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{{short description|Inflammation of the small airways in the lungs}}
{{distinguish|bronchitis|Obliterative bronchiolitis|Cryptogenic organizing pneumonia{{!}}bronchiolitis obliterans organizing pneumonia}}
{{Use dmy dates|date=December 2017}}
{{Use American English|date=December 2017}}
{{Infobox medical condition (new)
| name = Bronchiolitis
| synonyms =
| image = File:Bronchiolitis Medical Image.png
| caption = Depiction of the ___location of bronchiolitis in the lungs and viral shedding.
| pronounce =
| field = [[Emergency medicine]], [[pediatrics]]
| symptoms = Fever, cough, runny nose, [[Wheeze|wheezing]], breathing problems<ref name=Fri2014/>
| complications = [[Shortness of breath]], [[dehydration]]<ref name=Fri2014/>
| onset = Less than 2 years old<ref name=Sch2014/>
| duration =
| types =
| causes = [[Viral disease]] ([[respiratory syncytial virus]], [[Rhinovirus|human rhinovirus]])<ref name=Sch2014/>
| risks =
| diagnosis = Based on symptoms<ref name=Fri2014/>
| differential = [[Asthma]], [[pneumonia]], [[heart failure]], [[Allergy|allergic reaction]], [[cystic fibrosis]]<ref name=Fri2014/>
| prevention =
| treatment = [[Symptomatic treatment]] ([[Oxygen therapy|oxygen]], support with feeding, [[Intravenous therapy|intravenous fluids]])<ref name=Han2017/>
| medication =
| prognosis =
| frequency = ~20% (children less than 2)<ref name=Sch2014/><ref name=Fri2014/>
| deaths = 1% (among those hospitalized)<ref name=Ken2012/>
}}
<!-- Definition and symptoms -->
'''Bronchiolitis''' is inflammation of the small airways also known as the [[Bronchiole|bronchioles]] in the [[lung]]s. '''Acute bronchiolitis''' is caused by a [[Viral disease|viral infection]], usually affecting children younger than two years of age.<ref name="Ryu">{{cite journal | vauthors = Ryu JH, Azadeh N, Samhouri B, Yi E | title = Recent advances in the understanding of bronchiolitis in adults | journal = F1000Research | volume = 9 | page = 568 | date = 2020 | pmid = 32551095 | pmc = 7281671 | doi = 10.12688/f1000research.21778.1 | doi-access = free }}</ref> Symptoms may include [[fever]], cough, runny nose or [[rhinorrhea]], and [[Wheeze|wheezing]].<ref name=Fri2014/> More severe cases may be associated with [[Human nose|nasal flaring]], grunting, or respiratory distress.<ref name=Fri2014/> If the child has not been able to feed properly due to the illness, signs of [[dehydration]] may be present.<ref name=Fri2014/>
'''Chronic bronchiolitis''' is more common in adults and has various causes, one of which is [[bronchiolitis obliterans]].<ref name="Ryu"/><ref name="Robbins">{{cite book |title=Robbins basic pathology |date=2018 |___location=Philadelphia, Pennsylvania | publisher = Elsevier |isbn=9780323353175 |page=502 |edition=Tenth| vauthors = Kumar V, Abbas AK, Aster JC }}</ref> Often when people refer to bronchiolitis, they are referring to acute bronchiolitis in children.<ref name="Ryu" />
<!-- Cause and diagnosis -->
Acute bronchiolitis is usually the result of viral infection by [[respiratory syncytial virus]] (RSV) (59.2% of cases) or [[Rhinovirus|human rhinovirus]] (19.3% of cases).<ref name=":5">{{Cite journal |last1=Kenmoe |first1=Sebastien |last2=Kengne-Nde |first2=Cyprien |last3=Ebogo-Belobo |first3=Jean Thierry |last4=Mbaga |first4=Donatien Serge |last5=Fatawou Modiyinji |first5=Abdou |last6=Njouom |first6=Richard |date=2020-11-12 |editor-last=de Swart |editor-first=Rik L. |title=Systematic review and meta-analysis of the prevalence of common respiratory viruses in children < 2 years with bronchiolitis in the pre-COVID-19 pandemic era |journal=PLOS ONE |language=en |volume=15 |issue=11 |pages=e0242302 |doi=10.1371/journal.pone.0242302 |doi-access=free |issn=1932-6203 |pmc=7660462 |pmid=33180855|bibcode=2020PLoSO..1542302K }}</ref> Diagnosis is generally based on symptoms.<ref name=Fri2014>{{cite journal | vauthors = Friedman JN, Rieder MJ, Walton JM | title = Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age | journal = Paediatrics & Child Health | volume = 19 | issue = 9 | pages = 485–498 | date = November 2014 | pmid = 25414585 | pmc = 4235450 | doi = 10.1093/pch/19.9.485 }}</ref> Tests such as a [[Chest radiograph|chest X-ray]] or [[Viral culture|viral testing]] are not routinely needed, but may be used to rule out other diseases.<ref name=Sch2014/>
<!-- Treatment -->
There is no specific medicine that is used to treat bronchiolitis.<ref name=Han2017>{{cite journal | vauthors = Hancock DG, Charles-Britton B, Dixon DL, Forsyth KD | title = The heterogeneity of viral bronchiolitis: A lack of universal consensus definitions | journal = Pediatric Pulmonology | volume = 52 | issue = 9 | pages = 1234–1240 | date = September 2017 | pmid = 28672069 | doi = 10.1002/ppul.23750 | s2cid = 3454691 }}</ref><ref name=Kir2019>{{cite journal | vauthors = Kirolos A, Manti S, Blacow R, Tse G, Wilson T, Lister M, Cunningham S, Campbell A, Nair H, Reeves RM, Fernandes RM, Campbell H | display-authors = 6 | title = A Systematic Review of Clinical Practice Guidelines for the Diagnosis and Management of Bronchiolitis | journal = The Journal of Infectious Diseases | volume = 222 | issue = Suppl 7 | pages = S672–S679 | date = October 2020 | pmid = 31541233 | doi = 10.1093/infdis/jiz240 | doi-access = free | hdl = 20.500.11820/7d4708e3-7cdc-49f7-a9b3-a29040f4ff4e | hdl-access = free }}</ref> [[Symptomatic treatment]] at home is generally effective and most children do not require hospitalization.<ref name=Fri2014/> This can include [[antipyretic]]s such as acetaminophen for fever and nasal suction for nasal congestion, both of which can be purchased over the counter.<ref name="Fri2014" /> Occasionally, hospital admission for [[Oxygen therapy|oxygen]], particularly high flow nasal cannula, or [[Intravenous therapy|intravenous fluids]] is needed in more severe cases of disease.<ref name=Fri2014/>
<!-- Epidemiology and history -->
