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Bronchiolitis
Nathaniel A. Justice; Jacqueline K. Le.

Author Information
Last Update: July 2, 2021.

Continuing Education Activity

Bronchiolitis is a common lung infection in young individuals. The viral infection involves the
lower respiratory tract and can present with signs of mild to moderate respiratory distress.
Bronchiolitis is a mild, self-limited infection in the majority of children but may sometimes
progress to respiratory failure in infants. This activity describes the causes, pathophysiology, and
presentation of bronchiolitis and highlights the role of the interprofessional team in its
management.

Objectives:

Review the etiology of bronchiolitis.

Describe the presentation of a patient with bronchiolitis.

Summarize the treatment options for bronchiolitis.

Explain the importance of improving care coordination among interprofessional team

members to improve outcomes for patients affected by bronchiolitis.

Earn continuing education credits (CME/CE) on this topic.

Introduction
Bronchiolitis is a common lung infection in young individuals. The viral infection involves the
lower respiratory tract and can present with signs of mild to moderate respiratory distress. The
most common cause is the respiratory syncytial virus (RSV). Bronchiolitis is a mild, self-limited
infection in the majority of children but may sometimes progress to respiratory failure in infants.
Bronchiolitis is managed supportively with hydration and oxygen. No specific medications treat
the infection.

It is important to know that the respiratory syncytial virus is just one cause of bronchiolitis. The
infection can occur in individuals of any age, but overall, the most severe symptoms tend to be
common in infants.[1][2][3]

Etiology
The most common virus associated with bronchiolitis is the respiratory syncytial virus. However,
over the years, many other viruses have been found to cause the same infection, and they include 
the following:

Human rhinovirus

Coronavirus

Human metapneumovirus
 Adenovirus

Parainfluenza virus

Human bocavirus

RSV accounts for the majority of cases, although in about 30% of infants, there may be 2 viruses
present at the same time.

Risk factors include:

Low birth weight (premature infants)

Age less than 5 months

Low socioeconomic population

Airway anomalies

Congenital immune deficiency disorders

Parental smoking

Crowded living environment

Chronic lung disease (bronchopulmonary dysplasia)

Epidemiology
Bronchiolitis is most common in children less than 2 years of age. During the first year of life,
the incidence has been reported to be about 11% to 15%. Depending on the severity of the
infection, there are at least 5 hospitalizations for every 1000 children younger than 2 years of
age. Bronchiolitis is classically a seasonal disorder that is most common during autumn and
winter, but sporadic cases may occur throughout the year. Some of the risk factors that have been
identified for severe infections include the following:

History of prematurity (less than 32 to 34 weeks gestational age)

Age younger than 3 months

Neuromuscular disease

Congenital heart disease

Chronic lung illness

Immunodeficiency

Pathophysiology
The clinical features of bronchiolitis are primarily due to airway obstruction and diminished lung
compliance. The virus infects the epithelial cells in the airways and induces an inflammatory
reaction that leads to ciliary dysfunction and cell death. The accumulated debris, edema of the
airways, and narrowing of the airways due to the release of cytokines eventually lead to
symptoms and lowered lung compliance. The patient then tries to overcome the decreased
compliance by breathing harder. Typical features include:

Air trapping

Increased mucus production

 Atelectasis

Labored breathing

Decreased ventilation [4][5][6]

History and Physical

Once RSV is acquired, the symptoms of an upper respiratory tract infection appear and include a
cough, fever, and rhinorrhea. Within 48 to 72 hours, the acute infection involving the lower
airways will become evident. During the acute stage, the infant may develop small airway
obstruction that leads to symptoms of respiratory distress. The physical exam will reveal
crackles, wheezing, and rhonchi. The severity of respiratory distress may vary from infant to
infant. Some infants may have mild disease with only tachypnea, but others may show severe
retractions, grunting, and cyanosis. The course of the illness may last 7 to 10 days, and the infant
may become irritable and not feed. However, most infants improve within 14 to 21 days, as long
as they are well hydrated.

Evaluation
The diagnosis of bronchiolitis is made clinically. Blood work and imaging studies are only
needed to rule out other causes. Ordering serology and other laboratory tests to identify the virus
is only for academic purposes. The presence of the virus in the blood does not correlate with
symptoms or the course of the disease. Laboratory assays in bronchiolitis are useful for
epidemiological studies and have little practical application.

A chest x-ray should only be ordered if there is clinical suspicion of a complication such as
pneumothorax or bacterial pneumonia. Urine cultures may be obtained in children who have no
other source of infection and continue to spike temperatures. Concomitant urinary tract infections
are known to occur in about 5% to 10% of cases.

