Bronchiolitis

Alyssa H. Silver, MD,* Joanne M. Nazif, MD*

*Department of Pediatrics, Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY

f bronchiolitis, limiting the use of extensive diagnostic testing.

ngle effective therapeutic agent; therefore, with an aim to provide high-value and high-quality care, clinicians should be aware that the main treatment plan for

ObjectivesAfter completing this article, readers should be able to:

e and diagnose patients with bronchiolitis.
rize the 2014 American Academy of Pediatrics guidelines for the management and prevention of bronchiolitis.
y potential current therapies as well as interventions not recommended for routine use in bronchiolitis.
prevention measures for bronchiolitis.
e the prognosis for patients diagnosed as having bronchiolitis.

INTRODUCTION

Acute bronchiolitis refers to airway inflammation and obstruction of the

lower respiratory tract and is caused almost exclusively by viral infection
in children younger than 2 years. Commonly, symptoms of bronchiolitis
begin with rhinitis or congestion and cough and may develop into
symptoms of increasing respiratory distress (tachypnea, wheezing, and
accessory muscle use). (1) Severity of bronchiolitis can vary from mild
symptoms that can be managed at home to acute respiratory failure
AUTHOR DISCLOSURE Drs Silver and Nazif
requiring invasive ventilation. There is wide variation in care for infants have disclosed no financial relationships
admitted to the hospital with bronchiolitis, which persists despite the relevant to this article. This commentary does
existence of guidelines. (2)(3)(4) In 2014, the American Academy of not contain a discussion of an unapproved/
investigative use of a commercial product/
Pediatrics (AAP) published the “Clinical Practice Guideline: The Diagnosis, device.
Management, and Prevention of Bronchi- olitis” (1) (summarized in Table 1),
an updated, revised version of a previous 2006 AAP guideline. (5) The ABBREVIATIONS
strength of these recommendations are explained in Table 2. (1) AAP American Academy of Pediatrics
LOS length of stay
Pediatricians should be familiar with these guidelines as well as evidence
RSV respiratory syncytial virus
behind available diagnostic and treatment modalities. Greater

568 Pediatrics in Review

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TABLE 1. Summaryof the American Academy of Pediatrics Clinical
Practice Guideline: The Diagnosis, Management, and
Prevention of Bronchiolitis
KEY ACTION
RECOMMENDATION LEVEL OF EVIDENCE
STATEMENT STATEMENT
STRENGTH QUALITYa

1a Clinicians should diagnose bronchiolitis and assess disease severity on

the basis of history and physical examination findings Strong B

1b Clinicians should assess risk factors for severe disease, such as age
<12 wk, a history of prematurity, underlying cardiopulmonary Moderate B
disease, or immunodeficiency when making decisions about
evaluation and management of children with bronchiolitis

1c When clinicians diagnose bronchiolitis on the basis of history and

physical examination findings, radiographic or laboratory Strong B
studies should not be obtained routinely

2 Clinicians should not administer albuterol (or salbutamol) to infants

and children with a diagnosis of bronchiolitis Strong B

3 Clinicians should not administer epinephrine to infants and children

with a diagnosis of bronchiolitis Strong B

4a Nebulized hypertonic saline should not be administered to infants

with a diagnosis of bronchiolitis in the emergency department Moderate B

4b Clinicians may administer nebulized hypertonic saline to infants and

children hospitalized for bronchiolitis Weak (based on randomized B
controlled trials with
inconsistent findings)

5 Clinicians should not administer systemic corticosteroids to infants

with a diagnosis of bronchiolitis in any setting Strong A

6a Clinicians may choose not to administer supplemental oxygen if the

oxyhemoglobin saturation exceeds 90% in infants and children with Weak (based on low-level D
a diagnosis of bronchiolitis evidence and reasoning
from first principles)
6b Clinicians may choose not to use continuous pulse oximetry for infants
and children with a diagnosis of bronchiolitis Weak (based on lower-level C
evidence)

