Bronchiolitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2]

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Overview

The primary mode of treatment for bronchiolitis is supportive management. Supportive therapy includes frequent, small feeding and oxygen therapy. In severe cases, infants may require intravenous fluids and food via a nasogastric tube. In severe cases, mechanical ventilation or the use of continuous positive airway pressure (CPAP) might be necessary. Prophylaxis is indicated in infants with hemodynamically significant heart disease and preterm infants who require >21% oxygen for at least the first 28 days of life. The drug of choice for prophylaxis is palivizumab.

Medical Therapy

Recommendations for the treatment of bronchiolitis are based on the 2006 American Academy of Pediatrics Practice Guidelines for the Diagnosis and Management of Bronchiolitis.[1][2]

Prophylaxis

  • Indications for prophylaxis:
    • The first year of life during RSV season in infants with hemodynamically significant heart disease.
    • The first year of life during RSV season in preterm infants < 32 weeks 0 days gestation who require > 21% oxygen for at least the first 28 days of life.
  • Preferred regimen: Palivizumab 15 mg/kg IM monthly for 5 months.

Oxygen Therapy

Bronchodilators

  • There is no evidence that supports the routine use of bronchodilators for bronchiolitis.
  • Several clinical trials have been performed to assess the efficacy of albuterol treatment, which did not demonstrate significant changes in the course of the disease.
  • The use of racemic epinephrine has not been demonstrated to be effective for the long term improvement of the disease; however, one RCT showed improvement in the SpO2 in the first hour after nebulization.[4]
  • One study proved that nebulized l-epinephrine is more effective than albuterol to prevent hospitalization in patients with bronchiolitis.[5]
  • Benefits were observed only in outpatient trials, the use of Bronchodilators did not show improvements in hospitalized patients regarding the length of stay or duration of the illness.
  • Avoid the use of anticholinergic agents or leukotriene inhibitors, as there is no evidence that proves their benefit.

Corticosteroids

Antiviral Therapy

Antibiotic Therapy

Fluid Therapy

Respiratory Physical Therapy

  • It has been demonstrated that the use of respiratory physical therapy doesn't improve clinical signs or symptoms in patients with bronchiolitis.
  • Nasal clearance could produce temporary relief; however, deep pharynx aspiration has not shown efficacy in relieving signs and symptoms.

Hypertonic Saline

  • Nebulized hypertonic saline (HS) may reduce the length of stay among inpatients (see Forest plot).[6] However, the quality of evidence is low due to the imprecision of results and the substantial heterogeneity or inconsistency of results.
  • Nebulized hypertonic saline may reduce the rate of admission among outpatients according to a systematic review. In this review, the relative risk reduction from hypertonic saline was 0.77. In populations similar to those in this review which had a rate of admission of 25% without treatment, the number needed to treat is 14. However, the quality of evidence is low due to imprecision of results and likely publication bias. (see Forest plot)[7]
  • Shown below is the Forest plot depicting the different trials that evaluated the administration of nebulized hypertonic saline solution for the reduction of length of stay in acute bronchiolitis among children.
Nebulised hypertonic saline solution for reducing length of stay in acute bronchiolitis in children.png

  • Shown below is the Forest plot depicting the different trials that evaluated the administration of nebulized hypertonic saline solution for the reduction of the rate of hospitalization in acute bronchiolitis among children.
Nebulised hypertonic saline solution for reducing rate of hospitalization in acute bronchiolitis in children.png


Pulmonary Surfactant

References

  1. American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis (2006). "Diagnosis and management of bronchiolitis". Pediatrics. 118 (4): 1774–93. doi:10.1542/peds.2006-2223. PMID 17015575.
  2. Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM; et al. (2014). "Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis". Pediatrics. 134 (5): e1474–502. doi:10.1542/peds.2014-2742. PMID 25349312.
  3. 3.0 3.1 3.2 3.3 Wright M, Mullett CJ, Piedimonte G (2008). "Pharmacological management of acute bronchiolitis". Ther Clin Risk Manag. 4 (5): 895–903. PMC 2621418. PMID 19209271.
  4. Kristjánsson S, Lødrup Carlsen KC, Wennergren G, Strannegård IL, Carlsen KH (1993). "Nebulised racemic adrenaline in the treatment of acute bronchiolitis in infants and toddlers". Arch Dis Child. 69 (6): 650–4. PMC 1029646. PMID 8285776.
  5. Numa AH, Williams GD, Dakin CJ (2001). "The effect of nebulized epinephrine on respiratory mechanics and gas exchange in bronchiolitis". Am J Respir Crit Care Med. 164 (1): 86–91. doi:10.1164/ajrccm.164.1.2008090. PMID 11435244.
  6. GitHub Contributors. Hypertonic Saline for Bronchiolitis: a living systematic review. GitHub. Available at http://openmetaanalysis.github.io/Hypertonic-Saline-for-Bronchiolitis/. Accessed November 20, 2014.
  7. openMetaAnalysis Contributors. Hypertonic Saline for Bronchiolitis: a living systematic review. GitHub. Available at http://openmetaanalysis.github.io/Hypertonic-Saline-for-Bronchiolitis/. Accessed November 20, 2014.
  8. Ventre K, Haroon M, Davison C (2006). "Surfactant therapy for bronchiolitis in critically ill infants". Cochrane Database Syst Rev (3): CD005150. doi:10.1002/14651858.CD005150.pub2. PMID 16856080.


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