Edelson PJ. Respiratory syncytial virus pneumonia. Pediatric Emergency Casebook. New York: World Health Communications Inc.; 1985. 1-15.
Njoku DB, Kliegman RM. Atypical extrapulmonary presentations of severe respiratory syncytial virus infection requiring intensive care. Clin Pediatr (Phila). 1993 Aug. 32(8):455-60. [Medline].
[Guideline] Diagnosis and management of bronchiolitis. Pediatrics. 2006 Oct. 118(4):1774-93. [Medline].
Wegner S, Vann JJ, Liu G, Byrns P, Cypra C, Campbell W. Direct cost analyses of palivizumab treatment in a cohort of at-risk children: evidence from the North Carolina Medicaid Program. Pediatrics. 2004 Dec. 114(6):1612-9. [Medline].
Counihan ME, Shay DK, Holman RC, Lowther SA, Anderson LJ. Human parainfluenza virus-associated hospitalizations among children less than five years of age in the United States. Pediatr Infect Dis J. 2001 Jul. 20(7):646-53. [Medline].
Bada C, Carreazo NY, Chalco JP, Huicho L. Inter-observer agreement in interpreting chest X-rays on children with acute lower respiratory tract infections and concurrent wheezing. Sao Paulo Med J. 2007 May 3. 125(3):150-4. [Medline].
Unger S, Cunningham S. Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. Pediatrics. 2008 Mar. 121(3):470-5. [Medline].
AHRQ Publication Number 03-E009, January 2003. Agency for Healthcare Research and Quality, Rockville, MD. Management of Bronchiolitis in Infants and Children. Summary, Evidence Report/Technology Assessment: Number 69. US Department of Health and Human Services. Available at http://www.ahrq.gov/clinic/epcsums/broncsum.htm. Accessed: February 28, 2010.
Epler GR, Colby TV, McLoud TC, Carrington CB, Gaensler EA. Bronchiolitis obliterans organizing pneumonia. N Engl J Med. 1985 Jan 17. 312(3):152-8. [Medline].
Dornelles CT, Piva JP, Marostica PJ. Nutritional status, breastfeeding, and evolution of Infants with acute viral bronchiolitis. J Health Popul Nutr. 2007 Sep. 25(3):336-43. [Medline].
Downham MA, Scott R, Sims DG, Webb JK, Gardner PS. Breast-feeding protects against respiratory syncytial virus infections. Br Med J. 1976 Jul 31. 2(6030):274-6. [Medline].
Tristram DA, Welliver RC. Bronchiolitis. Long SS, Pickering LK, Prober CG. Principles and Practice of pediatric Infectious Diseases. 2nd. New York: Churchill Livingstone; 2003. 213.
McNamara PS, Flanagan BF, Baldwin LM, et al. Interleukin 9 production in the lungs of infants with severe respiratory syncytial virus bronchiolitis. Lancet. 2004 Mar 27. 363(9414):1031-7. [Medline].
McNamara PS, Flanagan BF, Hart CA, Smyth RL. Production of chemokines in the lungs of infants with severe respiratory syncytial virus bronchiolitis. J Infect Dis. 2005 Apr 15. 191(8):1225-32. [Medline].
Johnson JE, Gonzales RA, Olson SJ, Wright PF, Graham BS. The histopathology of fatal untreated human respiratory syncytial virus infection. Mod Pathol. 2007 Jan. 20(1):108-19. [Medline].
Marguet C, Bocquel N, Benichou J, et al. Neutrophil but not eosinophil inflammation is related to the severity of a first acute epidemic bronchiolitis in young infants. Pediatr Allergy Immunol. 2008 Mar. 19(2):157-65. [Medline].
Henderson FW, Collier AM, Clyde WA Jr, Denny FW. Respiratory-syncytial-virus infections, reinfections and immunity. A prospective, longitudinal study in young children. N Engl J Med. 1979 Mar 8. 300(10):530-4. [Medline].
Fodha I, Vabret A, Ghedira L, et al. Respiratory syncytial virus infections in hospitalized infants: association between viral load, virus subgroup, and disease severity. J Med Virol. 2007 Dec. 79(12):1951-8. [Medline].
Hall CB, Walsh EE, Schnabel KC, et al. Occurrence of groups A and B of respiratory syncytial virus over 15 years: associated epidemiologic and clinical characteristics in hospitalized and ambulatory children. J Infect Dis. 1990 Dec. 162(6):1283-90. [Medline].
