SPECIAL ISSUE 

ARTICLE Less is More: 

Evidence-Based Management 
of Bronchiolitis 
Elisa Hampton, MD; and Erika Abramson, MD, MS 

ABSTRACT 
Bronchiolitis is a common cause of outpatient visits and hospitalization in children younger than age 2 years. Despite the 
frequency with which pediatricians manage this di- agnosis, there is significant variability in care in both the inpatient and 
outpatient setting. This may be due in part to changing guidelines set forth by leading pediatric organizations such as the 
American Academy of Pediatrics, as increasing evidence emerges that tradi- tional therapies are not effective. This article 
reviews current evidence-based practices for diagnosis and treatment of bronchiolitis, and provides an overview of inpatient 
manage- ment. [Pediatr Ann. 2017;46(7):e252-e256.] I 
n are dren the often with winter, chief filled pediatricians’ complaints with offices young chil- of fever, cough, and 
wheezing. Frequently, this constellation of symptoms is a result of bronchiolitis—a clinical diagnosis made in 
children younger than age 2 years who present with lower respira- tory signs and symptoms (tachypnea, wheezing, 
increased work of breathing) in the setting of viral infection. The ini- tial presenting symptoms are often rhi- norrhea 
and cough, which later progress to lower respiratory tract illness.1 It will come as no surprise to a general pedia- 
trician that bronchiolitis accounts for more office visits than diaper rash, uri- nary tract infections, or gastroenteritis, 
and that bronchiolitis visits make up at least 10% of outpatient pediatric visits 
is the most common cause of hospital- ization for infants younger than age 12 months,1 and accounts for 18% of all 
hospitalizations for these children (ex- cluding routine births).2 Hospitalizations for bronchiolitis in the United 
States result in an estimated $1.73 billion an- nually in hospital charges.2 Despite the high prevalence of 
bronchiolitis, mortal- ity rates are low and have been decreas- ing over time (4 per 10,000 patients in 2011).6 Most 
deaths from bronchiol- and 16% of hospitalizations for chil- 
itis are in infants younger than age 12 dren younger than age 2 years.2,3 
This 
months and in children with complex article reviews current 
evidence-based 
chronic conditions (most commonly car- practices for diagnosis and 
treatment of 
diovascular conditions).6 bronchiolitis, with a focus on inpatient 
Despite the frequency with which management. 
 general pediatricians encounter this The 2014 American Academy of Pe- 
diagnosis, practice patterns are often diatrics (AAP) clinical practice 
guide- 
highly variable.7 We present a series of line on the diagnosis, 
management, and 
important questions that general pedia- prevention of bronchiolitis 
defines bron- 
tricians can ask to help them guide their chiolitis as “a constellation of 
signs and 
care for pediatric patients presenting symptoms occurring in children 
younger 
with suspected bronchiolitis. than 2 years including a viral upper re- 
spiratory tract prodrome followed by 
WHAT LABORATORY OR IMAGING increased respiratory effort and 
wheez- 
STUDIES SHOULD BE OBTAINED IF ing.”1 A number of viral 
etiologies have 
BRONCHIOLITIS IS SUSPECTED? been identified, but the primary 
cause is 
The 2014 AAP clinical practice respiratory syncytial virus (RSV), 
which 
guideline recommends against routinely is the causative virus for up to 
80% of 
obtaining laboratory or radiographic bronchiolitis in infants.4,5 
Bronchiolitis 
studies for bronchiolitis, as the diagno- sis can be made clinically.1 As always, Elisa Hampton, MD, is an Assistant Professor of 
Clinical Pediatrics, Weill Cornell Medicine. Erika 
obtaining a careful history is 
key, and it Abramson, MD, MS, is an Associate Professor of Pediatrics and Healthcare Policy & Research, Weill 
is important to consider 
alternative di- Cornell Medicine. 
agnoses such as ingestion of a 
foreign Address correspondence to Elisa Hampton, MD, Weill Cornell Medicine, 505 E. 70th Street, 5th Floor, 
body. Viral testing is not 
recommended New York, NY 10021; email: elp9047@med.cornell.edu. 
because there are many viruses 
that can Disclosure: The authors have no relevant financial relationships to disclose. 
