Bronchiolitis: supportive care only
The case
A previously well 6-month-old boy born at term presents to the emergency department with 3 days of coryza, worsening cough and poor feeding. There is no history of recurrent wheeze or cardiorespiratory disease. Respiratory rate is 68/min, heart rate 160/min, temperature 37.9°C and oxygen saturation 90% in room air. He has moderate subcostal and intercostal recession with diffuse expiratory wheeze and fine bilateral crackles, but no focal bronchial breathing. Capillary refill is 2 seconds with no signs of dehydration. Nasopharyngeal PCR is positive for respiratory syncytial virus. No chest X-ray has been performed. What is the most appropriate immediate management?
Options
- AOxygen, nasal suction and attention to hydration
- BOral amoxicillin and a chest X-ray
- CNebulised hypertonic saline in the emergency department
- DA single dose of intramuscular dexamethasone and observe
- EA trial of salbutamol, continued if it helps
Think it through before you read on. Which single option is best, and why are the other four wrong?
Show the answer and explanation
Answer
A. Oxygen, nasal suction and attention to hydration
Why this is the right answer
Bronchiolitis is the commonest reason for hospital admission in Australian infants. It is a viral infection of the small airways, most often RSV, in babies under 12 months. The picture is classic: a coryzal prodrome, then cough, tachypnoea, recession, wheeze and fine crackles throughout both lungs, with feeding difficulty.
The Australasian PREDICT bronchiolitis guideline (2016, updated 2022) is clear that treatment is supportive only. Nothing shortens the illness. Care consists of oxygen when saturations are persistently below 92% (some centres use 90%), gentle nasal suction to clear the upper airway before feeds, and maintaining hydration, by nasogastric feeds or intravenous fluids if the baby cannot take enough by mouth. Minimal handling helps.
This baby needs admission: he has hypoxaemia, moderate work of breathing and poor feeding, which are the main severity markers. High-flow nasal oxygen is used if standard oxygen is not enough.
The guideline is equally clear about what not to do. Salbutamol, adrenaline, corticosteroids, hypertonic saline and antibiotics have all been shown in trials not to help, and each carries side effects. Chest X-rays are not indicated in typical bronchiolitis; they often show patchy changes that lead to unnecessary antibiotics.
Risk factors for severe disease include prematurity, age under 6 weeks, chronic lung or heart disease and Aboriginal or Torres Strait Islander background, and these lower the threshold for admission.
Why the other options are wrong
- B
There are no features of bacterial pneumonia; antibiotics and X-rays are not indicated in typical bronchiolitis.
- C
Hypertonic saline has not shown benefit in the emergency department and is not recommended.
- D
Corticosteroids do not help bronchiolitis, regardless of severity.
- E
Wheeze in bronchiolitis is from oedema and mucus, not bronchospasm; salbutamol trials are not recommended.
High-yield takeaway
Bronchiolitis is treated with oxygen, suction and fluids only; salbutamol, steroids, hypertonic saline, antibiotics and X-rays are all off the list.
Reference: PREDICT Australasian Bronchiolitis Guideline (2022)
Common questions
Which treatments do not help in bronchiolitis?
Salbutamol, corticosteroids, nebulised adrenaline, hypertonic saline and antibiotics. None shortens the illness.
When does a baby with bronchiolitis need admission?
Persistent hypoxaemia, moderate or severe work of breathing, poor feeding, apnoea, or risk factors such as prematurity or young age.
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