[[File:Respiratory Syncytial Virus and Bronchiolitis.webm|thumb|Video explanation]]About 10% to 30% of children under the age of two years are affected by bronchiolitis at some point in time.<ref name=Fri2014/><ref name=Sch2014>{{cite journal | vauthors = Schroeder AR, Mansbach JM | title = Recent evidence on the management of bronchiolitis | journal = Current Opinion in Pediatrics | volume = 26 | issue = 3 | pages = 328–333 | date = June 2014 | pmid = 24739493 | pmc = 4552182 | doi = 10.1097/MOP.0000000000000090 }}</ref> It commonly occurs in the [[winter]] season in the [[Northern Hemisphere]].<ref name=Fri2014/> It is the leading cause of hospitalizations in those less than one year of age in the United States.<ref name=Ral2014>{{cite journal | vauthors = Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S, Hernandez-Cancio S | display-authors = 6 | title = Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis | journal = Pediatrics | volume = 134 | issue = 5 | pages = e1474–e1502 | date = November 2014 | pmid = 25349312 | doi = 10.1542/peds.2014-2742 | doi-access = free }}</ref><ref name=Kir2019 /> The risk of death among those who are admitted to hospital is extremely low at about 1%.<ref name=Ken2012>{{cite book | vauthors = Ali A, Plint AC, Klassen TP | chapter = Bronchiolitis | veditors = Kendig EL, Wilmott RW, Boat TF, Bush A, Chernick V |title=Kendig and Chernick's Disorders of the Respiratory Tract in Children|date=2012|publisher=Elsevier Health Sciences|isbn=978-1437719840|page=450| chapter-url=https://books.google.com/books?id=w1xRGEXZ_bIC&pg=PA450}}</ref> Outbreaks of the condition were first described in the 1940s.<ref>{{cite book | vauthors = Graham BS, Anderson LJ | title = Challenges and Opportunities for Respiratory Syncytial Virus Vaccines | series = Current Topics in Microbiology and Immunology | volume = 372 | pages = 391–404 | date = 2013 | pmid = 24362701 | pmc = 7121045 | doi = 10.1007/978-3-642-38919-1_20 | publisher = Springer Science & Business Media | isbn = 9783642389191 }}</ref>
== Signs and symptoms ==
Bronchiolitis typically presents in children under two years old and is characterized by symptoms of a respiratory illness.<ref name="Fri2014" />{{listen|filename=Wheeze2O noise reduced.ogg|title=Wheezing|description=Wheezing heard in the lungs of an adult using a stethoscope. Similar sounds might be heard in a child with bronchiolitis.}}Signs of the disease include:<ref name="Ral2014" />
* fever
* [[rhinorrhea]]
* [[cough]]
* [[wheeze]]
* mild [[tachypnea]] or increased breathing
Some signs of severe disease include:<ref>{{cite book|title=BRONCHIOLITIS IN CHILDREN (Sign Guideline 91)|year=2006|publisher=Scottish Intercollegiate Guidelines Network|isbn=9781905813018|url=http://www.sign.ac.uk/guidelines/fulltext/91/index.html|access-date=6 December 2012|archive-url=https://web.archive.org/web/20121101201244/http://www.sign.ac.uk/guidelines/fulltext/91/index.html|archive-date=1 November 2012|url-status=dead}}</ref>
* increased work of breathing (such as use of accessory muscles of respiration, rib & sternal retraction, tracheal tug)
* severe chest wall recession ([[Hoover's sign (pulmonary)|Hoover's sign]])
* presence of nasal flaring and/or grunting
* severe tachypnea or increased breathing
* [[Hypoxia (medical)|hypoxia]] (low oxygen levels)
* [[cyanosis]] (bluish skin)
* lethargy and decreased activity
* poor feeding (less than half of usual fluid intake in preceding 24 hours)
These symptoms can develop over one to three days.<ref name="Fri2014" /> [[Crepitations|Crackles]] or [[wheeze]] are typical findings on listening to the chest with a stethoscope. Wheezes can occasionally be heard without a stethoscope. The child may also experience [[apnea]], or brief pauses in breathing, but this can occur due to many conditions that are not just bronchiolitis. After the acute illness, it is common for the airways to remain sensitive for several weeks, leading to recurrent cough and wheeze.<ref name="Fri2014" />
== Causes ==
Bronchiolitis is most commonly caused by [[respiratory syncytial virus]]<ref name=":5" /> (RSV, also known as human pneumovirus). Other agents that cause this illness include, but are not limited to, human [[metapneumovirus]], [[influenza]], [[parainfluenza]], [[coronavirus]], [[adenovirus]], [[rhinovirus]] and [[mycoplasma]].<ref name="Bourke11">{{cite journal | vauthors = Bourke T, Shields M | title = Bronchiolitis | journal = BMJ Clinical Evidence | volume = 2011 | date = April 2011 | pmid = 21486501 | pmc = 3275170 }}</ref><ref name=":6" />
[[File:Human Respiratory Syncytial Virus (RSV).jpg|thumb|RSV, which is the most common cause of acute bronchiolitis in children.]]
=== Risk factors ===
Children are at an increased risk for progression to severe respiratory disease if they have any of the following additional risk factors:<ref name="Kir2019" /><ref name="Ral2014" /><ref name=":6" /><ref name=":7">{{cite journal | vauthors = Carbonell-Estrany X, Figueras-Aloy J, Law BJ | title = Identifying risk factors for severe respiratory syncytial virus among infants born after 33 through 35 completed weeks of gestation: different methodologies yield consistent findings | journal = The Pediatric Infectious Disease Journal | volume = 23 | issue = 11 Suppl | pages = S193–S201 | date = November 2004 | pmid = 15577573 | doi = 10.1097/01.inf.0000144664.31888.53 | s2cid = 39990266 | doi-access = free }}</ref>
* Preterm infant ([[Gestational age (obstetrics)|gestational age]] less than 37 weeks)
* Younger age at onset of illness (less than 3 months of age)
* [[Congenital heart defect|Congenital heart disease]]
* [[Immunodeficiency]]
* Chronic lung disease
* Neurological disorders
* Tobacco smoke exposure
== Diagnosis ==
The diagnosis is typically made by a provider through clinical history and physical exam. [[Chest X-ray]] is sometimes useful to exclude bacterial [[pneumonia]], but not indicated in routine cases.<ref name="Fri2014" /> Chest x-ray may also be useful in people with impending respiratory failure.<ref name=":3">{{cite journal | vauthors = Caballero MT, Polack FP, Stein RT | title = Viral bronchiolitis in young infants: new perspectives for management and treatment | journal = Jornal de Pediatria | volume = 93 | issue = Suppl 1 | pages = 75–83 | date = 2017-11-01 | pmid = 28859915 | doi = 10.1016/j.jped.2017.07.003 | doi-access = free }}</ref> Additional testing such as blood cultures, complete blood count, and electrolyte analyses are not recommended for routine use although may be useful in children with multiple [[Comorbidity|comorbidities]] or signs of sepsis or pneumonia.<ref name="Kir2019" /><ref name=":3" /> Electrolyte analyses may be performed if there is concern for dehydration.<ref name="Fri2014" />
[[File:RSV.PNG|thumb|An X-ray of a child with [[Respiratory syncytial virus|RSV]] showing the typical bilateral [[Root of the lung|perihilar]] fullness of bronchiolitis. The arrows are pointing to the portion of the X-ray that is abnormal and shows fluffy perihilar fullness. ]]
Testing for the specific viral cause can be done but has little effect on management and thus is not routinely recommended.<ref name="Peds10">{{cite journal |vauthors=Zorc JJ, Hall CB |date=February 2010 |title=Bronchiolitis: recent evidence on diagnosis and management |journal=Pediatrics |volume=125 |issue=2 |pages=342–349 |doi=10.1542/peds.2009-2092 |pmid=20100768 |s2cid=4932917}}</ref> The COVID pandemic has led to more viral testing to exclude COVID as a cause of the infection. At that point providers often also add on a flu and RSV test for completeness. <ref name=":10" /> RSV testing by [[direct immunofluorescence]] testing of a swab of the nose had a [[Sensitivity and specificity|sensitivity of 61% and specificity of 89%]], so it is not alway accurate.<ref name=":6">{{cite journal | vauthors = Bordley WC, Viswanathan M, King VJ, Sutton SF, Jackman AM, Sterling L, Lohr KN | title = Diagnosis and testing in bronchiolitis: a systematic review | journal = Archives of Pediatrics & Adolescent Medicine | volume = 158 | issue = 2 | pages = 119–126 | date = February 2004 | pmid = 14757603 | doi = 10.1001/archpedi.158.2.119 | doi-access = free }}</ref><ref name=":3" /> Identification of those who are RSV-positive can help providers recommend isolation precautions in the hospital or at home to avoid the infection spreading to others. <ref name="Kir2019" /> Identification of the virus may help reduce the use of antibiotics because antibiotics are not recommended for viral illnesses such as bronchiolitis.<ref name=":3" />
