made based on a good history and physical. There is rarely a need for an x-ray or diagnostic, such as an RSV Antigen or lab work. None of these studies are likely to change our approach to management.
  • Studies show that interventions other than nasal suctioning have no proven benefit in either the primary, acute or inpatient setting. There is generally no benefit from albuterol, nebulized epinephrine or systemic steroids. We do not routinely use any of these therapies.
  • Tolerance for lower saturations and higher respiratory rates has been shown to be safe in the outpatient setting
    • Supplemental oxygen is not necessary if saturations are >90% and the child is relatively comfortable
    • For infants up to 12 months of age, Tolerance of higher respiratory rates between 60 and 70 is recommended as long as the child maintains hydration.

In a large prospective study published in 2013, certain risk factors for apnea are identified.

Apnea risk in hospitalized infants is highest if:

  • Apnea occurred prior to the health care setting
  • A history of prematurity of <37 weeks
  • Age less than 48 weeks post gestation
  • RR< 30 or > 70 on presentation to the health care setting
  • Saturations <90% on admission

Also noted in this study is that the risk of apnea does not significantly differ in infants with RSV and those with non-RSV bronchiolitis.