McConnochie KM, Hall CB, Walsh EE, Roghmann KJ. Variation in severity of respiratory syncytial virus infections with subtype. J Pediatr. 1990 Jul. 117(1 Pt 1):52-62. [Medline].
Papadopoulos NG, Gourgiotis D, Javadyan A, et al. Does respiratory syncytial virus subtype influences the severity of acute bronchiolitis in hospitalized infants?. Respir Med. 2004 Sep. 98(9):879-82. [Medline].
Hall CB, Douglas RG Jr, Geiman JM. Respiratory syncytial virus infections in infants: quantitation and duration of shedding. J Pediatr. 1976 Jul. 89(1):11-5. [Medline].
Mansbach JM, Piedra PA, Teach SJ, et al. Prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis. Arch Pediatr Adolesc Med. 2012. 166:700-706. [Medline].
van den Hoogen BG, de Jong JC, Groen J, et al. A newly discovered human pneumovirus isolated from young children with respiratory tract disease. Nat Med. 2001 Jun. 7(6):719-24. [Medline].
Williams JV, Harris PA, Tollefson SJ, Halburnt-Rush LL, Pingsterhaus JM, Edwards KM. Human metapneumovirus and lower respiratory tract disease in otherwise healthy infants and children. N Engl J Med. 2004 Jan 29. 350(5):443-50. [Medline].
Bosis S, Esposito S, Niesters HG, Crovari P, Osterhaus AD, Principi N. Impact of human metapneumovirus in childhood: comparison with respiratory syncytial virus and influenza viruses. J Med Virol. 2005 Jan. 75(1):101-4. [Medline].
Caracciolo S, Minini C, Colombrita D, Rossi D, Miglietti N, Vettore E. Human metapneumovirus infection in young children hospitalized with acute respiratory tract disease: virologic and clinical features. Pediatr Infect Dis J. 2008 May. 27(5):406-12. [Medline].
Risnes KR, Radtke A, Nordbø SA, Grammeltvedt AT, Døllner H. [Human metapneumovirus--occurrence and clinical significance]. Tidsskr Nor Laegeforen. 2005 Oct 20. 125(20):2769-72. [Medline].
Werno AM, Anderson TP, Jennings LC, Jackson PM, Murdoch DR. Human metapneumovirus in children with bronchiolitis or pneumonia in New Zealand. J Paediatr Child Health. 2004 Sep-Oct. 40(9-10):549-51. [Medline].
van den Hoogen BG, Osterhaus DM, Fouchier RA. Clinical impact and diagnosis of human metapneumovirus infection. Pediatr Infect Dis J. 2004 Jan. 23(1 Suppl):S25-32. [Medline].
Garcia-Garcia ML, Calvo C, Casas I, et al. Human metapneumovirus bronchiolitis in infancy is an important risk factor for asthma at age 5. Pediatr Pulmonol. 2007 May. 42(5):458-64. [Medline].
Dollner H, Risnes K, Radtke A, Nordbo SA. Outbreak of human metapneumovirus infection in norwegian children. Pediatr Infect Dis J. 2004 May. 23(5):436-40. [Medline].
Garcia Garcia ML, Calvo Rey C, Martin del Valle F, et al. [Respiratory infections due to metapneumovirus in hospitalized infants]. An Pediatr (Barc). 2004 Sep. 61(3):213-8. [Medline].
McNamara PS, Flanagan BF, Smyth RL, Hart CA. Impact of human metapneumovirus and respiratory syncytial virus co-infection in severe bronchiolitis. Pediatr Pulmonol. 2007 Aug. 42(8):740-3. [Medline].
Semple MG, Cowell A, Dove W, et al. Dual infection of infants by human metapneumovirus and human respiratory syncytial virus is strongly associated with severe bronchiolitis. J Infect Dis. 2005 Feb 1. 191(3):382-6. [Medline].
Serafino RL, Gurgel RQ, Dove W, Hart CA, Cuevas LE. Respiratory syncytial virus and metapneumovirus in children over two seasons with a high incidence of respiratory infections in Brazil. Ann Trop Paediatr. 2004 Sep. 24(3):213-7. [Medline].