cause bronchiolitis, but the 
underlying doi: 10.3928/19382359-20170620-02 
viral etiology is generally not correlated 
e252 Copyright © SLACK Incorporated 
 
SPECIAL ISSUE ARTICLE 
with specific clinical findings or respon- siveness to interventions.5 
Therefore,  identifying  the  specific  vi-  ral  etiology  is  unlikely  to  add  significant  information  that  will  change 
prognosis  or  management.  In  addition,  polymerase  chain  reaction  testing  may  uncover  pro-  longed  viral  shedding 
from an unrelated prior illness and not be representative of the current etiology for symptoms.1 
Routine  radiographic  imaging  is  also  not  recommended  due  to  the  high  preva-  lence  of  abnormalities  on  chest 
X-ray in infants with bronchiolitis and the lack of correlation between these abnormalities and clinical outcomes.1 In 
fact,  imaging  with  chest  X-ray  is  correlated  with  an  in-  creased  use  of  antibiotics.8  Furthermore,  reducing  the 
number of chest X-rays has been shown to decrease costs without af- fecting clinical outcomes.9 
WHAT PREDISPOSING RISK FACTORS MIGHT LEAD TO A WORSE CLINICAL COURSE? 
Elements  of a patient’s history that are most relevant for an office visit for bronchiolitis are factors that contribute 
to  an  overall risk assessment for the patient. Risk factors for severe disease in bronchiolitis include age younger than 
12  weeks  and  underlying  medi-  cal  conditions  such  as  premature  birth,  cardiopulmonary  disease,  and  immuno- 
deficiency.1  Children  who have had re- current wheezing or have other chronic pulmonary disease likely represent a 
distinct population, and the management recommendations reviewed here do not apply to these infants. 
In  addition  to  assessing  for  risk  fac-  tors  for  severe  disease,  another  important  goal  of  the  initial  history  and 
physical  examination  in  the  office  setting  is  to  as-  sess  the  patient  for  severe  disease  at  this  moment  in  time.  Of 
particular impor- tance is assessing hydration, activity lev- el, mental status, and respiratory effort. 
In addition, as bronchiolitis is known to be a dynamic and rapidly changing dis- ease process, assessing the ability of 
the  family  to  provide  supportive  care,  under-  stand  concerning  signs  and  symptoms,  and  return  for  follow-up  is 
critical. 
HOW CAN PATIENTS AT HIGH RISK FOR SEVERE DISEASE BE BETTER PROTECTED? 
One  tool  available  to  the  outpatient  pediatrician  for  the  prevention  of  RSV  infection  is  palivizumab.  The  AAP 
Committee  on  Infectious  Diseases  pub-  lished  guidelines in 2014 on the use of palivizumab for prophylaxis of RSV 
in-  fection.10  This  policy  statement  recom-  mends  restricting  use  of  palivizumab  to  a  specific  group  of  high-risk 
infants,  including  premature  infants with a ges- tational age of less than 29 weeks, pre- term infants with a diagnosis 
of  chronic  lung disease of prematurity (defined as gestational age <32 weeks requir- ing supplemental oxygen >21% 
for  at  least  28  days  after  birth),  and  infants  younger  than  age  12  months  with  he-  modynamically  significant 
congenital  heart  disease.  Other  subsets  of  infants,  including  those  with  pulmonary  ab-  normalities,  neuromuscular 
disease, or severely immunocompromised states, may also be considered for prophylaxis in some situations. 
Additionally,  preventive  care  for  all  patients  should  include  counseling  on  hand  hygiene,  breast-feeding 
promotion, and avoidance of tobacco smoke.1 
ARE THERE TREATMENTS FOR BRONCHIOLITIS IN THE OFFICE? 