7 Clinicians should not use chest physiotherapy for infants and children
with a diagnosis of bronchiolitis Moderate B

8 Clinicians should not administer antibacterial medications to infants

and children with a diagnosis of bronchiolitis unless there is a Strong B
concomitant bacterial infection, or a strong suspicion of one

9 Clinicians should administer nasogastric or intravenous fluids for

infants with a diagnosis of bronchiolitis who cannot maintain Strong
hydration orally

10a Clinicians should not administer palivizumab to otherwise healthy X

infants with a gestational age of 29 weeks, 0 days or greater

10b Clinicians should administer palivizumab during the first year of life to Strong B
infants with hemodynamically significant heart disease or chronic
lung disease of prematurity defined as preterm infants on >21%
Moderate B
oxygen for at least the first 28 days of age

10c Clinicians should administer a maximum of 5 monthly doses (15 mg/kg

per dose) of palivizumab during the respiratory syncytial virus
season to infants who qualify for palivizumab in the first year of Moderate B
life

11a All people should disinfect hands before and after direct contact with
patients, after contact with inanimate objects in the direct vicinity
Strong B
of the patient, and after removing gloves

11b All people should use alcohol-based rubs for hand decontamination
when caring for children with bronchiolitis. When alcohol-based rubs
Strong B
are not available, individuals should wash their hands with soap and
water Continued

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 Vol. 40 No. 11 NOVEMBER 20 19 569

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 TABLE 1. (Continued)

KEY ACTION RECOMMENDATION STRENGTHLEVEL OF EVIDENCE QUALITYa

STATEMENT STATEMENT C

Clinicians should inquire about the 12a

exposure of the infant or child to tobacco smoke when assessing infants and children forModerate
bronchiolitis
Clinicians should counsel caregivers about exposing the infant or child to environmental tobacco smoke and about smoking cessation when assessing a child for bronchiolitis
Clinicians should encourage exclusive
12bbreastfeeding for ‡6 mo to decrease the morbidity of respiratory infections Strong B
Clinicians and nurses should educate personnel and family members on evidence-based diagnosis, treatment, and prevention of bronchiolitis

13 Moderate B

14 Moderate C

aLevel A ¼ Intervention: Well-designed and conducted trials, meta-analyses on applicable populations. Diagnosis: Independent gold standard studies of

applicable populations. Level B ¼ Trials or diagnostic studies with minor limitations; consistent findings from multiple observed studies. Level C ¼ Single or
few observational studies or multiple studies with inconsistent findings or major limitations. Level D ¼ Expert opinion, case reports, reasoning from first
principles. Level X ¼ Exceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit or harm.
Reprinted with permission from Ralston SL, Lieberthal AS, Meissner HC; American Academy of Pediatrics, et al. Clinical practice guideline: the diagnosis,
management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474–e1502.

