Current Therapy for Bronchiolitis
Bronchiolitis is a common, self-limiting, seasonal viral respiratory tract infection in infancy accounting for the majority of hospital admissions in this age group. Supportive care is the mainstay of treatment, concentrating on fluid replacement, gentle suctioning of nasal secretions, prone position (if in hospital), oxygen therapy and respiratory support if necessary. There is a long history of pharmacological agents offering no benefit in acute bronchiolitis. More recently, nebulised epinephrine has been demonstrated to offer short term benefits, while two stratagems have shown promise in decreasing risk of hospitalisation and length of hospital stay. The combination of oral dexamethasone with nebulised epinephrine potentially decreases the need for hospitalisation, while nebulised 3% hypertonic saline mixed with a bronchodilator decreases the length of hospitalisation. Although both stratagems appear safe and well tolerated, their role in clinical practice remains unclear.
It is nearly 50 years since Reynolds and Cook wrote that "oxygen therapy is vitally important in bronchiolitis and there is little convincing evidence that any other therapy is consistently or even occasionally useful". The mainstays of treatment remain oxygen, fluids and, if necessary, respiratory support. More recently, the combination of nebulised epinephrine and dexamethasone, or nebulised hypertonic saline with a bronchodilator have emerged as potential therapeutic strategies.
The Scottish Intercollegiate Guidelines Network defines bronchiolitis as "a seasonal viral illness characterised by fever, nasal discharge and dry wheezy cough. Examination of the chest reveals crepitations and/or wheeze". In contrast, the American Academy of Pediatrics subcommittee defines bronchiolitis as "a disorder most commonly caused in infants by viral LRTI; it is the most common lower respiratory infection in this age group and is characterised by acute inflammation, oedema and necrosis of epithelial cells lining small airways, increased mucus production and bronchospasm". These definitions reflect differences in the interpretation of the disease – in North America bronchiolitis may encompass children up to 2 years of age with a first episode of multi-trigger wheeze. These differences may also limit the generalisability of some studies.
Bronchiolitis is the most common cause for lower respiratory tract infection (LRTI) during the first year of life, and even allowing for differences in definition, accounts for majority of hospital admissions during this period in the UK and the USA. Between 2% and 3% of all infants are hospitalised in their first 12 months of life with bronchiolitis, imposing a significant burden on the healthcare system. Although many viruses may cause the constellation of symptoms and signs that characterise bronchiolitis, 60–85% of cases are caused by respiratory syncytial virus (RSV). Every year between 132 000 and 172 000 children less than 5 years of age are hospitalised in the USA with RSV infections. Smoking, overcrowding and low socioeconomic status are all associated with increased incidence of bronchiolitis related hospital admissions. Infants with co-morbidities including premature birth, immunodeficiency, left to right shunt congenital heart disease or interstitial lung diseases are more prone to develop severe disease. Approximately 2% of infants hospitalised with bronchiolitis will require intubation and mechanical ventilation.
Abstract and Introduction
Abstract
Bronchiolitis is a common, self-limiting, seasonal viral respiratory tract infection in infancy accounting for the majority of hospital admissions in this age group. Supportive care is the mainstay of treatment, concentrating on fluid replacement, gentle suctioning of nasal secretions, prone position (if in hospital), oxygen therapy and respiratory support if necessary. There is a long history of pharmacological agents offering no benefit in acute bronchiolitis. More recently, nebulised epinephrine has been demonstrated to offer short term benefits, while two stratagems have shown promise in decreasing risk of hospitalisation and length of hospital stay. The combination of oral dexamethasone with nebulised epinephrine potentially decreases the need for hospitalisation, while nebulised 3% hypertonic saline mixed with a bronchodilator decreases the length of hospitalisation. Although both stratagems appear safe and well tolerated, their role in clinical practice remains unclear.
Introduction
It is nearly 50 years since Reynolds and Cook wrote that "oxygen therapy is vitally important in bronchiolitis and there is little convincing evidence that any other therapy is consistently or even occasionally useful". The mainstays of treatment remain oxygen, fluids and, if necessary, respiratory support. More recently, the combination of nebulised epinephrine and dexamethasone, or nebulised hypertonic saline with a bronchodilator have emerged as potential therapeutic strategies.
The Scottish Intercollegiate Guidelines Network defines bronchiolitis as "a seasonal viral illness characterised by fever, nasal discharge and dry wheezy cough. Examination of the chest reveals crepitations and/or wheeze". In contrast, the American Academy of Pediatrics subcommittee defines bronchiolitis as "a disorder most commonly caused in infants by viral LRTI; it is the most common lower respiratory infection in this age group and is characterised by acute inflammation, oedema and necrosis of epithelial cells lining small airways, increased mucus production and bronchospasm". These definitions reflect differences in the interpretation of the disease – in North America bronchiolitis may encompass children up to 2 years of age with a first episode of multi-trigger wheeze. These differences may also limit the generalisability of some studies.
Bronchiolitis is the most common cause for lower respiratory tract infection (LRTI) during the first year of life, and even allowing for differences in definition, accounts for majority of hospital admissions during this period in the UK and the USA. Between 2% and 3% of all infants are hospitalised in their first 12 months of life with bronchiolitis, imposing a significant burden on the healthcare system. Although many viruses may cause the constellation of symptoms and signs that characterise bronchiolitis, 60–85% of cases are caused by respiratory syncytial virus (RSV). Every year between 132 000 and 172 000 children less than 5 years of age are hospitalised in the USA with RSV infections. Smoking, overcrowding and low socioeconomic status are all associated with increased incidence of bronchiolitis related hospital admissions. Infants with co-morbidities including premature birth, immunodeficiency, left to right shunt congenital heart disease or interstitial lung diseases are more prone to develop severe disease. Approximately 2% of infants hospitalised with bronchiolitis will require intubation and mechanical ventilation.
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