It is extremely rare for infants to be co-infected with a bacterial illness while having bronchiolitis. Infants with bronchiolitis between the age of two and three months have a second infection by bacteria (usually a [[urinary tract infection]]) less than 6% of the time.<ref>{{cite journal | vauthors = Ralston S, Hill V, Waters A | title = Occult serious bacterial infection in infants younger than 60 to 90 days with bronchiolitis: a systematic review | journal = Archives of Pediatrics & Adolescent Medicine | volume = 165 | issue = 10 | pages = 951–956 | date = October 2011 | pmid = 21969396 | doi = 10.1001/archpediatrics.2011.155 | doi-access = free }}</ref> When further evaluated with a urinalysis, infants with bronchiolitis had an accompanying UTI 0.8% of the time.<ref name=":4">{{cite journal | vauthors = McDaniel CE, Ralston S, Lucas B, Schroeder AR | title = Association of Diagnostic Criteria With Urinary Tract Infection Prevalence in Bronchiolitis: A Systematic Review and Meta-analysis | journal = JAMA Pediatrics | volume = 173 | issue = 3 | pages = 269–277 | date = March 2019 | pmid = 30688987 | pmc = 6439888 | doi = 10.1001/jamapediatrics.2018.5091 }}</ref>
=== Differential diagnosis ===
There are many childhood illnesses that can present with respiratory symptoms, particularly persistent cough, runny nose, and wheezing.<ref name="Ral2014" /><ref name=":2" /> Bronchiolitis may be differentiated from some of these by the characteristic pattern of preceding febrile upper respiratory tract symptoms lasting for 1 to 3 days with associated persistent cough, increased work of breathing, and wheezing.<ref name=":2" /> However, some infants may present without fever (30% of cases) or may present with [[apnea]] without other signs or with poor weight gain prior to onset of symptoms.<ref name=":2" /> In such cases, additional laboratory testing and radiographic imaging may be useful.<ref name="Ral2014" /><ref name=":2" /> The following are some other diagnoses to consider in an infant presenting with signs of bronchiolitis:<ref name="Fri2014" />
* [[Upper respiratory tract infection|Upper Respiratory Infection]]
* [[Asthma]] and [[reactive airway disease]]
* [[Bacterial pneumonia]]
* [[Whooping cough]]
* [[Foreign body aspiration]]
* [[Congenital heart disease]]
* [[Allergic Reaction|Allergic reaction]]
* [[Vascular ring]]
* [[Heart failure]]
* [[Cystic fibrosis]]
* [[Chronic pulmonary disease]]
== Prevention ==
Prevention of bronchiolitis relies strongly on measures to reduce the spread of the viruses that cause respiratory infections (that is, handwashing, and avoiding exposure to those symptomatic with respiratory infections).<ref name=Kir2019 /><ref name="Ral2014" /> Guidelines are mixed on the use of gloves, aprons, or [[personal protective equipment]].<ref name=Kir2019 />
[[File:Hand washing.jpg|thumb|Handwashing can help reduce the spread of bronchiolitis.]]
One way to improve the [[immune system]] is to feed the infant with breast milk, especially during the first month of life.<ref name=":7" /><ref name="pmid22103307">{{cite journal | vauthors = Belderbos ME, Houben ML, van Bleek GM, Schuijff L, van Uden NO, Bloemen-Carlier EM, Kimpen JL, Eijkemans MJ, Rovers M, Bont LJ | display-authors = 6 | title = Breastfeeding modulates neonatal innate immune responses: a prospective birth cohort study | journal = Pediatric Allergy and Immunology | volume = 23 | issue = 1 | pages = 65–74 | date = February 2012 | pmid = 22103307 | doi = 10.1111/j.1399-3038.2011.01230.x | s2cid = 7605378 }}</ref> Respiratory infections were shown to be significantly less common among breastfed infants and fully breastfed RSV-positive hospitalized infants had shorter hospital stays than non or partially breastfed infants.<ref name="Ral2014" /> Guidelines recommend exclusive breastfeeding for infants for the first 6 months of life to avoid infection with bronchiolitis.<ref name="Ral2014" />
The US [[Food and Drug Administration]] (FDA) has currently approved two [[Respiratory syncytial virus vaccine|RSV vaccines]] for adults ages 60 and older, Arexvy ([[GSK plc]]) and Abrysvo ([[Pfizer]]).<ref name="FDARSV">{{cite web |title=Respiratory Syncytial Virus (RSV) |url=https://www.fda.gov/consumers/covid-19-flu-and-rsv/respiratory-syncytial-virus-rsv |archive-url=https://web.archive.org/web/20230916152645/https://www.fda.gov/consumers/covid-19-flu-and-rsv/respiratory-syncytial-virus-rsv |url-status=dead |archive-date=16 September 2023 |website=U.S. Food & Drug Administration |date=14 September 2023 |access-date=27 October 2023}}</ref> Abrysvo is also approved for "[[immunization]] of pregnant individuals at 32 through 36 weeks gestational age for the prevention of lower respiratory tract disease (LRTD) and severe LRTD caused by respiratory syncytial virus (RSV) in infants from birth through 6 months of age."<ref name=":9">{{cite web |title=ABRYSVO |url=https://www.fda.gov/vaccines-blood-biologics/abrysvo |archive-url=https://web.archive.org/web/20230602023847/https://www.fda.gov/vaccines-blood-biologics/abrysvo |url-status=dead |archive-date=2 June 2023 |website=U.S. Food & Drug Administration |access-date=27 October 2023}}</ref> It is unclear how effective these vaccines will be in preventing infection with bronchiolitis since they are new, although the FDA has approved them due to the clear benefit that they have shown in clinical trials.<ref name=":9" />
[[Nirsevimab]], a [[monoclonal antibody]] against RSV, is approved by the FDA for all children younger than 8 months in their first RSV season.<ref name="FDARSV" /> Additionally, children aged 8 to 19 months who are at increased risk may be recommended to receive Nirsevimab as they enter their second RSV season if they have increased risk factors for infection with RSV.<ref>{{cite news |title=FDA Approves New Drug to Prevent RSV in Babies and Toddlers |url=https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-prevent-rsv-babies-and-toddlers |access-date=27 October 2023 |agency=U.S. Food & Drug Administration |date=17 July 2023}}</ref><ref>{{cite web |title=RSV Immunization for Children 19 months and Younger |url=https://www.cdc.gov/vaccines/vpd/rsv/public/child.html |website=Centers for Disease Control and Prevention |access-date=27 October 2023}}</ref>