Arnold JC, Singh KK, Spector SA, Sawyer MH. Human bocavirus: prevalence and clinical spectrum at a children's hospital. Clin Infect Dis. 2006 Aug 1. 43(3):283-8. [Medline].
Shaw KN, Bell LM, Sherman NH. Outpatient assessment of infants with bronchiolitis. Am J Dis Child. 1991. 145:151-5. [Medline].
Meissner HC. Selected populations at increased risk from respiratory syncytial viral infection. Pediatric Infectious Disease. 2003. 22:S40.
Wang EE, Law BJ, Stephens D. Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) prospective study of risk factors and outcomes in patients hospitalized with respiratory syncytial virus lower respiratory tract infections. J Pediatrics. 1995. 126:212-19.
Bloemers BL. Down syndrome: A novel risk factor for respiratory syncytial virus bronchiolitis-a prospective birth-cohort study. Pediatr. Oct 2007. 120:e1076-81.
Horn SD, Smout RJ. Effect of prematurity on respiratory syncytial virus hospital resource use and outcomes. J Pediatr. 2003 Nov. 143(5 Suppl):S133-41. [Medline].
Glezen WP, Paredes A, Allison JE, et al. Risk of respiratory syncytial virus infection for infants from low- income families in relationship to age, sex, ethnic group, and maternal antibody level. J Pediatr. 1981 May. 98(5):708-15. [Medline].
Carroll KN, Gebretsadik T, Griffin MR, et al. Maternal asthma and maternal smoking are associated with increased risk of bronchiolitis during infancy. Pediatrics. 2007 Jun. 119(6):1104-12. [Medline].
Feltes TF, Cabalka AK, Meissner HC, et al. Palivizumab prophylaxis reduces hospitalization due to respiratory syncytial virus in young children with hemodynamically significant congenital heart disease. J Pediatr. 2003 Oct. 143(4):532-40. [Medline].
Papoff P, Moretti C, Cangiano G, et al. Incidence and predisposing factors for severe disease in previously healthy term infants experiencing their first episode of bronchiolitis. Acta Paediatr. 2011 Jul. 100(7):e17-23. [Medline].
Choudhuri JA, Ogden LG, Ruttenber AJ, et al. Effect of altitude on hospitalization for respiratory syncytial virus infection. Pediatrics. 2006. 117:349-356. [Medline].
Carlsen KH, Orstavik I, Halvorsen K. Viral infections of the respiratory tract in hospitalized children. Acta Pediatr Scand. 1983. 72:53-54.
Henderson FW, Clyde WA Jr, Collier AM, Denny FW, Senior RJ, Sheaffer CI. The etiologic and epidemiologic spectrum of bronchiolitis in pediatric practice. J Pediatr. 1979 Aug. 95(2):183-90. [Medline].
Denny FW, Clyde WA. Acuet lower respiratory tract infections in non-hospitalized children. J Pediatr. 1986. 108:635-646.
La Via WV, Marks MI, Stutman HR. Respiratory syncytial virus puzzle: clinical features, pathophysiology, treatment, and prevention. J Pediatr. 1992 Oct. 121(4):503-10. [Medline].
Shay DK, Holman RC, Newman RD, Liu LL, Stout JW, Anderson LJ. Bronchiolitis-associated hospitalizations among US children, 1980-1996. JAMA. 1999 Oct 20. 282(15):1440-6. [Medline].
Stockman LJ, Curns AT, Anderson LJ, Fischer-Langley G. Respiratory syncytial virus-associated hospitalizations among infants and young children in the United States, 1997-2006. Pediatr Infect Dis J. 2012 Jan. 31(1):5-9. [Medline].
Hall CB, Weinberg GA, Blumkin AK, et al. Respiratory syncytial virus-associated hospitalizations among children less than 24 months. Pediatrics. 2013. 132:e341-e348. [Medline].
Hasegawa K, Tsugawa Y, Brown DFM, et al. Trends in bronchiolitis hospitalizations in the United States, 2000-2009. Pediatrics. 2013. 132:28-36. [Medline].
Byington CL, Wilkes J, Korgenski K, et al. Respiratory syncytial virus-associated mortality in hospitalized infants and young children. Pediatrics. 2015. 135:e24-e31. [Medline].
Brief report: respiratory syncytial virus activity--United States, 2005-2006. MMWR Morb Mortal Wkly Rep. 2006 Dec 1. 55(47):1277-9. [Medline].