The  mainstay  of  treatment  is  rou-  tine  supportive  care including ensur- ing adequate hydration and educating the 
family  about  signs  and  symptoms  that  signal  worsening  disease  and  need  for  re-evaluation.  Frequent  nasal  suc- 
tioning to remove secretions is help- 
ful,  although  “deep”  suctioning  of  the nasopharynx has been associated with increased length of stay in hospitalized 
children,  possibly  due  to  edema  of  the  upper airway.11 Chest physiotherapy with vibration or percussion is also not 
recommended as it has not been shown to be beneficial.1 
A  notable  change  between  an  earlier  version  of  the  AAP  bronchiolitis  clinical  practice guideline and the current 
guide-  line  relates  to  the  use of bronchodilators. Although some studies show an improve- ment in clinical symptom 
scores  with  the  use  of  albuterol,12,13  evidence  does  not  support  their  use  in  decreasing  need  for  hospitalization, 
shortening  length  of stay, or improving oxygen saturation. There- fore, there is a strong recommendation in the 2014 
AAP  guidelines  against  using  albuterol  in  patients  with  bronchiolitis.1  This  recommendation  relies  heavily  on  a 
Cochrane  review  from  2014  that  includ-  ed  30  studies  of  both  outpatients  and  in-  patients,14  and  included  the 
consideration  that  albuterol  use  can  cause  side  effects  such  as  tremor  and  tachycardia.  Despite  the  strong 
recommendation  against  the  use  of  bronchodilators  for  patients  with  bronchiolitis,  some  clinicians  might  still 
consider  a trial of albuterol for a patient who is wheezing for the first time and has a strong family history of asthma. 
It  is  important  to  note  that  although  a  small  number  of  children  with  viral-induced  wheezing  may  respond  to 
bronchodila-  tors,  there  is  no  reliable  way to determine which patients will have reversible air- way obstruction, nor 
whether the effect of the medication will be sustained with repeat administration. 
Nebulized  epinephrine  is  also  not  recommended.1  In  the  inpatient  setting,  epinephrine  use  has  been  associated 
with  increased  length  of  stay.15,16  In  the  outpatient  setting,  a  Cochrane  review  suggested  a  benefit  in  reducing 
admis- sion on the first day after an emergen- 
PEDIATRIC ANNALS • Vol. 46, No. 7, 2017 e253 
 
SPECIAL ISSUE ARTICLE 
cy  department  visit  but  not  at 7 days.17 Given that epinephrine is not gener- ally administered at home and that pro- 
longed  observation  after  administration  in  the  outpatient  setting  is  problematic,  the  authors  of  the  2014  clinical 
practice guideline1 strongly recommend against using epinephrine for the treatment of bronchiolitis. 
Similarly, corticosteroids are not recommended due to evidence showing no improvements in admission rates or 
venous  hydration  will  be  used.  Several  studies have compared nasogastric and intravenous hydration and found that 
clinical  outcomes  (including  duration of oxygen requirement, need for escala- tion of respiratory support, and length 
of  stay)  and parental satisfaction are simi- lar.1 Due to the evidence discussed in the previous section, infants are not 
routine-  ly  treated  with  albuterol,  epinephrine,  or  corticosteroids.12-14 Earlier evidence showed a possible decrease 
in  length  of  stay  when  nebulized  hypertonic  saline  treatments  were  used  in  hospitalized  infants;  however,  a 
reanalysis  of  this  data  in  2016  did  not  show  benefit  after  accounting  for  heterogeneity  of  the  in-  cluded  patient 
populations.19 Therefore, infants hospitalized for bronchiolitis are often not treated with any respiratory medications 
at all. 
Infants  will  be  treated  with  oxygen  for  sustained  hypoxia,  although  increas-  ing  oxygen  saturations  above  90% 
are  generally  accepted,  so  those  infants  are  not  treated  with  supplemental  oxygen.  This  is  due  to  an analysis of the 
oxy-  hemoglobin  dissociation  curve,  which  shows  that  increasing  oxygen  saturation  above  90%  requires  large 
elevations  in  arterial  pressure  of  oxygen.  Further-  more,  there  is  no  evidence  that  increas-  ing  oxygen  saturations 
above 90% af- fects clinical outcomes.1 
Another  change  in  the 2014 clinical practice guidelines is the option not to monitor hospitalized infants with con- 