A second monoclonal antibody, [[Palivizumab]], can be administered to prevent bronchiolitis to infants less than one year of age that were born prematurely and that have underlying heart disease or chronic lung disease of prematurity.<ref name="Ral2014" /> Otherwise healthy premature infants that were born after a gestational age of 29 weeks should not be administered Palivizumab, as the harms outweigh the benefits.<ref name="Ral2014" />
[[Tobacco smoke]] exposure has been shown to increase both the rates of lower respiratory disease in infants, as well as the risk and severity of bronchiolitis.<ref name="Ral2014" /> Tobacco smoke lingers in the environment for prolonged periods and on clothing even when smoking outside the home.<ref name="Ral2014" /> Guidelines recommend that parents be fully educated on the risks of tobacco smoke exposure on children with bronchiolitis.<ref name="Ral2014" /><ref name=":2" />
== Management ==
Treatment of bronchiolitis is usually focused on the hydration and symptoms instead of the infection itself since the infection will run its course. Complications of bronchiolitis are typically from the symptoms themselves.<ref name="Wright">{{cite journal | vauthors = Wright M, Mullett CJ, Piedimonte G | title = Pharmacological management of acute bronchiolitis | journal = Therapeutics and Clinical Risk Management | volume = 4 | issue = 5 | pages = 895–903 | date = October 2008 | pmid = 19209271 | pmc = 2621418 | doi = 10.2147/tcrm.s1556 | doi-access = free }}</ref> Without active treatment, cases resolved in approximately eight to fifteen days.<ref>{{cite journal | vauthors = Thompson M, Vodicka TA, Blair PS, Buckley DI, Heneghan C, Hay AD | title = Duration of symptoms of respiratory tract infections in children: systematic review | journal = BMJ | volume = 347 | pages = f7027 | date = December 2013 | pmid = 24335668 | pmc = 3898587 | doi = 10.1136/bmj.f7027 }}</ref> Children with severe symptoms, especially poor feeding or dehydration, may be considered for hospital admission.<ref name="Kir2019" /> [[Oxygen saturation]] under 90%-92% as measured with [[pulse oximetry]] is also frequently used as an indicator of need for hospitalization.<ref name="Kir2019" /> High-risk infants, [[apnea]], [[cyanosis]], malnutrition, and diagnostic uncertainty are additional indications for hospitalization.<ref name="Kir2019" />
Most guidelines recommend sufficient fluids and nutritional support for affected children along with frequent nasal suctioning. <ref name=Kir2019 /> Measures for which the recommendations were mixed include nebulized hypertonic saline, nebulized [[Adrenaline|epinephrine]], and [[chest physiotherapy]]. <ref name="Fri2014" /><ref name="Kir2019" /><ref name="Heliox inhalation therapy for bronc">{{cite journal | vauthors = Liet JM, Ducruet T, Gupta V, Cambonie G | title = Heliox inhalation therapy for bronchiolitis in infants | journal = The Cochrane Database of Systematic Reviews | volume = 2015 | issue = 9 | pages = CD006915 | date = September 2015 | pmid = 26384333 | pmc = 8504435 | doi = 10.1002/14651858.CD006915.pub3 }}</ref><ref name=":0">{{cite journal | vauthors = Hartling L, Bialy LM, Vandermeer B, Tjosvold L, Johnson DW, Plint AC, Klassen TP, Patel H, Fernandes RM | display-authors = 6 | title = Epinephrine for bronchiolitis | journal = The Cochrane Database of Systematic Reviews | issue = 6 | pages = CD003123 | date = June 2011 | pmid = 21678340 | doi = 10.1002/14651858.CD003123.pub3 }}</ref><ref>{{cite journal | vauthors = Roqué-Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J | title = Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old | journal = The Cochrane Database of Systematic Reviews | volume = 2023 | issue = 4 | pages = CD004873 | date = April 2023 | pmid = 37010196 | pmc = 10070603 | doi = 10.1002/14651858.CD004873.pub6 }}</ref> Treatments which the evidence does not support include [[salbutamol]], [[corticosteroids|steroids]], [[antibiotics]], [[antivirals]], and [[heliox]].<ref name=Fri2014/><ref>{{cite journal | vauthors = Fernandes RM, Bialy LM, Vandermeer B, Tjosvold L, Plint AC, Patel H, Johnson DW, Klassen TP, Hartling L | display-authors = 6 | title = Glucocorticoids for acute viral bronchiolitis in infants and young children | journal = The Cochrane Database of Systematic Reviews | volume = 2013 | issue = 6 | pages = CD004878 | date = June 2013 | pmid = 23733383 | pmc = 6956441 | doi = 10.1002/14651858.CD004878.pub4 }}</ref><ref>{{cite journal | vauthors = Jat KR, Dsouza JM, Mathew JL | title = Continuous positive airway pressure (CPAP) for acute bronchiolitis in children | journal = The Cochrane Database of Systematic Reviews | volume = 2022 | issue = 4 | pages = CD010473 | date = April 2022 | pmid = 35377462 | pmc = 8978604 | doi = 10.1002/14651858.CD010473.pub4 }}</ref><ref>{{cite journal | vauthors = Umoren R, Odey F, Meremikwu MM | title = Steam inhalation or humidified oxygen for acute bronchiolitis in children up to three years of age | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD006435 | date = January 2011 | pmid = 21249676 | doi = 10.1002/14651858.CD006435.pub2 }}</ref>
=== Outpatient Management ===
==== Nutrition ====
Maintaining hydration is an important part of management of bronchiolitis.<ref name="Ral2014" /><ref name=":3" /><ref>{{cite journal | vauthors = Kua KP, Lee SW | title = Complementary and alternative medicine for the treatment of bronchiolitis in infants: A systematic review | journal = PLOS ONE | volume = 12 | issue = 2 | pages = e0172289 | date = 2017 | pmid = 28212381 | pmc = 5315308 | doi = 10.1371/journal.pone.0172289 | doi-access = free | bibcode = 2017PLoSO..1272289K }}</ref> Infants with mild pulmonary symptoms may require only observation if feeding is unaffected.<ref name="Ral2014" /> However, oral intake may be affected by nasal secretions and increased work of breathing.<ref name="Ral2014" /> Poor feeding or dehydration, defined as less than 50% of usual intake, is often cited as an indication for hospital admission.<ref name="Kir2019" />
==== Breathing/ Oxygen ====
Children must be closely monitored for changes in ability to breathe. Nasal suction can be used at home in order to decrease nasal congestion and open the airways. <ref name="Fri2014" />
Inadequate oxygen supply to the tissue is one of the main concerns during severe bronchiolitis and [[oxygen saturation]] is often closely associated with both the need for hospitalization and continued length of hospital stay in children with bronchiolitis.<ref name=":3" /> However, oxygen saturation is a poor predictor of respiratory distress.<ref name="Ral2014" /> Accuracy of [[pulse oximetry]] is limited in the 76% to 90% range and there is weak correlation between oxygen saturation and respiratory distress as brief [[hypoxemia]] is common in healthy infants.<ref name="Ral2014" /><ref name=":3" /> Additionally, pulse oximetry is associated with frequent false alarms and [[parental stress]] and fatigue.<ref name="Ral2014" />