Halstead DC, Jenkins SG. Continuous non-seasonal epidemic of respiratory syncytial virus infection in the southeast United States. South Med J. 1998 May. 91(5):433-6. [Medline].
Panozzo CA, Fowlkes AL, Anderson LJ. Variation in timing of respiratory syncytial virus outbreaks: lessons from national surveillance. Pediatr Infect Dis J. 2007 Nov. 26(11 Suppl):S41-5. [Medline].
Hall CB, Geiman JM, Biggar R, Kotok DI, Hogan PM, Douglas GR Jr. Respiratory syncytial virus infections within families. N Engl J Med. 1976 Feb 19. 294(8):414-9. [Medline].
Hall CB, Douglas RG Jr, Geiman JM, Messner MK. Nosocomial respiratory syncytial virus infections. N Engl J Med. 1975 Dec 25. 293(26):1343-6. [Medline].
Leclair JM, Freeman J, Sullivan BF, Crowley CM, Goldmann DA. Prevention of nosocomial respiratory syncytial virus infections through compliance with glove and gown isolation precautions. N Engl J Med. 1987 Aug 6. 317(6):329-34. [Medline].
Isaacs D, Dickson H, O'Callaghan C, Sheaves R, Winter A, Moxon ER. Handwashing and cohorting in prevention of hospital acquired infections with respiratory syncytial virus. Arch Dis Child. 1991 Feb. 66(2):227-31. [Medline].
Rudan I, Tomaskovic L, Boschi-Pinto C, Campbell H. Global estimate of the incidence of clinical pneumonia among children under five years of age. Bull World Health Organ. 2004 Dec. 82(12):895-903. [Medline]. [Full Text].
Weber MW, Mulholland EK, Greenwood BM. Respiratory syncytial virus infection in tropical and developing countries. Trop Med Int Health. 1998 Apr. 3(4):268-80. [Medline].
Nair H, Nokes DJ, Gessner BD, et al. Global Burden of acute lower respiratory infections due to respiratory syncytial virus in young children: a systematic review and meta-analysis. Lancet. 2010. 375:1545-1555. [Medline].
Haynes AK, Mananagan AP, Iwane MK, et al. Respiratory syncytial virus circulation in seven countries with Global Disease Detection Regional Centers. J Infect Dis. 2013. 208:S246-S254. [Medline].
Koehoorn M, Karr CJ, Demers PA, Lencar C, Tamburic L, Brauer M. Descriptive epidemiological features of bronchiolitis in a population-based cohort. Pediatrics. 2008 Dec. 122(6):1196-203. [Medline].
Terrosi C, Di Genova G, Martorelli B, Valentini M, Cusi MG. Humoral immunity to respiratory syncytial virus in young and elderly adults. Epidemiol Infect. 2009 Dec. 137(12):1684-6. [Medline].
Falsey AR, Hennessey PA, Formica MA, Cox C, Walsh EE. Respiratory syncytial virus infection in elderly and high-risk adults. N Engl J Med. 2005 Apr 28. 352(17):1749-59. [Medline].
Ebbert JO, Limper AH. Respiratory syncytial virus pneumonitis in immunocompromised adults: clinical features and outcome. Respiration. 2005 May-Jun. 72(3):263-9. [Medline].
Iwane MK, Edwards KM, Szilagyi PG, Walker FJ, Griffin MR, Weinberg GA. Population-based surveillance for hospitalizations associated with respiratory syncytial virus, influenza virus, and parainfluenza viruses among young children. Pediatrics. 2004 Jun. 113(6):1758-64. [Medline].
Mage DT, Donner EM. The fifty percent male excess of infant respiratory mortality. Acta Paediatr. 2004 Sep. 93(9):1210-5. [Medline].
Iwane MK, Chaves SS, Szilagyi PG, et al. Disparities between black and white children in hospitalizations associated with acute respiratory illness and laboratory-confirmed influenza and respiratory syncytial virus in 3 US counties--2002-2009. Am J Epidemiol. 2013. 177:656-665. [Medline].
La Via WV, Grant SW, Stutman HR, Marks MI. Clinical profile of pediatric patients hospitalized with respiratory syncytial virus infection. Clin Pediatr (Phila). 1993 Aug. 32(8):450-4. [Medline].
World Health Organization. Health in 2015. Global Health Observatory data. Available at http://www.who.int/gho/database/en/. December 2015; Accessed: July 8, 2016.
