Current Therapy For Bronchiolitis

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Review

Current therapy for bronchiolitis
Prasad Nagakumar, Iolo Doull
Department of Paediatric
Respiratory Medicine/
Paediatric Cystic Fibrosis
Centre, Children’s Hospital for
Wales, Cardiff, UK
Correspondence to
Iolo Doull, Department
of Paediatric Respiratory
Medicine/Paediatric Cystic
FibrosisCentre, Children’s
Hospital for Wales, Cardiff
CF14 4XW, UK
Received 20 December 2011
Accepted 16 May 2012
Published Online First
25 June 2012

ABSTRACT
Bronchiolitis is a common, self-limiting, seasonal
viral respiratory tract infection in infancy accounting
for the majority of hospital admissions in this age
group. Supportive care is the mainstay of treatment,
concentrating on fluidreplacement, gentle suctioning of
nasal secretions, prone position (if in hospital), oxygen
therapy and respiratory support if necessary. There is
a long history of pharmacological agents offering no
benefit in acute bronchiolitis. More recently, nebulised
epinephrine has been demonstrated to offer short term
benefits, while two stratagems have shown promise in
decreasing risk of hospitalisationand length of hospital
stay. The combination of oral dexamethasone with
nebulised epinephrine potentially decreases the need
for hospitalisation, while nebulised 3% hypertonic saline
mixed with a bronchodilator decreases the length of
hospitalisation. Although both stratagems appear safe
and well tolerated, their role in clinical practice remains
unclear.

INTRODUCTION
It is nearly 50years since Reynolds and Cook
wrote that “oxygen therapy is vitally important
in bronchiolitis and there is little convincing evidence that any other therapy is consistently or even
occasionally useful”.1 T he mainstays of treatment
remain oxygen, fluids and, if necessary, respiratory support. More recently, the combination of
nebulised epinephrine and dexamethasone, or
nebulised hypertonicsaline with a bronchodilator
have emerged as potential therapeutic strategies.
The
Scottish
Intercollegiate
Guidelines
Network defi nes bronchiolitis as “a seasonal viral
illness characterised by fever, nasal discharge
and dry wheezy cough. Examination of the chest
reveals crepitations and/or wheeze”. 2 I n contrast,
the American Academy of Pediatrics subcommittee defi nes bronchiolitis as “adisorder most commonly caused in infants by viral LRTI; it is the
most common lower respiratory infection in this
age group and is characterised by acute infl ammation, oedema and necrosis of epithelial cells lining
small airways, increased mucus production and
bronchospasm”. 3 T hese defi nitions reflect differences in the interpretation of the disease – in
North America bronchiolitis mayencompass children up to 2 years of age with a fi rst episode of
multi-trigger wheeze. These differences may also
limit the generalisability of some studies.
Bronchiolitis is the most common cause for
lower respiratory tract infection (LRTI) during
the fi rst year of life, and even allowing for differences in defi nition, accounts for majority of hospital admissions during this period in the UK andthe USA.4 5 Between 2% and 3% of all infants are
Arch Dis Child 2012;97:827–830. doi:10.1136/archdischild-2011-301579

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archdischild-2011-301579.indd 1

hospitalised in their fi rst 12 months of life with
bronchiolitis,6 i mposing a significant burden on
the healthcare system.7 A lthough many viruses
may cause the constellation of symptoms and
signs thatcharacterise bronchiolitis, 60–85% of
cases are caused by respiratory syncytial virus
(RSV).8 9 Every year between 132 000 and 172 000
children less than 5 years of age are hospitalised
in the USA with RSV infections.10 Smoking,
overcrowding and low socioeconomic status are
all associated with increased incidence of bronchiolitis related hospital admissions.11 I nfants
with co-morbidities...