==== Nasal Suction ====
Infants are nose breathers and bronchiolitis causes congestion of the airways with secretions that can make it difficult to feed and breathe.<ref>{{Cite journal |last1=Chirico |first1=G. |last2=Beccagutti |first2=F. |date=October 2010 |title=Nasal obstruction in neonates and infants |journal=Minerva Pediatrica |volume=62 |issue=5 |pages=499–505 |issn=0026-4946 |pmid=20940683}}</ref> Nasal suctioning is a very common supportive measure used at home to decrease nasal congestion.<ref name=":11">{{Cite journal |last1=Schuh |first1=Suzanne |last2=Coates |first2=Allan L. |last3=Sweeney |first3=Judy |last4=Rumantir |first4=Maggie |last5=Eltorki |first5=Mohamed |last6=Alqurashi |first6=Waleed |last7=Plint |first7=Amy C. |last8=Zemek |first8=Roger |last9=Poonai |first9=Naveen |last10=Parkin |first10=Patricia C. |last11=Soares |first11=Diane |last12=Moineddin |first12=Rahim |last13=Finkelstein |first13=Yaron |last14=Pediatric Emergency Research Canada (PERC) Network |last15=Carciumaru |first15=Redjana |date=2023-10-19 |title=Nasal Suctioning Therapy Among Infants With Bronchiolitis Discharged Home From the Emergency Department: A Randomized Clinical Trial |journal=JAMA Network Open |language=en |volume=6 |issue=10 |pages=e2337810 |doi=10.1001/jamanetworkopen.2023.37810 |issn=2574-3805 |pmc=10587796 |pmid=37856126}}</ref> It has not been extensively studied in the literature, but can be used to decrease secretions in the nose and has been proven mildly effective in one experimental trial.<ref name=":11" /> A nasal suction bulb can be purchased over the counter and directions for its use can be explained by a provider or on the back of the box. Clinical guidelines state that routine suctioning is safe and can provide relief for infants which allows them to eat and sleep more comfortably.<ref name="Ral2014" />
In those same clinical guidelines, it is stated that deep suctioning, which is often performed in the hospital is not recommended as it may lead to increased length of hospital stay in children with bronchiolitis.<ref name="Ral2014" />
=== Inpatient/ Hospital Management ===
==== Nutrition/ Fluid Therapy ====
When children are experiencing poor feeding or dehydration, the child may be admitted to the hospital.<ref name="Ral2014" /><ref name=":2" /><ref name=":3" /> Approximately 50% of infants who are hospitalized due to bronchiolitis require fluid therapy.<ref name=":8">{{cite journal |vauthors=Gill PJ, Anwar MR, Kornelsen E, Parkin P, Mahood Q, Mahant S |date=December 2021 |title=Parenteral versus enteral fluid therapy for children hospitalised with bronchiolitis |journal=The Cochrane Database of Systematic Reviews |volume=2021 |issue=12 |pages=CD013552 |doi=10.1002/14651858.CD013552.pub2 |pmc=8635777 |pmid=34852398}}</ref> There are two main approaches to fluid therapy: [[Intravenous therapy|intravenous]] (IV) fluid therapy and [[Enteral administration|enteral tube]] fluid therapy ([[Nasogastric intubation|nasogastric]] or [[Orogastric intubation|orogastric]]).<ref name=":8" /> Both approaches to fluid therapy are associated with a similar length of hospital stay.<ref name=":8" /> Enteral tube fluid therapy may reduce the risk of local complications, but the evidence for or against each approach is not clear.<ref name=":8" /> The risk of health care caused [[hyponatremia]] and fluid retention are minimal with the use of isotonic fluids such as [[normal saline]].<ref name="Ral2014" />
==== Oxygen ====
[[File:Nasal Prongs.jpg|thumb|Nasal cannula]]
If children are having trouble maintaining their oxygen saturations on room air, clinicians may choose to give additional oxygen to children with bronchiolitis if their oxygen saturation is below 90%.<ref name="Ral2014" /><ref name=":2" /><ref name=":3" /> Additionally, clinicians may choose to use continuous pulse oximetry in these people to monitor them.<ref name="Ral2014" />
The use of humidified, heated, high-flow [[nasal cannula]] may be a safe initial therapy to decrease work of breathing and need for [[intubation]].<ref name="Ral2014" /><ref name=":1">{{cite journal | vauthors = Lin J, Zhang Y, Xiong L, Liu S, Gong C, Dai J | title = High-flow nasal cannula therapy for children with bronchiolitis: a systematic review and meta-analysis | journal = Archives of Disease in Childhood | volume = 104 | issue = 6 | pages = 564–576 | date = June 2019 | pmid = 30655267 | doi = 10.1136/archdischild-2018-315846 | s2cid = 58666508 }}</ref><ref>{{Cite journal |last1=Dafydd |first1=Carwyn |last2=Saunders |first2=Benjamin J. |last3=Kotecha |first3=Sarah J. |last4=Edwards |first4=Martin O. |date=2021-07-29 |title=Efficacy and safety of high flow nasal oxygen for children with bronchiolitis: systematic review and meta-analysis |url=https://bmjopenrespres.bmj.com/content/8/1/e000844 |journal=BMJ Open Respiratory Research |language=en |volume=8 |issue=1 |pages=e000844 |doi=10.1136/bmjresp-2020-000844 |issn=2052-4439 |pmc=8323377 |pmid=34326153}}</ref> High flow nasal cannula may still be used in severe cases prior to intubation.<ref name=":2" /><ref>{{cite journal | vauthors = Combret Y, Prieur G, LE Roux P, Médrinal C | title = Non-invasive ventilation improves respiratory distress in children with acute viral bronchiolitis: a systematic review | journal = Minerva Anestesiologica | volume = 83 | issue = 6 | pages = 624–637 | date = June 2017 | pmid = 28192893 | doi = 10.23736/S0375-9393.17.11708-6 }}</ref> The use of [[Continuous positive airway pressure|CPAP]] has very limited evidence for improving breathing (a decreased respiratory rate) and does not reduce the need for mechanical ventilation.<ref>{{Cite journal |last1=Jat |first1=Kana R |last2=Dsouza |first2=Jeanne M |last3=Mathew |first3=Joseph L |date=2022-04-04 |editor-last=Cochrane Acute Respiratory Infections Group |title=Continuous positive airway pressure (CPAP) for acute bronchiolitis in children |journal=Cochrane Database of Systematic Reviews |language=en |volume=2022 |issue=4 |pages=CD010473 |doi=10.1002/14651858.CD010473.pub4 |pmc=8978604 |pmid=35377462}}</ref>
[[Arterial blood gas test|Blood gas testing]] is not routinely recommended for people hospitalized with the disease.<ref name=":3" /><ref name=":2" /> However, people with severe worsening respiratory distress or impending respiratory failure may be considered for capillary blood gas testing.<ref name=":2" />
=== Contradicting Evidence ===
==== Hypertonic saline ====
Guidelines recommend against the use of [[Nebulizer|nebulized]] [[hypertonic saline]] in the emergency department for children with bronchiolitis but it may be given to children who are hospitalized.<ref name="Ral2014" /><ref name=":3" />