Hall CB, Weinberg GA, Iwane MK, et al. The burden of respiratory syncytial virus infection in young children. N Engl J Med. 2009 Feb 5. 360(6):588-98. [Medline].
Holman RC, Shay DK, Curns AT, Lingappa JR, Anderson LJ. Risk factors for bronchiolitis-associated deaths among infants in the United States. Pediatr Infect Dis J. 2003 Jun. 22(6):483-90. [Medline].
Thorburn K. Pre-existing disease is associated with a significantly higher risk of death in severe respiratory syncytial virus infection. Arch Dis Child. 2009 Feb. 94(2):99-103. [Medline].
Goetghebuer T, Isles K, Moore C, Thomson A, Kwiatkowski D, Hull J. Genetic predisposition to wheeze following respiratory syncytial virus bronchiolitis. Clin Exp Allergy. 2004 May. 34(5):801-3. [Medline].
Stein RT, Sherrill D, Morgan WJ, et al. Respiratory syncytial virus in early life and risk of wheeze and allergy by age 13 years. Lancet. 1999 Aug 14. 354(9178):541-5. [Medline].
Krilov LR, Mandel FS, Barone SR, Fagin JC. Follow-up of children with respiratory syncytial virus bronchiolitis in 1986 and 1987: potential effect of ribavirin on long term pulmonary function. The Bronchiolitis Study Group. Pediatr Infect Dis J. 1997 Mar. 16(3):273-6. [Medline].
Kuppermann N, Bank DE, Walton EA, Senac MO Jr, McCaslin I. Risks for bacteremia and urinary tract infections in young febrile children with bronchiolitis. Arch Pediatr Adolesc Med. 1997 Dec. 151(12):1207-14. [Medline].
Titus MO, Wright SW. Prevalence of serious bacterial infections in febrile infants with respiratory syncytial virus infection. Pediatrics. 2003 Aug. 112(2):282-4. [Medline].
Levine DA, Platt SL, Dayan PS, Macias CG, Zorc JJ, Krief W, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics. 2004 Jun. 113(6):1728-34. [Medline].
Purcell K, Fergie J. Concurrent serious bacterial infections in 2396 infants and children hospitalized with respiratory syncytial virus lower respiratory tract infections. Arch Pediatr Adolesc Med. 2002 Apr. 156(4):322-4. [Medline].
Greenes DS, Harper MB. Low risk of bacteremia in febrile children with recognizable viral syndromes. Pediatr Infect Dis J. 1999 Mar. 18(3):258-61. [Medline].
Becker S, Soukup J, Yankaskas JR. Respiratory syncytial virus infection of human primary nasal and bronchial epithelial cell cultures and bronchoalveolar macrophages. Am J Respir Cell Mol Biol. 1992 Apr. 6(4):369-74. [Medline].
Ralston S, Hill V. Incidence of apnea in infants hospitalized with respiratory syncytial virus bronchiolitis: a systematic review. J Pediatr. 2009 Nov. 155(5):728-33. [Medline].
Willwerth BM, Harper MB, Greenes DS. Identifying hospitalized infants who have bronchiolitis and are at high risk for apnea. Ann Emerg Med. 2006 Oct. 48(4):441-7. [Medline].
Abreu e Silva FA, Brezinova V, Simpson H. Sleep apnoea in acute bronchiolitis. Arch Dis Child. 1982 Jun. 57(6):467-72. [Medline].
Al-balkhi A, Klonin H, Marinaki K, Southall DP, Thomas DA, Jones P. Review of treatment of bronchiolitis related apnoea in two centres. Arch Dis Child. 2005 Mar. 90(3):288-91. [Medline].
Bruhn FW, Mokrohisky ST, McIntosh K. Apnea associated with respiratory syncytial virus infection in young infants. J Pediatr. 1977 Mar. 90(3):382-6. [Medline].
Church NR, Anas NG, Hall CB, Brooks JG. Respiratory syncytial virus-related apnea in infants. Demographics and outcome. Am J Dis Child. 1984 Mar. 138(3):247-50. [Medline].
Schroeder AR, Masbach JM, Stevenson M, et al. Apnea in children hospitalized with bronchiolitis. Pediatrics. 2013. 132:e1194-e1201. [Medline].
