1. Home>
2. Specialties>
3. Emergency Medicine>
4. Summary and Comment

Update on Evaluation and Treatment of Bronchiolitis

Recent evidence supports the 2006 American Academy of Pediatrics recommendations for the evaluation and treatment of bronchiolitis.

One third of children in the U.S. have bronchiolitis by age 2 years, and, among children younger than 6 months, the annual rate of respiratory syncytial virus (RSV)-related emergency department visits is 55 per 1000 children. In this review, the authors examined evidence from studies published after the 2006 American Academy of Pediatrics (AAP) guidelines on the evaluation and treatment of bronchiolitis (JW Pediatr Adolesc Med Jan 10 2007).

The AAP guidelines were issued in response to evidence for standardizing care and reducing unnecessary radiographic and laboratory testing. Subsequent studies have solidified this recommendation, showing that routine chest radiography leads to inappropriate use of antibiotics. Recent studies of rapid viral antigen tests demonstrate variable sensitivity and specificity, and testing is not recommended, except for admitted patients, in whom it might help reduce inpatient spread. Recent studies show that during the first few months of life, infants with bronchiolitis and fever have near-zero risk for serious bacterial illness; when bacterial illness is identified in these patients, it most often is urinary in origin.

Studies on use of bronchodilators have had mixed results, and meta-analyses have not demonstrated any benefit. Although some small studies indicated that nebulized epinephrine is beneficial, a large, well-designed 2009 Canadian study of 800 infants did not show any benefit (JW Emerg Med May 13 2009). Benefits of corticosteroid treatment also remain unproven. In a 2007 U.S. study of 600 infants, a single dose of dexamethasone did not improve hospitalization rates or clinical scores (JW Emerg Med Jul 25 2007), and, in the 2009 Canadian study, a 6-day course of dexamethasone demonstrated no benefit.

The authors conclude that recent evidence supports the 2006 AAP guidelines, which recommend limiting the use of epinephrine and steroids as well as radiographic and laboratory testing in children with bronchiolitis. More studies are needed to address combination therapies, home oxygen therapy, and newer treatments, such as nebulized hypertonic saline.

Comment: Providers often feel the need to do something specific for bronchiolitis, but these guidelines clearly support limiting chest radiography, viral testing, and administration of steroids or epinephrine. Management instead should focus on radiography for children with suspected bacterial pneumonia coinfection, viral testing to risk-stratify infants with fever and equivocal diagnoses of bronchiolitis, and bronchodilators for patients with underlying reactive airway disease. For all patients, providers should consider supportive measures, such as suctioning of secretions, supplemental oxygen therapy, and oral rehydration.

— Katherine Bakes, MD

Published in Journal Watch Emergency Medicine February 26, 2010

Citation(s):

Zorc JJ and Hall CB. Bronchiolitis: Recent evidence on diagnosis and management. Pediatrics 2010 Feb; 125:342.

• Original article (Subscription may be required)
• Medline abstract (Free)

2011 Top Stories