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Bronchiolitis

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Updated 2023 CDC guidelines for nirsevimab prophylaxis against respiratory syncytial virus infection.

Background

Overview

Definition
Bronchiolitis is an inflammatory condition primarily affecting the small airways or bronchioles, often characterized by acute viral infection in infants and young children.
1
Pathophysiology
The pathophysiology of bronchiolitis involves the infection of the epithelial cells lining the small airways, predominantly by the RSV. This infection leads to cell damage, increased mucus production, and inflammation, resulting in airway obstruction.
2
Epidemiology
It is estimated that 33 million cases of RSV-associated acute lower respiratory infections occurred globally in children < 5 years old in 2019.
3
Disease course
Clinically, bronchiolitis typically begins as an upper respiratory tract infection, progressing to lower respiratory symptoms such as cough, wheezing, and respiratory distress.
2
Prognosis and risk of recurrence
The prognosis of bronchiolitis is generally good, with most cases being self-limiting and resolving without complications.
1

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of bronchiolitis are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023), the American College of Obstetricians and Gynecologists (ACOG 2023), the Center for Disease Control (CDC 2023), the French Group for Pediatric Intensive Care and Emergencies (GFRUP 2023), the National Advisory Committee ...
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Screening and diagnosis

Diagnosis: as per CPS 2021 guidelines, diagnose bronchiolitis clinically based on history and physical examination.
E
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Classification and risk stratification

Risk assessment: as per PREDICT 2019 guidelines, regard the following as risk factors for more serious illness:
gestational age < 37 weeks
chronological age at presentation < 10 weeks
indigenous ethnicity
breastfeeding for < 2 months
exposure to cigarette smoke
failure to thrive
chronic pulmonary, heart, or neurological disease.
B

Diagnostic investigations

Clinical assessment: as per GFRUP 2023 guidelines, consider using clinical scores (such as the modified Wood's Clinical Asthma Score, the Wang score, and the Critical Bronchiolitis Score) for the initial assessment and follow-up.
E
Modified Wood's Clinical Asthma Score (mWCAS)
SpO2
≥ 95%, on room air
90-94%, on room air
≥ 90%, with a FiO2 > 0.21
< 90%, with a FiO2 > 0.21
Inspiratory breath sounds
Normal
Mild
Moderate
Decreased/absent
Expiratory wheezing
None
Mild
Moderate
Marked
Use of accessory muscles
None
Mild
Moderate
Maximal
Cerebral function
Normal
Agitated when disturbed
Depressed/agitated
Markedly depressed/coma
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  • CXR

  • Chest ultrasound

  • Laboratory tests

Respiratory support

Oxygen monitoring: as per GFRUP 2023 guidelines, consider monitoring the trend of respiratory parameters and/or clinical scores to assess disease evolution. Avoid obtaining systematic monitoring of pCO2 (and tcpCO2).
E

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  • Supplemental oxygen

  • Noninvasive ventilation

  • Invasive ventilation

Medical management

Setting of care, hospital admission: as per CPS 2021 guidelines, decide on hospital admission based on clinical judgment, factoring in the risk for progression to severe disease, respiratory status, ability to maintain adequate hydration and the family's ability to cope at home.
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  • Setting of care (pediatric ICU admission)

  • Supportive care

  • Nebulized hypertonic saline

  • Nebulized epinephrine

  • Bronchodilators

  • Corticosteroids

  • Antibiotics

  • Therapies with no evidence for benefit

Nonpharmacologic interventions

Chest physiotherapy: as per AAFP 2023 guidelines, do not offer chest physiotherapy for the treatment of RSV bronchiolitis.
D

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  • Nasal suctioning

Patient education

General counseling: as per AAP 2014 guidelines, ask about the exposure of the infant or child to tobacco smoke when assessing infants and children for bronchiolitis.
B
counsel caregivers about exposing the infant or child to environmental tobacco smoke and smoking cessation when assessing infants and children for bronchiolitis.
B
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Preventative measures

Maternal immunization: as per ACOG 2023 guidelines, offer a single dose of an approved RSV vaccine in pregnant individuals at 32-36 weeks of gestation, using seasonal administration (for example, September-January in most of the continental US), to prevent RSV-associated lower respiratory tract infection in infants through age 6 months.
E

More topics in this section

  • Nirsevimab prophylaxis

  • Palivizumab prophylaxis (general principles)

  • Palivizumab prophylaxis (prematurity)

  • Palivizumab prophylaxis (multiple birth)

  • Palivizumab prophylaxis (congenital heart disease)

  • Palivizumab prophylaxis (immunodeficiency)

  • Palivizumab prophylaxis (cystic fibrosis)

  • Palivizumab prophylaxis (Down syndrome)

  • Palivizumab prophylaxis (other comorbidities)

  • Palivizumab prophylaxis (prevention of wheezing or asthma)

  • Palivizumab prophylaxis (prevention of healthcare-associated RSV infection)

  • Palivizumab prophylaxis (remote communities)

  • Palivizumab prophylaxis (regimens)

  • Hand hygiene

Follow-up and surveillance

Discharge from hospital
As per PREDICT 2019 guidelines:
Take into account oxygen saturations, adequacy of feeding, age (< 8 weeks), and lack of social support at the time of discharge as a risk for representation.
E
Consider discharging infant patients at low risk for severe bronchiolitis, after a period of observation, on home oxygen with a clear return-to-hospital advice.
C

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  • Management of chronic cough