adherence to clinical practice guidelines can help to 100 deaths annually, although mortality due to bronchiolitis is
minimize unwanted variation in care (such as varying significantly higher in resource-limited countries. (9)
rates of albuterol use), which can have unintended The epidemiology of RSV differs globally based on
consequences (such as the adverse effects of tachycardia mete- orologic conditions. In temperate climates, illness
and jitteriness or increased length of stay [LOS]), and can from RSV occurs in epidemics based on colder
help to improve high- value, high-quality care, with temperatures. In the Northern Hemisphere, infection rates
improvement in clinically important outcomes for increase from late October through April and peak in
patients. (3)(6) January or February.
(8) This is followed by wintertime epidemics in the South-
EPIDEMIOLOGY ern Hemisphere from May to September. (10) During
As the leading reason for hospitalization in the first year of these peak times, viral transmission and disease severity
life, bronchiolitis is responsible for approximately 100,000 are thought to be facilitated by indoor crowding, the
hospital admissions annually in the United States. impair- ment of ciliary function by cold air, and the
Although the number of admissions declined from 2000 to temperature dependence of innate antiviral immune
2009, the number of emergency department visits, responses. (8) Alter- natively, in tropical or semitropical
disease severity, use of noninvasive or invasive climates, RSV outbreaks tend to be more common during
mechanical ventilation, and hospital charges all increased the rainy season. (10)
during this time. Nationwide, hospital charges for
patients with bronchiolitis exceeded PATHOGENESIS
$1.7 billion in 2009. (7)
The pathogenesis of bronchiolitis involves a combination of
Use of molecular detection techniques has made it airway edema, increased mucus production, and necrosis of
possible to identify a variety of causative viral agents for airway epithelial cells due to direct cytotoxic injury. (8) RSV
bronchiolitis. Respiratory syncytial virus (RSV) is by far the transmission occurs from person to person either by direct
most commonly identified virus, detected in up to 80% of inoculation of nasal mucosa with contaminated secretions or
patients, followed by human rhinovirus. Clinical features of by inhalation of large infectious droplets. Virus replicates in
bronchiolitis caused by individual viruses are generally the nasal epithelium, and an exaggerated immune
similar, although each virus demonstrates slight variation response occurs, with an influx of natural killer cells,
in seasonality and geographic distribution, and there are lymphocytes, and granulocytes into the epithelium. After an
some data to suggest that RSV may be associated with a incubation period of 4 to 6 days from transmission, upper
more severe illness course. (8) Some studies also point to respiratory tract symp- toms appear, including nasal
greater disease severity in infants with co- infection by 2 or congestion and rhinorrhea. (9) In approximately one-third
more viruses, although data are conflicting. (9) In the of infected patients, infection then spreads to the lower
United States, RSV bronchiolitis accounts for fewer than respiratory tract by sloughing and
570 Pediatrics in Review
aspiration of necrotic nasopharyngeal epithelial cells. chronic lung disease of prematurity and hemodynamically
(9) Viral replication subsequently occurs in the mucosal significant congenital heart disease, especially in
epi- thelial cells of the bronchioles. Similar to the upper patients with pulmonary hypertension or congestive
respi- ratory tract, the resultant immune response in heart failure. Trisomy 21, lower weight, and
the lower tract leads to edema, further sloughing of neuromuscular disorders have also been described as
epithelial cells, and mucus secretion. This leads to airway independent predictors of severe bronchiolitis. (11) Sex
narrowing and obstruction, further worsened by impaired may also play a role, with boys seeming to be at higher
ciliary function. Cough, wheezing, tachypnea, nasal risk for severe illness than girls. There does not seem
flaring, and retractions are the clinical manifestations of to be a disparity in rate of hospital- ization between
the airway obstruction. Distal air trapping causes African American and white infants; data for other racial
hyperinflation and localized atel- ectasis. Mismatching of and ethnic groups are limited. (9)
ventilation and perfusion leads to further increased work Several recent studies have focused on preventable envi-
of breathing and hypoxemia. Fever is not universal, ronmental risk factors for severe bronchiolitis. Although
occurring in approximately 50% of patients. An the mechanism is not completely understood, cigarette
uncomplicated illness may last 1 to 3 weeks before all smoke has been shown to affect the incidence and
symptoms are completely resolved, although viral shedding severity of bronchiolitis. Infants with in utero tobacco
may last up to 4 weeks, especially in very young or immu- smoke exposure were more likely to be admitted to the ICU
nocompromised patients. Unfortunately, despite the robust for bronchiolitis in one study, (12) and in another,
immune response, RSV infections occur throughout postnatal tobacco smoke exposure was associated with
life, even in the absence of detectable antigenic change. significantly increased odds of developing severe disease.
(9) (13) Other research suggests that air pollution, even at
levels widely accepted as “safe,” may increase bronchiolitis
RISK FACTORS risk. (14)
For most previously well infants, bronchiolitis is generally
a self-limited disease. However, a subset of patients may be CLINICAL ASPECTS
at risk for more severe disease, with several host and The diagnosis of bronchiolitis is made primarily based on
environ- mental factors contributing to severity risk. Age is history and physical examination findings. AAP guidelines
the most important predictor of disease severity, with recommend against the routine use of laboratory or radio-
greatest risk between 1 and 3 months, when protective graphic testing. Patients often present with a history of a
maternal anti- bodies wane. (9) Similarly, preterm infants, few days of initial upper respiratory symptoms
especially those less than 29 weeks of gestation who (rhinorrhea, congestion) and fever, progressing into lower
miss the window of greatest transplacental transfer of respiratory tract symptoms. Prominent lower respiratory
antibodies, are at higher risk for severe disease. Other tract symp- toms include cough, wheezing, tachypnea, and
severity risk factors include signs of

