Bronchiolitis – “Seriously, what should I do?”

Bronchiolitis and RSVBronchiolitis is the most common lower respiratory infection in infants.
– Characterized by acute inflammation, edema and necrosis of epithelial cells lining small airways, increased mucus production, mucous plugging, bronchospasm and V/Q mismatch.
– Diagnosis is based on clinical history and physical. No lab test is useful.


  • DEEP NASAL Suctioning!! (no randomized control trials to assess this… but seems to make the most sense!)
  • There are numerous studies that continually conflict with each other. Part of the problem is the heterogeneity of the disease makes it difficult to study consistently.
    • What seems to be agreed upon:
      • Steroids alone do not benefit.
      • Ribaviran does not benefit.
      • Supplement oxygen is required if the patient persistently has Pulse Ox below 90%.
        • Supplemental oxygen can be discontinued once the pt is sat’ing above 90%, feeding well, and in no resp distress.
      • Bronchodilators alone do not show significant benefit and shouldn’t be used routinely.
        • A trial can be attempted and if there is a positive response, they can be continued.
        • Some choose albuterol to use as the trial medication.
          • Pro: if there is an improvement, you can send them home with it. Subcommittee recommended its consideration.
          • Con: no consistent evidence to support its use. May confuse family to think there kid has asthma.
        • Some choose racemic epinephrine as the trial medication
          • The most recent studies looking at Racemic Epi plus Decadron do argue for this combination’s use and tout its cost-effectiveness; however, the doses of steroids that they use are high (Decadron 1mg/kg x first dose, then 0.6mg/kg for 5 days [Max dose = 10mg]).
          • Pro: makes you feel fancy when you give it. Many studies support its use (of course others do not).
          • Con: can’t go home with it.
      • The current debate: Hypertonic saline (3% or even 5%) plus Epinephrine OR Steroids plus Epinephrine (because if one thing doesn’t work, try two).
        • There are studies that support hypertonic saline as a therapy to reduce length of stay once hospitalized. Mixed results as to whether it is useful to help reduce admissions from the ED.
        • There is evidence that 5% may be better than 3%, but still generates unimpressive statistics to truly support its use.

Bottom Line {from my unscientific and non-randomized opinion}

  • Bronchiolitis will continue to be studied and these studies will continue to yield conflicting results.
  • It offers you the opportunity to actually use your clinical skills to determine the best management strategy. Tailor the management to the particular patient.
  • These children should be assessed multiple times to determine their respiratory status while alert, sleepy, eating, playing, etc.
  • A trial of bronchodilator is appropriate… but you must assess them right before and after its use to determine efficacy in that patient (not useful to go back 2 hours later to see if it worked).
  • For those who aren’t responding… try the other bronchodilator… and perhaps some hypertonic saline.
  • Then, consider Heliox and or BiPap (again, not consistently supported in the literature, but if you can prevent intubation I would consider that a victory for the common sense approach).



2016 UPDATE:



Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and Management of Bronchiolitis. PEDIATRICS Vol. 118 No. 4 October 2006, pp. 1774-1793 (doi:10.1542/peds.2006-2223

Fernandes Rm, et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database of Systematic Reviews 2010.

Zhang L, et al. Nebulized hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database of Systematic Reviews 2008.

Grewal S, et al. A randomized trial of nebulized 3% hypertonic saline with epirnephrine in the treatment of acute bronchiolitis in the emergency department. Arch Pediatr Adolesc Med. 2009 Nov;163(11):1007-12.

Al-Ansari K, et al. Nebulized 5% or 3% hypertonic or 0.9% saline for treating acute bronchiolitis in infants. J Pediatr. 2010 Oct;157(4):630-4, 634.e1.

Summer A, et al. Cost-effectiveness of epinephrine and dexamethasone in children with bronchiolitis. PEDIATRICS Vol. 126 No. 4 October 2010, pp. 623-631

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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