Bronchiolitis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overveiw

There is no effective specific treatment for bronchiolitis. Therapy is principally supportive. Frequent small feeds are encouraged to maintain good urine output, and sometimes oxygen may be required to maintain blood oxygen levels. In severe cases the infant may need to be fed via a nasogastric tube or it may even need intravenous fluids. In extreme cases, mechanical ventilation (for example, using continuous positive airway pressure (CPAP) might be necessary.

Pharmacological 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

Oxygen therapy

• Supplemental oxygen therapy must be used to maintain oxygen saturation above (SpO₂) 90% in patients with previous normal SpO₂.

• Infants with persistent respiratory distress who do not respond to supplemental oxygen therapy should be treated with nasal continuous positive airway pressure (CPAP) or tracheal intubation.

• It is recommended to closely monitor SpO₂ if the patient's clinical status does not improve.
• It is strongly recommended to closely monitor SpO₂ while gradually decreasing oxygen therapy in high risk patients (congenital heart disease with significant hemodynamic changes, chronic lung disease or premature infants).

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 without demonstrating significant changes in the course of the disease.
• The use of racemic epinephrine has not been demonstrated efficient for the long term improvement of the disease, however, one RCT showed improvement in the SpO₂ in the first hour after nebulization.
• One study proved that nebulized l-epinephrin is more effective than albuterol to prevent hospitalization in patients with bronchiolitis.

• 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 leukotrien inhibitors as there is no evidence that proves their benefit.

Corticosteroids

• Regular use of corticosteroids (either systemic or inhaled) is not recommended as clinical trials have shown no benefit in the length of stay, blood oxygen saturation level, respiratory rate and revisit or readmission.
• Special cases, such as patients with family history of asthma or atopy and/or previous atopic dermatitis, could benefit from the use of corticosteroid therapy.

Antiviral therapy

• Ribavirin should not be used regularly for the treatment of bronchiolitis. Several RCT have demonstrated that the use of rivavirin does not improve the course of the disease nor reduce the need of oxygen therapy or length of stay.
• Patients with severe disease or risk of severe disease (immunocompromised patients and patients with congenital heart disease with significant hemodynamic changes or chronic lung disease) may benefit from the use of ribavirin.

Atibiotics

• Randomized clinical trials showed no benefit in antibiotic treatment for bronchiolitis if there is no concomitant bacterial infection.
• Urinary tract infection and acute otitis media (AOM) are the most common cause of secondary bacterial infections in patients with bronchiolitis. The treatment for bacterial infections should not differ in patients with bronchiolitis than in those without bronchiolitis.
• acute otitis media is a common infection associated with bronchiolitis. Though RSV can cause AOM, clinical findings are usually similar to those in bacterial infections; therefore it should be managed as a bacterial infection. Clinical trials have demonstrated that the common etiologic pathoges producing AOM in patients with bronchiolitis are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. The empiric antibiotic treatment for AOM is shown below.

Initial treatment Preferred Regimen (sussceptible to penicillin) ▸ Amoxicillin 40-45 mg/kg PO q12h OR ▸ Amoxicillin-clavulanate 90/6.5 mg/kg/day PO divided in 2 doses Alternative Regimen (penicillin allergy or resistant strains) ▸ Cefdinir 14 mg/kg PO q24h OR ▸ Ceftriaxone 50 mg/kg IM or IV q24h OR ▸ Cefuroxime 15 mg/kg PO q12h OR ▸ Cefpodoxime 5 mg/kg PO q12h

Initial treatment Preferred Regimen (sussceptible to penicillin) ▸ Amoxicillin-clavulanate 90/6.5 mg/kg/day PO divided in 2 doses OR ▸ Ceftriaxone 50 mg/kg IM or IV q24h Alternative Regimen (penicillin allergy or resistant strains) ▸ Clindamycin 10 mg/kg PO q8h PLUS ▸ Ceftriaxone 50 mg/kg IM or IV q24h

• Failure of initial antibiotic treatment is defined as lack of clinical improvement during the first 48 to 72 hours. Fever should decrease and irritability should disappear of considerably decline.
• If severe symptoms remain or worsen antibiotic treatment should be changed. Recommended changes appear below:

• Children receiving amoxicillin should receive high dose amoxicillin-clavulanate
• Children receiving amoxicillin-clavulanate or oral third-generation cephalosporines should receive IM or IV ceftriaxone
• Three day treatment with ceftriaxone is recommended

• Tympanocentesis should be considered if more than one regimen has failed
• Clindamycin should be administered to patients who didn't respond to several antibiotic treatments and tympanocentesis can't be performed.

Fluid therapy

• Hydration and ingestion capacity of oral fluids must be evaluated in order to determine the need of intravenous hydration.
• Fluid therapy should be restricted to patients who present signs of severe respiratory distress (60-70 breaths per minute, intercostal retraction, sternal retraction and/or prolonged expiratory wheezing), as these patients will have increased risk of food aspiration.
• Fever and tachypnea increase the insensible losses, therefore IV fluid therapy must be calculated accordingly.

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.

Pulmonary surfactant

• Pulmonary surfactant have been proven to contain protein components A and D which enhance the elimination of viruses and bacteria by the immune system.
• Protein D is related with the production of free radicals by the macrophages in the alveoli.
• A meta-analysis demonstrated significant reduction in ICU stay and in the need for mechanical ventilation with the use of surfactant against placebo or not surfactant in patients using mechanical ventilators due to viral bronchiolitis.

References

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