tinuous  pulse  oximetry.  Studies  have  found  that  a  perceived  need  for  oxygen  is  a  key  driver  of  length  of  stay  in 
bron-  chiolitis,20  and  that  transient  hypoxemia  is  common  even  in  healthy  infants.21  A  2016  study22  showed that 
most  infants  evaluated  in  the  emergency  department  for  bronchiolitis  who  were  determined  to  be  stable  for 
discharge home had either transient or sustained oxygen desaturations. There were no differ- 

TABLE 1. Summary of Recommendations for Children with Bronchiolitis 

Diagnostic Test/Treatment 
Recommendation Based on 2014 AAP Clinical Practice Guideline1 
Laboratory studies, including viral testing 
Not routinely recommended 
Radiographic studies (chest X-ray) Not routinely recommended 
Nasal suctioning Often helpful 
“Deep” nasopharyngeal suctioning Insufficient evidence to make a recommendation (but 
unlikely to be beneficial) 
Chest physiotherapy Not recommended 
Albuterol Not recommended 
Epinephrine Not recommended 
Corticosteroids Not recommended 
History to identify risk factors for severe disease 
Recommendation to assess for risk factors including 
Age <12 weeks Underlying medical conditions such as prematurity, cardiopulmonary disease, and immunodeficiency 
Preventive measures Recommendation to disinfect hands before and after 
patient contact, contact with objects near patient, and after removing gloves using alcohol-based rubs or soap and water if alcohol 
rubs not available Recommendation to encourage breast-feeding Recommendation to assess for and counsel against 
environmental smoke exposure Recommend administering palivizumab during RSV season to infants who qualify 
Support for patients who cannot maintain oral hydration 
Recommendation to provide nasogastric or intravenous hydration 
Supplemental oxygen Option not to administer supplemental oxygen if satu- 
ration exceeds 90% 
Continuous pulse oximetry Option not to use continuous pulse oximetry 
Abbreviations: AAP, American Academy of Pediatrics; RSV, respiratory syncitial virus. 
length of stay, most notably from a 2013 Cochrane review.1,18 
IF MY PATIENT REQUIRES HOSPITALIZATION, WHAT CARE WILL THEY RECEIVE IN THE 
INPATIENT SETTING? 
When  infants  with  bronchiolitis  are  hospitalized,  the  goals  of  care  remain  supportive  while  the  acute  illness  re- 
solves. For infants who cannot hydrate themselves orally, nasogastric or intra- 
e254 Copyright © SLACK Incorporated 
 
SPECIAL ISSUE ARTICLE 
ences  between  those  with  and without desaturations in terms of unscheduled follow-up visits or delayed hospitaliza- 
tions;22 therefore, intermittent oxygen saturation monitoring is considered to be safe. 
Children  who  have  significant  re-  spiratory  distress  may  be  treated  with  high-flow  nasal  cannula,  which  is  a 
relatively  new mode of respiratory sup- port that supplies humidified, heated, high flow of an air-oxygen mixture via 
a  nasal  cannula.  This  therapy  is  increas-  ingly  being  used  in  all  clinical  settings,  including  the  emergency 
department,  intensive  care  unit,  and  some  inpatient  units.  It  has  been  shown  to  improve respiratory effort, generate 
positive airway pressure, and may decrease the need for intubation.1 
Once  an  infant  demonstrates  an im- provement of symptoms, no longer has significant respiratory distress, and is 
able  to  maintain  oral  hydration,  they  may  be  discharged  home  with  close  follow-up  with  their  outpatient  pediatri- 
cian.  There  should  be  close  communica-  tion  between  the  discharging  hospital  and  the  primary  pediatrician,  and 
fami-  lies  should  receive  education  about  the  expected  course  of  symptoms  as  well  as  signs  and  symptoms  that 
should prompt a return visit. 
SHOULD PARENTS EXPECT THEIR CHILD TO EXPERIENCE RECURRENT WHEEZING AFTER AN 
EPISODE OF BRONCHIOLITIS? 
Many  parents  worry about the likeli- hood of recurrent wheezing or the devel- opment of asthma later in life after 
an  episode  of  bronchiolitis.  Some  studies  do  show  an  association  between  severe  bronchiolitis  and  childhood 
asthma,  particularly  with  RSV  and  rhinovirus,  but  the  causality  is  unclear.23,24  It  is  not  yet  known  whether  some 
infants have a predisposition to both severe bronchiol- 
Dis J. 2013;32(9):950-955. doi: 10.1097/ INF.0b013e31829b7e43. 5. Meissner HC. Viral bronchiolitis in children. N Engl J Med. 