Kneyber MC, Brandenburg AH, de Groot R, Joosten KF, Rothbarth PH, Ott A. Risk factors for respiratory syncytial virus associated apnoea. Eur J Pediatr. 1998 Apr. 157(4):331-5. [Medline].
Thomas JA, Raroque S, Scott WA, Toro-Figueroa LO, Levin DL. Successful treatment of severe dysrhythmias in infants with respiratory syncytial virus infections: two cases and a literature review. Crit Care Med. 1997 May. 25(5):880-6. [Medline].
Rivers RP, Forsling ML, Olver RP. Inappropriate secretion of antidiuretic hormone in infants with respiratory infections. Arch Dis Child. 1981 May. 56(5):358-63. [Medline].
Stretton M, Ajizian SJ, Mitchell I, Newth CJ. Intensive care course and outcome of patients infected with respiratory syncytial virus. Pediatr Pulmonol. 1992 Jul. 13(3):143-50. [Medline].
Piastra M, Caresta E, Tempera A, Langer A, Zorzi G, Pulitano S. Sharing features of uncommon respiratory syncytial virus complications in infants. Pediatr Emerg Care. 2006 Aug. 22(8):574-8. [Medline].
Hyvarinen MK, Kotaniemi-Syrjanen A, Reijonen TM, Korhonen K, Korppi MO. Lung function and bronchial hyper-responsiveness 11 years after hospitalization for bronchiolitis. Acta Paediatr. 2007 Oct. 96(10):1464-9. [Medline].
Fjaerli HO, Farstad T, Rod G, Ufert GK, Gulbrandsen P, Nakstad B. Acute bronchiolitis in infancy as risk factor for wheezing and reduced pulmonary function by seven years in Akershus County, Norway. BMC Pediatr. 2005. 5:31. [Medline].
Piippo-Savolainen E, Korppi M. Wheezy babies--wheezy adults? Review on long-term outcome until adulthood after early childhood wheezing. Acta Paediatr. 2008 Jan. 97(1):5-11. [Medline].
Openshaw PJ, Dean GS, Culley FJ. Links between respiratory syncytial virus bronchiolitis and childhood asthma: clinical and research approaches. Pediatr Infect Dis J. 2003 Feb. 22(2 Suppl):S58-64; discussion S64-5. [Medline].
Bucasas KL, Mian AI, Demmler-Harrison GL, et al. Global gene expression profiling in infants with acute respiratory syncytial virus broncholitis demonstrates systemic activation of interferon signaling networks. Pediatr Infect Dis J. 2013. 32:e68-e76. [Medline].
Thomsen SF, van der Sluis S, Stensballe LG, et al. Exploring the association between severe respiratory syncytial virus infection and asthma: a registry-based twin study. Am J Resp Crit Care Med. 2009. 179:1091-1097. [Medline].
Sweetman LL, Ng YT, Butler IJ, Bodensteiner JB. Neurologic complications associated with respiratory syncytial virus. Pediatr Neurol. 2005 May. 32(5):307-10. [Medline].
Saijo M, Ishii T, Kokubo M, Murono K, Takimoto M, Fujita K. White blood cell count, C-reactive protein and erythrocyte sedimentation rate in respiratory syncytial virus infection of the lower respiratory tract. Acta Paediatr Jpn. 1996 Dec. 38(6):596-600. [Medline].
Vieira RA, Diniz EM, Vaz FA. Clinical and laboratory study of newborns with lower respiratory tract infection due to respiratory viruses. J Matern Fetal Neonatal Med. 2003 May. 13(5):341-50. [Medline].
[Guideline] Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014 Oct 27. [Medline].
Liebelt EL, Qi K, Harvey K. Diagnostic testing for serious bacterial infections in infants aged 90 days or younger with bronchiolitis. Arch Pediatr Adolesc Med. 1999 May. 153(5):525-30. [Medline].
Antonow JA, Hansen K, McKinstry CA, Byington CL. Sepsis evaluations in hospitalized infants with bronchiolitis. Pediatr Infect Dis J. 1998 Mar. 17(3):231-6. [Medline].
Bloomfield P, Dalton D, Karleka A, Kesson A, Duncan G, Isaacs D. Bacteraemia and antibiotic use in respiratory syncytial virus infections. Arch Dis Child. 2004 Apr. 89(4):363-7. [Medline]. [Full Text].