TABLE 2. Guideline Definitions for Evidence-Based Statements

STATEMENT DEFINITION IMPLICATION

Strong recommendation A particular action is favored because anticipated

benefits clearly exceed harms (or vice versa), Clinicians should follow a strong
and quality of evidence is excellent or recommendation unless a clear and
unobtainable. compelling rationale for an alternative
approach is present.
Moderate recommendation A particular action is favored because anticipated
benefits clearly exceed harms (or vice versa), Clinicians would be prudent to follow a moderate
and the quality of evidence is good but not recommendation but should remain alert to
excellent (or is unobtainable). new information and sensitive to patient
preferences.

Weak recommendation (based on benefits and harms)

low-quality evidence)
Weak recommendation
(based on balance of
A particular action is favored because anticipated the options in their decision making, but
benefits clearly exceed harms (or vice versa), but the Clinicians would be prudent patient preference may have a substantial
quality of evidence is weak. to follow a weak role.
recommendation but
should remain alert to
Weak recommendation is provided when the aggregate new information and very
database shows evidence of both benefit and harm sensitive to patient
that seem similar in magnitude for any available preferences.
courses of action.
Clinicians should consider
Vol. 40 No. 11 NOVEMBER 20 19 571
increased work of breathing (intercostal, subcostal, or circumstance for which it could be considered is in the setting of
supra- clavicular retractions; nasal flaring; head suspected potential influenza infection if the clinical
bobbing; or grunting). (9) Apnea alone may also be presentation as well as current community epide- miologic
an initial pre- sentation of bronchiolitis, particularly in factors support the possibility of influenza infec- tion, and,
infants younger than 2 months. Risk of apnea in young therefore, influenza antiviral agents could be considered. (16)
infants varies in studies from less than 1% to 24%.
(9)(15) Infants can present with difficulty feeding and
dehydration due to upper respiratory tract obstruction
from mucus produc- tion and airway edema.
Physical examination findings vary from mild, with
tachypnea, to severe, with complete respiratory failure.
Vital sign changes include tachypnea, hypoxemia, and
tachycar- dia (due to dehydration or as a reflection of
hypoxemia). (16) Other physical findings include
varying measures of increased work of breathing,
including varying degrees of retractions, head bobbing,
nasal flaring, and grunting. Signs of dehydration may also
be seen on examination, including delayed capillary
refill, sunken fontanelle, dry mucous membranes, and
poor skin turgor. Findings on auscultation can include
diffuse wheezing, crackles, coarse prolonged expiratory
phase, and transmitted upper airway sounds.
The course of illness can be varied and dynamic,
chang- ing from moment to moment. The typical course of
illness peaks at approximately day 3 to 4 of illness (16);
however, this can have significant variation. Similarly, in
assessing patients with bronchiolitis, physical examination
findings may vary from moment to moment so that often-
repeated observations are helpful to truly assess clinical
severity. The nature of inherent variability in children with
bronchiolitis has made it difficult for a single clinical
severity scoring system to be widely accepted in
predicting severity or clinical disposition. (17)