2016;374(18):1793-1794. doi: 10.1056/NEJMc1601509. 6. Byington CL, Wilkes J, Korgenski K, Sheng X. Respiratory syncytial 
virus-associated mortality in hospitalized infants and young children. Pediatrics. 2015;135(1):e24-31. doi: 
10.1542/peds.2014-2151. 7. Macias CG, Mansbach JM, Fisher ES, et al. Variability in inpatient management of chil- dren 
hospitalized with bronchiolitis. Acad Pediatr. 2015;15(1):69-76. doi: 10.1016/j. acap.2014.07.005. 8. Schuh S, Lalani A, Allen U, 
et al. Evaluation of the utility of radiography in acute bronchi- olitis. J Pediatr. 2007;150(4):429-433. doi: 
10.1016/j.jpeds.2007.01.005. 9. Yong JH, Schuh S, Rashidi R, et al. A cost effec- tiveness analysis of omitting radiography in di- 
agnosis of acute bronchiolitis. Pediatr Pulmonol. 2009;44(2):122-127. doi: 10.1002/ppul.20948. 10. American Academy of 
Pediatrics Committee on Infectious Diseases; American Academy of Pediatrics Bronchiolitis Guidelines Com- mittee. Updated 
guidance for palivizumab prophylaxis among infants and young chil- dren at increased risk of hospitalization for respiratory 
syncytial virus infection. Pedi- atrics. 2014;134(2):415-420. doi: 10.1542/ peds.2014-1665. 11. Mussman GM, Parker MW, 
Statile A, Sucha- rew H, Brady PW. Suctioning and length of stay in infants hospitalized with bronchiolitis. JAMA Pediatr. 
2013;167(5):414-421. doi: 10.1001/jamapediatrics.2013.36. 12. Kellner JD, Ohlsson A, Gadomski AM, Wang EE. Efficacy of 
bronchodilator therapy in bronchiolitis. A meta-analysis. Arch Pediatr Adolesc Med. 1996;150(11):1166-1172. 13. Flores G, 
Horwitz RI. Efficacy of beta2-ago- nists in bronchiolitis: a reappraisal and meta- analysis. Pediatrics. 1997;100(2 Pt 1):233-239. 
14. Gadomski AM, Scribani MB. Broncho- dilators for bronchiolitis. Cochrane Da- tabase Syst Rev. 2014(6):CD001266. doi: 
10.1002/14651858.CD001266.pub4. 15. Wainwright C, Altamirano L, Cheney M, et al. A multicenter, randomized, 
double-blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med. 2003;349(1):27-35. doi: 
10.1056/NEJ- Moa022226. 16. Skjerven HO, Hunderi JO, Brügmann-Pieper SK, et al. Racemic adrenaline and inhalation 
strategies in acute bronchiolitis. N Engl J Med. 2013;368(24):2286-2293. doi: 10.1056/ NEJMoa1301839. 17. Hartling L, Bialy 
LM, Vandermeer B, et al. Epinephrine for bronchiolitis. Cochrane Da- tabase Syst Rev. 2011(6):CD003123. doi: 
itis  and  recurrent  wheezing  later  in  life  due  to  epidemiologic  or genetic factors, or whether there is injury or altered 
de-  velopment  of  the  lungs  during  the  acute  illness  that  later  causes  recurrent  wheez-  ing.5  In  other  words,  as 
pediatricians, our best answer to this question may only be “time will tell.” 
CONCLUSION 
We  have  presented  a  series  of  ques-  tions  that  can  guide  pediatricians  in  car- ing for children with bronchiolitis, 
and  these  recommendations  are  summarized  in  Table  1.  When  caring  for  patients  in  the  outpatient  setting, 
pediatricians  should  carefully  assess  patients  for  risk  factors  for  severe  disease,  assess  current  respiratory  and 
hydration  status,  and  as-  sess  the  family’s  ability  to  care  for  the  patient  at  home.  If  hospitalization  is  indi-  cated, 
pediatricians  and  families  should  expect  infants  to  receive  supportive  care  until  the  acute  illness  has  resolved.  In- 
creasingly,  evidence  is  suggesting  that  medical  interventions  such  as  diagnostic  testing,  respiratory  medications 
other  than  oxygen,  and  continuous  monitoring  do  not  alter the course of bronchiolitis. In general, less is more when 
caring for infants with bronchiolitis. 
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1. Ralston SL, Lieberthal AS, Meissner HC, et al.; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, 
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10.1002/14651858.CD003123.pub3. 18. Fernandes RM, Bialy LM, Vandermeer B, et al. Glucocorticoids for acute viral 
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10.1056/NEJMoa1211592. 
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