Bronchiolitis

Most cases of bronchiolitis are caused by

• Respiratory syncytial virus (RSV)

• Rhinovirus

• Parainfluenza virus type 3

Less frequent causes are influenza viruses A and B, parainfluenza viruses types 1 and 2, human metapneumovirus, adenoviruses, and Mycoplasma pneumoniae.

Risk factors for more severe disease include low birth weight and prenatal exposure to tobacco smoke and secondhand smoke (1).

The virus spreads from the upper respiratory tract to the medium and small bronchi and bronchioles, causing epithelial necrosis and initiating an inflammatory response. The developing edema and exudate result in partial obstruction, which is most pronounced on expiration and leads to alveolar air trapping. Complete obstruction and absorption of the trapped air may lead to multiple areas of atelectasis, which can be exacerbated by breathing high inspired oxygen concentrations.

Typically, an affected infant has symptoms of upper respiratory infection. Some infants have progressively increasing respiratory distress characterized by tachypnea, retractions, and a wheezy or hacking cough.

Young infants (< 2 months) and infants born prematurely may present with recurrent apneic spells followed by resolution of apnea and onset of more typical symptoms and signs of bronchiolitis over 24 to 48 hours. Signs of distress may include circumoral cyanosis, deepening retractions, and audible wheezing. Fever is usually but not always present. Infants initially appear nontoxic and in no distress, despite tachypnea and retractions, but may become increasingly lethargic as the infection progresses. Hypoxemia is the rule in more severely affected infants.

Dehydration may result from vomiting and decreased oral intake. With fatigue, respirations may become more shallow and ineffective, leading to respiratory acidosis. Auscultation reveals wheezing, prolonged expiration, and, often, fine crackles. More than half of children 3 to 18 months old have accompanying acute otitis media (1).

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Wheezing

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Crackles

• Clinical evaluation

• Pulse oximetry

• Chest radiograph for more severe cases

• Respiratory syncytial virus (RSV) antigen test on nasal washings, nasal aspirates, or nasal swabs for seriously ill children

Diagnosis of bronchiolitis is suspected by history, examination, and occurrence of the illness as part of an epidemic. Symptoms similar to bronchiolitis can result from an asthma exacerbation, which is often precipitated by a respiratory viral infection and is more likely in a child > 18 months of age, especially if previous episodes of wheezing and a family history of asthma have been documented. Gastric reflux with aspiration of gastric contents also may cause the clinical picture of bronchiolitis; multiple episodes in an infant may be clues to this diagnosis. Foreign body aspiration occasionally causes wheezing and should be considered if the onset is sudden and not associated with manifestations of upper respiratory infection, especially if the lung examination is asymmetric. Heart failure associated with a left-to-right shunt manifesting at age 2 to 3 months also can be confused with bronchiolitis.

Patients suspected of having bronchiolitis should undergo pulse oximetry to evaluate oxygenation. No further testing is required for mild cases with normal oxygen levels, but in cases of hypoxemia and severe respiratory distress, a chest radiograph supports the diagnosis and typically shows hyperinflated lungs, depressed diaphragm, and prominent hilar markings. Infiltrates resulting from atelectasis and/or RSV pneumonia may be present; RSV pneumonia is relatively common among infants with RSV bronchiolitis.

RSV rapid antigen testing done on nasal washings, nasal aspirates, or nasal swabs is diagnostic but not generally necessary; it may be reserved for patients with illness severe enough to require hospitalization because it may guide isolation and bed assignment decisions. Other laboratory testing is nonspecific and is not routinely indicated.

• Supportive therapy

• Oxygen supplementation as needed

• IV hydration as needed

Treatment of bronchiolitis is usually supportive, and most children can be managed at home with hydration and comfort measures.

Indications for hospitalization include

• Accelerating respiratory distress

• Ill appearance (eg, cyanosis, lethargy, fatigue)

• Apnea by history

• Hypoxemia

• Inadequate oral intake

Children with underlying disorders such as cardiac disease, immunodeficiency, or bronchopulmonary dysplasia, which put them at high risk of severe or complicated disease, also should be considered candidates for hospitalization.

In hospitalized children, 30 to 40% oxygen delivered by nasal cannula, tent, or face mask is usually sufficient to maintain oxygen saturation > 90%. Endotracheal intubation is indicated for severe recurrent apnea, hypoxemia unresponsive to oxygen therapy, or CO2 retention or if the child cannot clear bronchial secretions. High-flow nasal cannula therapy, continuous positive airway pressure (CPAP) therapy, or both are often used to avoid intubation in patients who are at risk of respiratory failure.

Hydration may be maintained with frequent small feedings of clear liquids. For sicker children, fluids should be given IV initially, and the level of hydration should be monitored by urine output and specific gravity and by serum electrolyte determinations.

There is some evidence that systemic corticosteroids are beneficial when given very early in the course of the illness in children with underlying corticosteroid-responsive conditions (eg, bronchopulmonary dysplasia, asthma), but there is no benefit in previously well infants.

Antibiotics should be withheld unless a secondary bacterial infection (a rare sequela) occurs.

Bronchodilators are not uniformly effective, but a substantial subset of children may respond with short-term improvement. This is particularly true of infants who have wheezed previously. Hospital stays probably are not shortened.

Ribavirin, an antiviral medication active in vitro against respiratory syncytial virus (RSV), influenza, and measles, is probably not effective clinically and is no longer recommended except for immunosuppressed children with severe RSV infection; it also is potentially toxic to hospital staff. RSV immune globulin has been tried but is ineffective.

Prevention of RSV for indications).

Prognosis is excellent. Most children recover in 3 to 5 days without sequelae, although wheezing and cough may continue for 2 to 4 weeks. Mortality is < 0.1% when medical care is adequate.

An increased incidence of asthma is suspected in children who have had bronchiolitis in early childhood, but the association is controversial because the children who later develop asthma may be more severely affected by RSV and therefore are more likely to seek medical attention. The incidence seems to decrease as children age.