The AAP clinical practice guideline specifically
recom- mends against the routine use of chest radiography
for the evaluation of bronchiolitis. (1) Most patients with
bronchi- olitis have chest radiographs with hyperinflation,
possibly with atelectasis or infiltrates, which often do not
correlate with disease severity or aid with management.
(18) Abnor- mal findings may lead to increased use of
antibiotics without true underlying bacterial
pneumonia, increasing both potential harms to the
patient and health-care costs. (19)(20) Similarly, the
AAP clinical practice guideline rec- ommends against
routine viral testing given that identifi- cation of a given
virus does not alter management. (1) The only
MANAGEMENT practice guideline suggests that clinicians may choose to
not give supplemental oxygen therapy if saturations are
The management of bronchiolitis is largely
greater than 90%. (1) Similarly, for children hospitalized
supportive; despite numerous trials of various
with bronchiolitis, clinicians may choose not to use
medical therapeutic interventions, no clear
continuous pulse oximetry for those who do not require
single therapy has been found to be
supplemental oxygen. Both of these recom- mendations
significantly beneficial. The mainstay of therapy
have been shown to be safe compared with previous
begins with an assessment of need for supportive
oxygen targets and pulse oximetry measurement practices.
care by assessing hydration status and
(23)(24) The use of continuous pulse oximetry is not only
oxygenation. Dehydration can occur due to
potentially associated with increased LOS but also
increased insensible losses with tachypnea, fever,
occasionally feeds into the plight of overdiagnosis due
and increased secretions or due to decreased oral
to frequent false alarms, which can additionally lead to
intake in the setting of decreased energy, increased
sub- sequent decreased rest for patients and families. (25)
work of breathing, or congestion impeding oral
(26)
intake. Support for dehydration can be provided in
Although a common measure of supportive care, there
the form of encouraging frequent small aliquots of
is currently insufficient evidence to recommend for or
oral, nasogastric, or intravenous hydration, with-
against nasal suctioning as a potential intervention to
out a single modality being superior to the
help with upper airway obstruction due to mucus
others. Severe bronchiolitis may be associated
production. How- ever, there is evidence to recommend
with greater potential for hyponatremia, (21) and
against deep suction- ing because it can prolong LOS in
management with hypotonic fluids may also be
infants hospitalized with bronchiolitis. (27) Possible
associated with less favorable outcomes. (22)
explanations for this finding are that deep suctioning may
Hypoxemia may also accompany
cause more airway trauma and, therefore, edema and
bronchiolitis, and it may be intermittent or
irritation, inadvertently prolonging symptoms, or,
variable due to the intermittent nature of
alternatively, that the use of a larger-caliber catheter for
plugging of bronchioles by mucus resulting in
nasopharyngeal suctioning may be more effec- tive in
ventilation-perfusion mismatch. Whereas in the
clearing nasal secretions and, thus, improve symp- toms
past there has been debate about acceptable levels
sooner. (27) Similarly, chest physiotherapy has been
of oxygen saturation, the most recent AAP clinical
examined as a potential supportive measure that overall has

