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[1]
Oxygen therapy
- Supplemental oxygen therapy must be used to mantain oxygen saturation above (SpO2) 90% in patients with previous normal SpO2.
- Infants with persistant respiratory distress who do not respond to supplemental oxygen therapy should be treated with nasal continous positive airway pressure (CPAP) or tracheal intubation.[2]
- It is recommended to closely monitor SpO2 if the patient's clinical status does not improve.
- It is strongly recommended to closely monitorize 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 eficacy of albuterol treatment without demonstrating significant changes in the course of the disease.
- The use of racemic epinephrine has not been demostrated efficient for the long term improvement of the disease, however, one RCT showed improvement in the SpO2 in the first hour after nebulization.[3]
- One study proved that nebulized l-epinephrin is more effective than albuterol to prevent hospitalization in patients with bronchiolitis.[4]
- Benefits were observed only in outpatient trials, the use of bronchodilators did not show improvements in hospitlized 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 revist or readmission.
- Spacial cases, such as patients with family history of asthma or atopy and/or previous atopic dermatitis, could benefit from the use of corticosteroid therapy.[2]
Antiviral therapy
- Ribavirin should not be used regularly for the treatment of bronchiolitis. Several RCT have demostrated 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
- Randimized clinical trials showed no benefit in antibiotic treatment for brochiolitis if there is no concomitant bacterial infection.
- Urinary tract infection and acute otitis media (AOM) are the most common cause of seecondary bacterial infections in patients with bronchiolitis. The treatment for bacterial infections should not differ in patients with brochiolitis than in those without brochiolitis.
- acute otitis media is a common infection associated with brochiolitis. Though RSV can cause AOM, clinical findings are ussually simillar 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 pathogen based antibiotic treatment for AOM is shown below.
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Bacterial AOM pathogen based treatment ▸ Streptococcus pneumoniae ▸ Haemophilus influenzae ▸ Moraxella catarrhalis |
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.[2]
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.[2]
- 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.[5]
Prevention
Recommendations for the prevention of bronchiolitis are based on the 2006 American Academy of Pediatrics Practice Guidelines for the Diagnosis and Management of Bronchiolitis.[1]
Palivizumab prophylaxis
Recommendations are based on the 2009 AAP Modified Recomendations for Use of Palivizumab for Prevention of Respiratory Syncytial Virus Infections.[6]
- Prophylaxis is recommended in selected patients with high risk of severe bronchiolitis:
- Patients younger than 2 years of age who required medical therapy for chronic lung disease 6 months or less before the RSV season.
- Patients younger than 2 years of age with congenital heart disease.
- Infants who are receiving congestive heart failure treatment.
- Cyanotic heart disease.
- Moderate to severe pulmonary hypertention.
- Hystory of prematurity.
- Prophylaxis is recommended in premature infants with less than 32 weeks of gestation with or without chronic lung disease of prematurity.
- For patients born with 28 weeks of gestation or less, prophylaxis is recommended for their first RSV season disregarding the age of the patient. If the prophylaxis is started, it should continue through all the RSV season.
- For patients born with 29 to 32 weeks of gestation, prophylaxis is recommended for patients are born 6 months or less before the RSV season. If the prophylaxis is started, it should continue through all the RSV season.
- For patients bor with 32 to 35 weeks of gestation, prophylaxis ir recommended in patients who are born 3 months before the RSV season or during the RSV season and 1 of the following risk factors which may require hospitalization due to bronchiolitis:
- Infants with school-aged sbilings.
- Infants who attend to child care centers.
- Infants who have either congenital abnormalities of the airway or neuromuscular disease that compromises handling of respiratory secretions.
Dosage
- 15 mg/kg monthly doses to a maximum of 5 doses is the recommended regimen for patients born before 32 weeks of gestation, congenital heart disease with significant hemodynamic consequences or chronic lung disease.
- 15 mg/kg montly doses to a maximum of 3 doses is the recommended regimen for patients bor between 32 and 35 weeks of gestation who meet the criteria for prophylaxis.
Other measures
- Infants should not be exposed to tobacco as it has been shown that it increases the risk of RSV infection.
- Breasfeeding lowers the risk of lower tract infections in infants by the ingestion of immune factors such as immunoglobulins A and G.
- The use of alcohol-based rubs or antimicrobial soaps to mantain a correct hand hygiene in health care workers is important to prevent nosocomial dissemination of the disease when dealing with hospitalized patients.
References
- ↑ 1.0 1.1 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.
- ↑ 2.0 2.1 2.2 2.3 Wright M, Mullett CJ, Piedimonte G (2008). "Pharmacological management of acute bronchiolitis". Ther Clin Risk Manag. 4 (5): 895–903. PMC 2621418. PMID 19209271.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Committee on Infectious Diseases (2009). "From the American Academy of Pediatrics: Policy statements--Modified recommendations for use of palivizumab for prevention of respiratory syncytial virus infections". Pediatrics. 124 (6): 1694–701. doi:10.1542/peds.2009-2345. PMID 19736258.