[[Nebulized]] [[hypertonic saline]] (3%) has limited evidence of benefit and previous studies lack consistency and standardization.<ref name="Zh2017">{{cite journal |vauthors=Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP |date=December 2017 |title=Nebulised hypertonic saline solution for acute bronchiolitis in infants |journal=The Cochrane Database of Systematic Reviews |volume=2017 |issue=12 |pages=CD006458 |doi=10.1002/14651858.CD006458.pub4 |pmc=6485976 |pmid=29265171}}</ref><ref name="Brook2016">{{cite journal |vauthors=Brooks CG, Harrison WN, Ralston SL |date=June 2016 |title=Association Between Hypertonic Saline and Hospital Length of Stay in Acute Viral Bronchiolitis: A Reanalysis of 2 Meta-analyses |journal=JAMA Pediatrics |volume=170 |issue=6 |pages=577–584 |doi=10.1001/jamapediatrics.2016.0079 |pmid=27088767 |doi-access=free}}</ref><ref>{{cite journal | vauthors = Zhang L, Mendoza-Sassi RA, Klassen TP, Wainwright C | title = Nebulized Hypertonic Saline for Acute Bronchiolitis: A Systematic Review | journal = Pediatrics | volume = 136 | issue = 4 | pages = 687–701 | date = October 2015 | pmid = 26416925 | doi = 10.1542/peds.2015-1914 | doi-access = free }}</ref> It does not reduce the rate of hospitalization when therapy is given in the emergency department or outpatient setting.<ref name="Ral2014" /> A 2017 review found tentative evidence that it reduces the risk of hospitalization, duration of hospital stay, and improved the severity of symptoms.<ref name="Zh2017" /><ref>{{cite journal | vauthors = Zhang L, Gunther CB, Franco OS, Klassen TP | title = Impact of hypertonic saline on hospitalization rate in infants with acute bronchiolitis: A meta-analysis | journal = Pediatric Pulmonology | volume = 53 | issue = 8 | pages = 1089–1095 | date = August 2018 | pmid = 29893029 | doi = 10.1002/ppul.24066 | s2cid = 48358175 }}</ref> Side effects were mild and resolved spontaneously.<ref name="Zh2017" />
==== Bronchodilators ====
Guidelines recommend against the use of bronchodilators in children with bronchiolitis as evidence does not support a change in outcomes with such use.<ref name="Ral2014" /><ref name=":2" /><ref name="gadomski" /><ref>{{Cite web|url=https://www.aafp.org/patient-care/clinical-recommendations/all/bronchiolitis.html|title=Bronchiolitis - Clinical Practice Guideline|website=www.aafp.org|access-date=2019-10-23|archive-date=23 October 2019|archive-url=https://web.archive.org/web/20191023224948/https://www.aafp.org/patient-care/clinical-recommendations/all/bronchiolitis.html|url-status=dead}}</ref> Additionally, there are adverse effects to the use of bronchodilators in children such as [[tachycardia]] and [[tremor]]s, as well as adding increased cost to the medical visit.<ref>{{cite journal | vauthors = Chavasse R, Seddon P, Bara A, McKean M | title = Short acting beta agonists for recurrent wheeze in children under 2 years of age | journal = The Cochrane Database of Systematic Reviews | volume = 2002 | issue = 3 | pages = CD002873 | date = 2002 | pmid = 12137663 | pmc = 8456461 | doi = 10.1002/14651858.CD002873 }}</ref><ref name="gadomski">{{cite journal | vauthors = Gadomski AM, Scribani MB | title = Bronchodilators for bronchiolitis | journal = The Cochrane Database of Systematic Reviews | volume = 2014 | issue = 6 | pages = CD001266 | date = June 2014 | pmid = 24937099 | pmc = 7055016 | doi = 10.1002/14651858.CD001266.pub4 }}</ref>
Several studies have shown that [[Bronchodilator|bronchodilation]] with [[Beta-adrenergic agonist|β-adrenergic]] agents such as [[salbutamol]] may improve symptoms briefly but do not affect the overall course of the illness or reduce the need for hospitalization.<ref name="Ral2014" />
However, there are conflicting recommendations about the use of a trial of a bronchodilator, especially in those with history of previous wheezing.<ref name="Kir2019" /><ref name="Ral2014" /><ref name=":3" /> Bronchiolitis-associated wheezing is likely not effectively alleviated by bronchodilators anyway as it is caused by airway obstruction and plugging of the small airway diameters by luminal debris, not bronchospasm as in asthma-associated wheezing that bronchodilators usually treat well.<ref name="gadomski" /> If a clinician is concerned that reactive airway disease or asthma may be a component of the illness, a bronchodilator may be administered. <ref name="Ral2014" />
[[Anticholinergic]] inhalers, such as [[ipratropium bromide]], have a modest short-term effect at best and are not recommended for treatment.<ref name=":2" /><ref>{{cite journal | vauthors = Kellner JD, Ohlsson A, Gadomski AM, Wang EE | title = Efficacy of bronchodilator therapy in bronchiolitis. A meta-analysis | journal = Archives of Pediatrics & Adolescent Medicine | volume = 150 | issue = 11 | pages = 1166–1172 | date = November 1996 | pmid = 8904857 | doi = 10.1001/archpedi.1996.02170360056009 | s2cid = 25465924 }}</ref><ref>{{cite journal |last1=Everard |first1=ML |last2=Bara |first2=A |last3=Kurian |first3=M |last4=Elliott |first4=TM |last5=Ducharme |first5=F |last6=Mayowe |first6=V |title=Anticholinergic drugs for wheeze in children under the age of two years. |journal=The Cochrane Database of Systematic Reviews |date=20 July 2005 |volume=2005 |issue=3 |pages=CD001279 |doi=10.1002/14651858.CD001279.pub2 |pmid=16034861 |pmc=7027683 }}</ref>
==== Epinephrine ====
The current state of evidence suggests that [[Nebulizer|nebulized]] [[epinephrine]] is not indicated for children with bronchiolitis except as a trial of rescue therapy for severe cases.<ref name="Ral2014" /><ref name=":2" />
Epinephrine is an α and β [[adrenergic agonist]] that is used to treat other upper respiratory tract illnesses, such as [[croup]], as a nebulized solution.<ref>{{cite journal | vauthors = Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW | title = Nebulized epinephrine for croup in children | journal = The Cochrane Database of Systematic Reviews | issue = 10 | pages = CD006619 | date = October 2013 | pmid = 24114291 | doi = 10.1002/14651858.CD006619.pub3 | pmc = 11800190 }}</ref> Current guidelines do not support the outpatient use of epinephrine in bronchiolitis given the lack of substantial sustained benefit.<ref name="Ral2014" />
A 2017 review found inhaled [[racemic epinephrine|epinephrine]] with corticosteroids did not change the need for hospitalization or the time spent in hospital.<ref>{{cite journal | vauthors = Kua KP, Lee SW | title = Systematic Review and Meta-Analysis of the Efficacy and Safety of Combined Epinephrine and Corticosteroid Therapy for Acute Bronchiolitis in Infants | journal = Frontiers in Pharmacology | volume = 8 | pages = 396 | date = 2017 | pmid = 28690542 | pmc = 5479924 | doi = 10.3389/fphar.2017.00396 | doi-access = free }}</ref> Other studies suggest a synergistic effect of epinephrine with corticosteroids but have not consistently demonstrated benefits in clinical trials.<ref name="Ral2014" /> Guidelines recommend against its use currently.<ref name="Ral2014" /><ref name=Kir2019 />
=== Non-effective Treatments ===