572 Pediatrics in Review

been shown to be ineffective at improving outcomes such treat bronchiolitis. (33) One study’s findings conflict
as LOS or disease severity; however, there are some with this statement; the study showed some potential
conflicting more recent studies that may suggest benefit when combining racemic epinephrine with
benefit, specifically using passive expiratory techniques, corticosteroids spe- cifically in the emergency department
such as providing bimanual thoracic and abdominal setting. (34) However, this has not been conclusively
pressure during expira- tion and holding the pressure for determined. Similarly, corti- costeroids have been shown
a few respiratory cycles. (28)(29) There is some potentially to be ineffective in the routine treatment of bronchiolitis.
conflicting evidence on this topic due to the heterogeneity (35)
of studies in the sense that the severity of illness in Nebulized hypertonic saline is a treatment option
patients included in these studies varies, as well as the that has received recent attention due to conflicting clinical
chest physiotherapy techniques vary between studies. (29) trial results, the conflict coming from reported widely
However, currently there is not enough benefit shown in varying LOSs, particularly in studies conducted outside
any particular group or method to warrant general the United States; but even when solely examining studies
recommendation. conducted in the United States, differences exist. (36)
Various studies and systematic reviews (30)(31)(32) have (37)(38) Several meta-analyses and systematic reviews
demonstrated that neither albuterol nor any other b-agonist have also come to different conclusions. (39)(40)(41)
bronchodilators should be used to treat children with bron- (42) The most recent publication using a more novel
chiolitis, concluding that the adverse effects and costs method, trial sequence analysis, has concluded that
supersede possible benefits. (1) Similarly, racemic epineph- results from previous meta- analyses that show a benefit
rine and other a receptor agonists should not be used to likely represent a type I error (concluding that a
statistically significant treatment exists, when one does not feeding while on high-flow nasal cannula, suggest that
exist in reality). Therefore, clear benefit from hypertonic heated humidified high-flow nasal cannula oxygen therapy
saline cannot be concluded. (43) is a safe treatment modality. (47)
Heated humidified high-flow nasal cannula oxygen is a
Antibiotic drug therapy is not recommended for the
treatment modality that has more recently gained
treatment of bronchiolitis unless an identified concomitant
popularity in use for the treatment of infants with
bacterial infection (such as acute otitis media or urinary
bronchiolitis, although its efficacy has not been
tract infection) is confirmed or suspected. Studies vary on
conclusively proved. There are data to suggest that heated
the potential risk of serious bacterial infection in infants
humidified high-flow nasal cannula oxygen may decrease
with bronchiolitis, which also differs by the age of the
respiratory effort and work of breathing, as well as some
patient in question. Although bacteremia and meningitis
potential evidence of decreasing need for escalation of care;
are extremely rare, infections such as urinary tract infection
however, again, conflicting data exist. (44)(45)(46) All of
or acute otitis media may be more common. (48)(49)
these studies, as well as additional studies focusing on
Laboratory testing to confirm concomitant bacterial
potential safety issues, including
infection when suspected should be obtained before
initiating antibiotic drug use. Antiviral drug therapy is not
recommended unless specifi- cally in the setting of
influenza infection, as noted previously herein. (16)
Measures to prevent bronchiolitis are important for the
pediatric provider to be familiar with to assist in
treating patients and educating families and caregivers. (1)
Prema- ture infants or infants with comorbidities (such
as hemo- dynamically significant heart disease,
immunodeficiency, or neuromuscular disease) should
receive prophylaxis with palivizumab as appropriate
during the RSV season, as per AAP guidelines, which may
vary year to year as to eligibility and specific
recommendations, with the most recent rec-
ommendations referenced. (50) In the clinical setting,
appropriate isolation precaution measures should be used
to minimize spread of infection to other patients or care-
givers. When speaking with families and caregivers of
young infants and children, clinicians should also empha-
size measures that will decrease risk of developing or
spreading bronchiolitis, such as appropriate hand hygiene
(using alcohol-based hand rubs or, when not available, soap
and water) and decreasing exposure of young infants
in particular to others who are ill. Other measures that
may decrease both the occurrence and severity of
bronchiolitis are decreasing tobacco smoke exposure as
well as encour- aging breastfeeding.
When specifically discussing emergency department or
inpatient management of bronchiolitis, differences in care
practices have been shown to correlate with differences in
hospital costs and LOS. Overuse of resources that are not
supported by the AAP guidelines has been associated with
increased LOS without the benefit of decreased
readmis- sion. (3) Clinical pathways that reinforce the
conservative approach (eg, not using bronchodilators) have
been associ- ated with decreased LOS, (51) decreased use
of ineffective therapies (such as bronchodilators or
corticosteroids), and decreased LOS without affecting
readmissions. (52)
Vol. 40 No. 11 N OV E M B E R 2 0 1 9 573
 The existence of the AAP clinical practice guideline has
itis should not routinely includefor
allowed thesignificant opportunity
use of bronchodilators, to implement
corticosteroids, various (1)(31)(32) Although there has been early conflicting evidence on the utility of nebulized hypertoni
or antibiotics.
nsus, clinicians should educate and counsel families about bronchiolitis and ways to minimize risk, including proper hand hygiene, decreasing tobacco smoke exposure, and encouraging breas
• quality
se palivizumab prophylaxis improvement
in specific populationsinitiatives, such as
based on specific using
annual clinical path- (50)
recommendations.
r using clinical pathways incorporating American Academy of Pediatrics clinical practice guidelines to help minimize variation of care, improve outcomes for patients, and prevent overuse of t
ways at an institution level, and to implement initiatives that
s is good because it is a self-limited illness. (1) Based on some research evidence and consensus, given the association with potential for future risk of wheezing and development of asthma, p
have resulted from national collaboratives. (53)(54)(55)
(56) Potential initiatives could target various outcomes
(such as LOS) or reduce evaluation or treatment measures
that are
not routinely recommended (such as chest radiography or •
bronchodilators, respectively).

