Bronchiolitis: An Evidence-Based Approach to Management

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Bronchiolitis is a common respiratory illness in infancy for which there is a great deal of clinical practice variation, leading to costly resource utilization without clear evidence for benefit. Recent literature has focused on developing a broad base of evidence through systematic reviews and meta-analyses. This review will focus on this literature as it relates to pharmacologic and nonpharmacologic therapies and other management decisions. In addition, it will highlight some emerging evidence regarding the management of bronchiolitis and innovative new therapies.

Section snippets

Diagnostic Testing

Bronchiolitis is generally diagnosed on the basis of typical history and physical examination findings. Patients are usually younger than 2 years, presenting with cough, coryza, and first-time wheezing. This is preceded by a few days of upper respiratory symptoms, such as rhinorrhea and nasal congestion. Despite this easily recognizable clinical presentation, many clinicians use chest radiography as an adjunct in the diagnosis of bronchiolitis. In a study of 30 large children's hospitals, chest

Therapy

As with diagnostic testing, there is a high degree of practice variability with respect to therapeutic measures for bronchiolitis. Many therapies that have proven effective in other disease entities, such as asthma and cystic fibrosis, have been used, although it is important to recognize differences in pathophysiology that may lead to different clinical responses. Recent literature has focused on systematically analyzing the available data regarding common therapies to determine whether it

Emerging Evidence

There are a variety of other therapies for which the literature continues to evolve. A great deal of literature supports the use of nebulized hypertonic saline in the treatment of cystic fibrosis, in which clearance of thickened secretions is essential. A recent multicenter trial of 96 patients admitted for bronchiolitis compared nebulized 3% hypertonic saline with nebulized normal saline in a double-blind fashion. The group treated with hypertonic saline had a 26% reduction in hospital length

Disposition and Predicting Outcomes

An essential component in the evaluation and management of bronchiolitis in the ED is the ability to predict its natural course and assess the risk of progression to more severe disease. Infants' symptoms generally worsen for the first 3 to 5 days and then gradually improve, sometimes over a prolonged period. According to one series, nearly 40% of patients remain symptomatic at 2 weeks and nearly 1 in 10 will not have returned to baseline even at 4 weeks [38]. It is important to explain this

Summary

Bronchiolitis is a common respiratory disease in infancy, and it results in a large number of health care visits and expenditures. Despite an abundance of literature addressing various treatment modalities, management remains largely supportive. Emergency department clinicians must continue to develop a comprehensive understanding of the dynamic and variable nature of the disease process and be able to effectively predict the severity of its clinical course. Finally, there is emerging evidence

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      It is critical to note, however, that these studies compared nebulized bronchodilator coadministered with 0.9% normal saline and “placebo” containing only nebulized normal saline. In a reappraisal of an earlier Cochrane Review of this topic, it was noted that inhalation with normal saline alone successfully reduced respiratory distress scores in 43% of infants in the control arms.20 We already know that inhaled 3% hypertonic saline improves airway clearance in bronchiolitis8 and that perhaps it is the total amount of sodium chloride delivered to the airway surface, and not the concentration nebulized, that is beneficial.21,22

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