* [[Ribavirin]] is an antiviral drug which does not appear to be effective for bronchiolitis.<ref name="Bourke11" />
* [[Antibiotic]]s are often given in case of a bacterial infection complicating bronchiolitis, but have no effect on the underlying viral infection and their benefit is not clear.<ref name="Bourke11" /><ref name="pmid25300167">{{cite journal |vauthors=Farley R, Spurling GK, Eriksson L, Del Mar CB |date=October 2014 |title=Antibiotics for bronchiolitis in children under two years of age |journal=The Cochrane Database of Systematic Reviews |volume=2014 |issue=10 |pages=CD005189 |doi=10.1002/14651858.CD005189.pub4 |pmc=10580123 |pmid=25300167}}</ref><ref>{{cite journal |vauthors=McCallum GB, Plumb EJ, Morris PS, Chang AB |date=August 2017 |title=Antibiotics for persistent cough or wheeze following acute bronchiolitis in children |journal=The Cochrane Database of Systematic Reviews |volume=2017 |issue=8 |pages=CD009834 |doi=10.1002/14651858.CD009834.pub3 |pmc=6483479 |pmid=28828759}}</ref> The risks of bronchiolitis with a concomitant [[Neonatal sepsis|serious bacterial infection]] among hospitalized febrile infants is minimal and work-up and antibiotics are not justified.<ref name="Ral2014" /><ref name=":4" /> [[Azithromycin]] [[adjuvant therapy]] may reduce the duration of wheezing and coughing in children with bronchiolitis but has not effect on length of hospital stay or duration of oxygen therapy.<ref>{{cite journal |vauthors=Che SY, He H, Deng Y, Liu EM |date=August 2019 |title=[Clinical effect of azithromycin adjuvant therapy in children with bronchiolitis: a systematic review and Meta analysis] |journal=Zhongguo Dang Dai Er Ke Za Zhi = Chinese Journal of Contemporary Pediatrics |volume=21 |issue=8 |pages=812–819 |doi=10.7499/j.issn.1008-8830.2019.08.014 |pmc=7389899 |pmid=31416508}}</ref>
* [[Corticosteroids]], although useful in other respiratory disease such as [[asthma]] and [[croup]], have no proven benefit in bronchiolitis treatment and are not advised.<ref name="Ral2014" /><ref name="Kir2019" /><ref name="Bourke11" /><ref>{{cite journal |vauthors=Alarcón-Andrade G, Cifuentes L |date=May 2018 |title=Should systemic corticosteroids be used for bronchiolitis? |journal=Medwave |volume=18 |issue=3 |pages=e7207 |doi=10.5867/medwave.2018.03.7206 |pmid=29750779 |doi-access=free}}</ref><ref>{{cite journal |vauthors=Alarcón-Andrade G, Cifuentes L |date=April 2018 |title=Do inhaled corticosteroids have a role for bronchiolitis? |journal=Medwave |volume=18 |issue=2 |pages=e7183 |doi=10.5867/medwave.2018.02.7182 |pmid=29677180 |doi-access=free}}</ref> Additionally, corticosteroid therapy in children with bronchiolitis may prolong [[viral shedding]] and [[Transmissibility (epidemiology)|transmissibility.]]<ref name="Ral2014" /> The overall safety of corticosteroids is questionable.<ref>{{cite journal |display-authors=6 |vauthors=Fernandes RM, Wingert A, Vandermeer B, Featherstone R, Ali S, Plint AC, Stang AS, Rowe BH, Johnson DW, Allain D, Klassen TP, Hartling L |date=August 2019 |title=Safety of corticosteroids in young children with acute respiratory conditions: a systematic review and meta-analysis |journal=BMJ Open |volume=9 |issue=8 |pages=e028511 |doi=10.1136/bmjopen-2018-028511 |pmc=6688746 |pmid=31375615}}</ref>
* [[Leukotriene inhibitors]], such as [[montelukast]], have not been found to be beneficial and may increase adverse effects.<ref name="Kir2019" /><ref>{{cite journal |vauthors=Pérez-Gutiérrez F, Otárola-Escobar I, Arenas D |date=December 2016 |title=Are leukotriene inhibitors useful for bronchiolitis? |journal=Medwave |volume=16 |issue=Suppl5 |pages=e6799 |doi=10.5867/medwave.2016.6799 |pmid=28032855 |doi-access=free}}</ref><ref>{{cite journal |vauthors=Peng WS, Chen X, Yang XY, Liu EM |date=March 2014 |title=Systematic review of montelukast's efficacy for preventing post-bronchiolitis wheezing |journal=Pediatric Allergy and Immunology |volume=25 |issue=2 |pages=143–150 |doi=10.1111/pai.12124 |pmid=24118637 |s2cid=27539127}}</ref><ref>{{cite journal |vauthors=Liu F, Ouyang J, Sharma AN, Liu S, Yang B, Xiong W, Xu R |date=March 2015 |title=Leukotriene inhibitors for bronchiolitis in infants and young children |journal=The Cochrane Database of Systematic Reviews |volume=2015 |issue=3 |pages=CD010636 |doi=10.1002/14651858.CD010636.pub2 |pmc=10879915 |pmid=25773054}}</ref>
* [[Immunoglobulin]]s are of unclear benefit.<ref>{{Cite journal |last1=Sanders |first1=Sharon L. |last2=Agwan |first2=Sushil |last3=Hassan |first3=Mohamed |last4=Bont |first4=Louis J. |last5=Venekamp |first5=Roderick P. |date=2023-10-23 |title=Immunoglobulin treatment for hospitalised infants and young children with respiratory syncytial virus infection |journal=The Cochrane Database of Systematic Reviews |volume=2023 |issue=10 |pages=CD009417 |doi=10.1002/14651858.CD009417.pub3 |issn=1469-493X |pmc=10591280 |pmid=37870128}}</ref>
=== Experimental Trials ===
Currently other medications do not yet have evidence to support their use, although they have been studied for use in bronchiolitis.<ref name="Ral2014" /><ref name=BMJ11>{{cite journal | vauthors = Hartling L, Fernandes RM, Bialy L, Milne A, Johnson D, Plint A, Klassen TP, Vandermeer B | display-authors = 6 | title = Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis | journal = BMJ | volume = 342 | pages = d1714 | date = April 2011 | pmid = 21471175 | pmc = 3071611 | doi = 10.1136/bmj.d1714 }}</ref> Experimental trials with novel antiviral medications in adults are promising but it remains unclear if the same benefit will be present.<ref name=":3"/>
* [[Surfactant]] had favorable effects for severely critical infants on duration of mechanical ventilation and ICU stay however studies were few and small.<ref>{{cite journal | vauthors = Jat KR, Chawla D | title = Surfactant therapy for bronchiolitis in critically ill infants | journal = The Cochrane Database of Systematic Reviews | volume = 2015 | issue = 8 | pages = CD009194 | date = August 2015 | pmid = 26299681 | pmc = 7104667 | doi = 10.1002/14651858.CD009194.pub3 }}</ref><ref name="Bourke11"/>
* [[Chest physiotherapy]], such as vibration or percussion, to promote airway clearance may slightly reduce duration of oxygen therapy but there is a lack of evidence that demonstrates any other benefits.<ref name="Ral2014" /><ref>{{cite journal | vauthors = Lauwers E, Ides K, Van Hoorenbeeck K, Verhulst S | title = The effect of intrapulmonary percussive ventilation in pediatric patients: A systematic review | journal = Pediatric Pulmonology | volume = 53 | issue = 11 | pages = 1463–1474 | date = November 2018 | pmid = 30019451 | doi = 10.1002/ppul.24135 | hdl-access = free | s2cid = 51680313 | hdl = 10067/1522720151162165141 }}</ref><ref>{{Cite journal |last1=Roqué-Figuls |first1=Marta |last2=Giné-Garriga |first2=Maria |last3=Granados Rugeles |first3=Claudia |last4=Perrotta |first4=Carla |last5=Vilaró |first5=Jordi |date=2023-04-03 |editor-last=Cochrane Acute Respiratory Infections Group |title=Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old |journal=Cochrane Database of Systematic Reviews |language=en |volume=2023 |issue=4 |pages=CD004873 |doi=10.1002/14651858.CD004873.pub6 |pmc=10070603 |pmid=37010196}}</ref> People with difficulty clearing secretions due to underlying disorders such as spinal muscle atrophy or severe tracheomalacia may be considered for chest physiotherapy.<ref name=":2">{{Cite web|url=https://www.nice.org.uk/guidance/ng9/chapter/1-Recommendations|title=1 Recommendations {{!}} Bronchiolitis in children: diagnosis and management {{!}} Guidance {{!}} NICE|website=www.nice.org.uk|date=June 2015 |access-date=2019-10-31}}</ref>