PROGNOSIS

By nature, bronchiolitis is a self-limited disease with a •

relatively good prognosis. Mortality risk is relatively low

and declining in otherwise healthy children, including those
younger than 1 year, with recent analysis revealing an odds
•

ratio of 0.25 in the United States when examining in-

hospital mortality out of all patients hospitalized with bron-
chiolitis, comparing 2009 and 2000 mortality data, which
approximates fewer than 100 deaths annually. (7)(9) The •
most common sequela attributed to bronchiolitis is the
development of reactive airway disease or asthma later in
childhood. Although the reported risk varies from 20% to
60%, infants with severe bronchiolitis, such as those requir-
ing hospitalization (particularly infants <6 months of age),
have a higher risk of developing asthma later in life. (57)
(58) Asthma may occur with increased frequency in infants
with a personal or family history of atopy. Therefore,
counseling to all families after the initialToepisode
view teaching
of slides that accompany this article, visit content/40/11/568.supplemental.
bronchiolitis should include advice to be attentive to the
potential for wheezing or increased respiratory distress if
the child develops another viral respiratory illness in the
future.

nicians should not routinely use chest radiography or laboratory tests to evaluate. (1)
nuous pulse oximetry to monitor hospitalized patients with bronchiolitis and may choose to provide only supplemental oxygen therapy for oxygen saturations less than 90%. (23)(24)

References for this article are at

http://pedsinreview.aappubli- cations.org/content/40/11/568.
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phase. A diagnosis of viral bronchiolitis is made. In addition to deep nasal suctioning, which passing score on each, and
of the following is the next best step in management in this patient? start claiming MOC credits as
A. Administer a nebulized albuterol treatment. early as October 2019. To learn
B. Begin supplemental oxygen. how to claim MOC points, go
C. Obtain a chest radiograph. to:
D. Order a complete blood cell count and a blood culture. http://www.aappublications.
E. Start empirical broad spectrum antibiotics. org/content/moc-credit.

Vol. 40 No. 11 NOVEMBER 20 19 575

A 6-month-old boy is brought to the clinic by his parents for follow-up after discharge from
the hospital where he was admitted for 72 hours for respiratory syncytial virus (RSV) bronchiolitis. The parents are very concerned about their 2 older children in th
Administer palivizumab to the 6-month-old.
Begin prophylactic antibiotics for the other children.
Emphasize appropriate hand hygiene.
Ensure that all household members are up-to-date with recommended vaccines.
Keep the older children home from school for 7 days.
The parents of the infant described in the vignette in question 4 are concerned whether this RSV episode would result in late and long-term sequelae. They seek in
Chronic obstructive pulmonary disease.
Epilepsy.
Reactive airway disease.
Recurrent pneumonia.
Sinusitis.

576 Pediatrics in Review

 Bronchiolitis
Alyssa H. Silver and Joanne M. Nazif
Pediatrics in Review 2019;40;568
DOI: 10.1542/pir.2018-0260

Updated Information & including high resolution figures, can be found at:
Services http://pedsinreview.aappublications.org/content/40/11/568
Supplementary Material Supplementary material can be found at:
http://pedsinreview.aappublications.org/content/suppl/2019/10/31/40
.11.568.DC1
References This article cites 53 articles, 20 of which you can access for free at:
http://pedsinreview.aappublications.org/content/40/11/568.full#ref-li
st-1
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Pulmonology
http://classic.pedsinreview.aappublications.org/cgi/collection/pulmo
nology_sub
Bronchiolitis
http://classic.pedsinreview.aappublications.org/cgi/collection/bronch
iolitis_sub

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 Bronchiolitis
Alyssa H. Silver and Joanne M. Nazif
Pediatrics in Review 2019;40;568
DOI: 10.1542/pir.2018-0260

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/content/40/11/568

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