As RSV season approaches, remember these key points in managing bronchiolitis:
Diagnosis is clinical - labs and XRays will not help you, unless you want to rule out a specific alternate diagnosis. It's all about the H&P.
Supportive care, including bulb suction of secretions, placing the child in a position of comfort, and possibly providing humidified air, is the mainstay of treatment.
Ribavirin, corticosteroids, and antibiotics are not indicated. Don't use them.
Bronchodilators have no benefit in bronchiolitis alone, and non-response to bronchodilators supports the diagnosis of bronchiolitis. If a trial does work, know what you are treating - some children with bronchiolitis may have an underlying component of reactive airway disease, and should be treated accordingly.
Before disposition be sure that the child can tolerate PO. A fussy, tachypneic child may require admission for IV hydration if they are unable to tolerate feeds - recall that infants are obligate nose breathers.
Finally, beware the RSV bronchiolitis bounceback - the peak incidence of respiratory failure in RSV bronchiolitis is after 3-4 days of illness, when most children should be improving.
References
American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. Oct 2006;118(4):1774-93.
Jartti T, Mäkelä MJ, Vanto T, Ruuskanen O. The link between bronchiolitis and asthma. Infect Dis Clin North Am. Sep 2005;19(3):667-89.
Kellner JD, Ohlsson A, Gadomski AM, Wang EE. Efficacy of bronchodilator therapy in bronchiolitis. A meta-analysis. Arch PediatrAdolesc Med. Nov 1996;150(11):1166-72.
