Rish Academy

Bronchiolitis

Bronchiolitis is the commonest serious respiratory infection of infancy: 2–3% of all infants are admitted to hospital with the disease each year during annual winter epidemics; 90% are aged 1–9 months (bronchiolitis is rare after 1 year of age). Respiratory syncytial virus (RSV) is the pathogen in 80% of cases. The remainder are accounted for by human metapneumovirus, parainfluenza virus, rhinovirus, adenovirus, influenza virus, and Mycoplasma pneumoniae. Dual infection with RSV and human metapneumovirus is associated with severe bronchiolitis.

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Coryzal symptoms precede a dry cough and increasing breathlessness. Feeding difficulty associated with increasing dyspnoea is often the reason for admission to hospital. Recurrent apnoea is a serious complication, especially in young infants. Infants born prematurely who develop bronchopulmonary dysplasia or with other underlying lung disease, such as cystic fibrosis or have congenital heart disease, are most at risk from severe bronchiolitis. The characteristic findings on examination are:

  • Sharp, dry cough
  • Tachypnoea
  • Subcostal and intercostal recession
  • Hyperinflation of the chest:
    • Prominent sternum
    • Liver displaced downwards
  • Fine end-inspiratory crackles
  • High-pitched wheezes – expiratory > inspiratory
  • Tachycardia
  • Cyanosis or pallor.

Respiratory viruses are now usually identified by PCR analysis of nasopharyngeal secretions. A chest X-ray is unnecessary in straightforward cases, but if performed, typically shows hyperinflation of the lungs due to small airways obstruction, air trapping and often focal atelectasis. Pulse oximetry is used to measure and monitor arterial oxygen saturation continuously. Blood gas analysis, usually a capillary sample, is only performed in severe disease to identify hypercarbia when additional ventilatory support is considered.

This is supportive. Humidified oxygen is delivered via nasal cannulae; the concentration required is determined by pulse oximetry. The infant is monitored for apnoea. Mist, antibiotics, steroids and nebulised bronchodilators, such as salbutamol or ipratropium, have not been shown to reduce the severity or duration of the illness. Fluids may need to be given by nasogastric tube or intravenously. Assisted ventilation in the form of nasal or facemask CPAP or full ventilation is required in a small percentage of infants admitted to hospital. RSV is highly infectious, and infection control measures, particularly good hand hygiene, are needed to prevent cross-infection to other infants in hospital.

Most infants recover from the acute infection within 2 weeks. However, as many as half will have recurrent episodes of cough and wheeze (see below). Rarely, usually following adenovirus infection, the illness may  result in permanent damage to the airways (bronchiolitis obliterans).

A monoclonal antibody to RSV (palivizumab, given monthly by intramuscular injection) reduces the number of hospital admissions in high-risk preterm infants. Its use is limited by cost and the need for multiple intramuscular injections.

Reference – Illustrated Textbook of Paediatrics 4th Edition

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