* [[Heliox]], a mixture of oxygen and the inert gas helium, may be beneficial in infants with severe acute RSV bronchiolitis who require CPAP but overall evidence is lacking.<ref name="Heliox inhalation therapy for bronc"/><ref>{{Cite journal |last1=Kuitunen |first1=Ilari |last2=Kiviranta |first2=Panu |last3=Sankilampi |first3=Ulla |last4=Salmi |first4=Heli |last5=Renko |first5=Marjo |date=June 2022 |title=Helium–oxygen in bronchiolitis—A systematic review and meta-analysis |journal=Pediatric Pulmonology |language=en |volume=57 |issue=6 |pages=1380–1391 |doi=10.1002/ppul.25895 |issn=8755-6863 |pmc=9313870 |pmid=35297227}}</ref>
* [[DNAse]] has not been found to be effective but might play a role in severe bronchiolitis complicated by [[atelectasis]].<ref>{{cite journal | vauthors = Enriquez A, Chu IW, Mellis C, Lin WY | title = Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months | journal = The Cochrane Database of Systematic Reviews | volume = 2012 | issue = 11 | pages = CD008395 | date = November 2012 | pmid = 23152257 | pmc = 7388903 | doi = 10.1002/14651858.CD008395.pub2 }}</ref>
* There are no systematic reviews or controlled trials on the effectiveness of nasal decongestants, such as [[xylometazoline]], for the treatment of bronchiolitits.<ref name="Bourke11"/>
* Overall evidence is insufficient to support the use of alternative medicine.<ref name="Ku2017">{{cite journal | vauthors = Kua KP, Lee SW | title = Complementary and alternative medicine for the treatment of bronchiolitis in infants: A systematic review | journal = PLOS ONE | volume = 12 | issue = 2 | pages = e0172289 | date = 2017-02-17 | pmid = 28212381 | pmc = 5315308 | doi = 10.1371/journal.pone.0172289 | doi-access = free | bibcode = 2017PLoSO..1272289K }}</ref> There is tentative evidence for [[Chinese herbal medicine]], [[vitamin D]], [[N-acetylcysteine]], and [[magnesium]] but this is insufficient to recommend their use.<ref name="Ku2017" />
== Epidemiology ==
[[File:Acute bronchiolitis (8519105494).jpg|alt=Acute inflammatory exudate occluding the lumen of the bronchiole and acute inflammation of part of the wall of the bronchiole|thumb|[[Histology]] Slide - Acute inflammatory exudate occluding the lumen of the bronchiole and acute inflammation of part of the wall of the bronchiole. It shows at the cellular level the inflammation that occurs in the bronchiole of a child with bronchiolitis.]]Bronchiolitis typically affects infants and children younger than two years, principally during the autumn and winter.<ref name=":3" /> It is the leading cause of hospital admission for respiratory disease among infants in the United States and accounts for one out of every 13 primary care visits.<ref name=Kir2019 /> Bronchiolitis accounts for 3% of emergency department visits for children under 2 years old.<ref name="Bourke11"/> Bronchiolitis is the most frequent lower respiratory tract infection and hospitalization in infants worldwide.<ref name=":3" />
=== COVID-19 Pandemic ===
The [[COVID-19 pandemic|COVID-19]] pandemic rapidly changed the transmission and presentation starting in late 2019.<ref name=":10">{{Cite journal |last1=Sabeena |first1=Sasidharanpillai |last2=Ravishankar |first2=Nagaraja |last3=Robin |first3=Sudandiradas |last4=Pillai |first4=SabithaSasidharan |date=2023 |title=The impact of coronavirus disease 2019 pandemic on bronchiolitis (lower respiratory tract infection) due to respiratory syncytial virus: A systematic review and meta-analysis |journal=Indian Journal of Public Health |language=en |volume=67 |issue=2 |pages=284–291 |doi=10.4103/ijph.ijph_1334_22 |doi-access=free |pmid=37459026 |issn=0019-557X}}</ref> During the pandemic, there was a sharp decrease in cases of bronchiolitis and other respiratory illness, which is likely due to [[social distancing]] and other precautions.<ref name=":10" /> After social distancing and other precautions were lifted, there was increases in the cases of RSV and bronchiolitis worldwide to varying degrees. <ref name=":10" /> There is unclear evidence on how COVID-19 will affect bronchiolitis moving forward. Recent evidence suggests that bronchiolitis still poses a large disease burden to both primary care providers and emergency departments. <ref>{{Cite journal |last1=Heemskerk |first1=Susanne |last2=van Heuvel |first2=Lotte |last3=Asey |first3=Tamana |last4=Bangert |first4=Mathieu |last5=Kramer |first5=Rolf |last6=Paget |first6=John |last7=van Summeren |first7=Jojanneke |date=August 2024 |title=Disease Burden of RSV Infections and Bronchiolitis in Young Children (< 5 Years) in Primary Care and Emergency Departments: A Systematic Literature Review |journal=Influenza and Other Respiratory Viruses |language=en |volume=18 |issue=8 |pages=e13344 |doi=10.1111/irv.13344 |issn=1750-2640 |pmc=11298312 |pmid=39098881}}</ref>
== References ==
{{reflist}}
== External links ==
* [http://www.nhs.uk/conditions/Bronchiolitis Bronchiolitis]. Patient information from [[NHS Choices]]
* {{cite web |url= http://www.sign.ac.uk/pdf/sign91.pdf |title= Bronchiolitis in children – A national clinical guideline |access-date= 6 December 2007 |archive-url= https://web.archive.org/web/20160304031949/http://www.sign.ac.uk/pdf/sign91.pdf |archive-date= 4 March 2016 |url-status= dead }} {{small|(1.74 MB)}} from the [[Scottish Intercollegiate Guidelines Network]]
* {{cite journal | vauthors = Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S, Hernandez-Cancio S | display-authors = 6 | title = Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis | journal = Pediatrics | volume = 134 | issue = 5 | pages = e1474–e1502 | date = November 2014 | pmid = 25349312 | doi = 10.1542/peds.2014-2742 | doi-access = free }}
{{Medical resources
| DiseasesDB = 1701
| ICD10 = {{ICD10|J|21||j|20}}
| ICD9 = {{ICD9|466.1}}
| ICDO =
| OMIM =
| MedlinePlus = 000975
| eMedicineSubj = emerg
| eMedicineTopic = 365
| MeshID = D001988
}}
{{Wiktionary}}
{{Respiratory pathology}}
{{Common Cold}}
[[Category:Animal viral diseases]]
[[Category:Inflammations]]
[[Category:Pediatrics]]
[[Category:Acute lower respiratory infections]]
[[Category:Coronavirus-associated diseases]]
[[Category:Wikipedia medicine articles ready to translate]]
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