Treatment / Management
The hallmark of management for children with bronchiolitis is symptomatic care. All infants and
children who are diagnosed with bronchiolitis should be carefully assessed for adequacy of
hydration, respiratory distress, and presence of hypoxia.[7][8][9][10]

Children who present with mild to moderate symptoms can be treated with interventions like
nasal saline, antipyretics, and a cool-mist humidifier. Those children with severe symptoms of
acute respiratory distress, signs of hypoxia, and/or dehydration should be admitted and
monitored. These children need aggressive hydration. The use of beta-adrenergic agonists like
epinephrine or albuterol, or even steroids, has not been shown to be effective in children with
bronchiolitis. Instead, these children should be provided with humidified oxygen and nebulized
hypertonic saline. Ensuring that the infant is well hydrated is key, especially for those who
cannot eat. Oxygen therapy to maintain saturations just above 90% is adequate.

Children who develop signs of severe respiratory distress may progress to respiratory failure.
These children may require intensive care for mechanical ventilation or non-invasive support. A
high-flow nasal cannula is an emerging modality of non-invasive support for children with
bronchiolitis. Clinical trials are in progress.

Passive immunization against RSV is available with palivizumab for those who are at the
greatest risk for severe illness. During the RSV season, this requires monthly injections of the
drug, but this may not only be expensive but not also not practical for most infants.
Current recommendations by the American Academy of Pediatrics support the use of
palivizumab during the first year of life for children with a gestational age less than 29 weeks,
symptomatic congenital heart disease, chronic lung disease of prematurity, neuromuscular
disorders that make it difficult to clear the airways, airway abnormalities, and immunodeficiency.
Prophylaxis may be continued in the second year of life for children who require continued
interventions for chronic lung disease of prematurity or those who remain immunosuppressed.

Differential Diagnosis

Asthma

Bacterial pneumonia

Gastroesophageal reflux disease (GERD)

Vascular ring

Croup

Foreign body aspiration

Pertussis

Prognosis
Bronchiolitis is a self-limited infectious process. It is commonly managed with supportive care,
hydration, fever control, and oxygenation. When the disorder is recognized and treated, the
prognosis is excellent. The majority of children recover without any adverse effects. Past studies
suggest that infants with severe bronchiolitis will develop wheezing in the future, but this has not
been borne out by longitudinal studies.

About 3% of infants will require admission to the hospital, and the mortality rates vary from
0.5% to 7%. The large variation in mortality is because of different risk factors and the lack of
availability of intensive care units in certain countries.

Complications
Complications include:

Nosocomial infection in infants who are admitted

Barotrauma is ventilation is required

Arrhythmias induced by beta-agonists

Nutritional deficiencies if there is persistent vomiting

Consultations
If an infant has been diagnosed with severe bronchiolitis, then a pediatrician and in infectious
disease expert should be consulted regarding their management.

Deterrence and Patient Education

Maintain oral hydration

Control temperature
 Avoid exposure to smoke in the home

Wash hands

Pearls and Other Issues

Bronchiolitis is a common lung infection in young individuals

The viral infection involves the lower respiratory tract and can present with signs of mild
to moderate respiratory distress.

Bronchiolitis is a mild, self-limited infection in the majority of children but may

sometimes progress to respiratory failure in infants.

The management of bronchiolitis is supportive hydration and oxygen. No specific

medications treat the infection.

Enhancing Healthcare Team Outcomes

Bronchiolitis is a common presentation to clinicians and adds significantly to the cost of
healthcare. To lower morbidity, the diagnosis and management of bronchiolitis are best done
with an interprofessional team that includes the emergency department physician, nurse
practitioner, pediatrician, primary caregiver, and infectious disease consultant. The diagnosis is
clinical, and in most cases, the treatment is supportive.

While most children benefit from hydration, some may require antipyretics and a cool-mist
humidifier. About 1% to 3% of children with bronchiolitis may require admission for more
aggressive respiratory support.

The key is the education of the caregiver. Clinicians, including the pharmacist and nurse
practitioner, should educate the caregiver with regards to:

The positioning of the infant

Temperature control in the home

Importance of oral hydration

Avoiding exposure to tobacco smoke and other irritants

Handwashing

Compliance with medications

When the infant is ill, the caregiver should be educated about when to bring him or her to the
hospital/clinician and not seek alternative care remedies. Follow-up of the infant is necessary to
ensure that improvement is taking place. Only through open communication with the
interprofessional team can the outcomes be improved and complications reduced.

Outcomes

When the disorder is recognized and treated, the prognosis is excellent. The majority of children
recover without any adverse effects. Past studies suggest that infants with severe bronchiolitis
will develop wheezing in the future, but this has not been borne out by longitudinal studies.[11]
[12]

Continuing Education / Review Questions

 Access free multiple choice questions on this topic.

Earn continuing education credits (CME/CE) on this topic.

Comment on this article.

References
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