Macfarlane P, Denham J, Assous J, Hughes C. RSV testing in bronchiolitis: which nasal sampling method is best?. Arch Dis Child. 2005 Jun. 90(6):634-5. [Medline].
Casiano-Colon AE, Hulbert BB, Mayer TK, Walsh EE, Falsey AR. Lack of sensitivity of rapid antigen tests for the diagnosis of respiratory syncytial virus infection in adults. J Clin Virol. 2003 Oct. 28(2):169-74. [Medline].
Falsey AR, McCann RM, Hall WJ, Criddle MM. Evaluation of four methods for the diagnosis of respiratory syncytial virus infection in older adults. J Am Geriatr Soc. 1996 Jan. 44(1):71-3. [Medline].
Huguenin A, Moutte L, Renois F, et al. Broad respiratory virus detection in infants hospitalized for bronchiolitis by use of a multiplex RT-PCR DNA microarray system. J Med Virol. 2012 Jun. 84(6):979-85. [Medline].
Quinonez RA, Coon ER, Schroeder AR, Moyer VA. When technology creates uncertainty: pulse oximetry and overdiagnosis of hypoxaemia in bronchiolitis. BMJ. 2017 Aug 16. 358:j3850. [Medline].
Mallory MD, Shay DK, Garrett J, Bordley WC. Bronchiolitis management preferences and the influence of pulse oximetry and respiratory rate on the decision to admit. Pediatrics. 2003 Jan. 111(1):e45-51. [Medline].
McCulloh R, Koster M, Ralston S, Johnson M, Hill V, Koehn K, et al. Use of Intermittent vs Continuous Pulse Oximetry for Nonhypoxemic Infants and Young Children Hospitalized for Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr. 2015 Aug 31. [Medline].
Brown, T. Pediatric Bronchiolitis: Intermittent Pulse Oximetry OK. Medscape Medical News. Available at http://www.medscape.com/viewarticle/850335. September 01, 2015; Accessed: September 02, 2015.
Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S. Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants Discharged From the Emergency Department With Bronchiolitis. JAMA Pediatr. 2016 Feb 29. [Medline].
Henderson D. Oximetry Fails to Predict Future Bronchiolitis Care. Oximetry Fails to Predict Future Bronchiolitis Care. Available at http://www.medscape.com/viewarticle/860282. March 11, 2016; Accessed: May 16, 2016.
Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J Paediatr Child Health. 1990 Aug. 26(4):209-11. [Medline].
Schuh S, Lalani A, Allen U, Manson D, Babyn P, Stephens D. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007 Apr. 150(4):429-33. [Medline].
Leer JA Jr, Green JL, Heimlich EM, Hyde JS, Moffet HL, Young GA. Corticosteroid treatment in bronchiolitis. A controlled, collaborative study in 297 infants and children. Am J Dis Child. 1969 May. 117(5):495-503. [Medline].
Kellner JD, Ohlsson A, Gadomski AM, Wang EE. Efficacy of bronchodilator therapy in bronchiolitis. A meta-analysis. Arch Pediatr Adolesc Med. 1996 Nov. 150(11):1166-72. [Medline].
Flores G, Horwitz RI. Efficacy of beta2-agonists in bronchiolitis: a reappraisal and meta-analysis. Pediatrics. 1997 Aug. 100(2 Pt 1):233-9. [Medline].
Dobson JV, Stephens-Groff SM, McMahon SR, Stemmler MM, Brallier SL, Bay C. The use of albuterol in hospitalized infants with bronchiolitis. Pediatrics. 1998 Mar. 101(3 Pt 1):361-8. [Medline].
Prendiville A, Green S, Silverman M. Ipratropium bromide and airways function in wheezy infants. Arch Dis Child. 1987 Apr. 62(4):397-400. [Medline].
Everard ML, Bara A, Kurian M, Elliott TM, Ducharme F, Mayowe V. Anticholinergic drugs for wheeze in children under the age of two years. Cochrane Database Syst Rev. 2005 Jul 20. CD001279. [Medline].
Ralston S, Roohi M. A randomized, controlled trial of nasal phenylephrine in infants hospitalized for bronchiolitis. J Pediatr. 2008 Dec. 153(6):795-8. [Medline].
Boogaard R, Hulsmann AR, van Veen L, Vaessen-Verberne AA, Yap YN, Sprij AJ. Recombinant human deoxyribonuclease in infants with respiratory syncytial virus bronchiolitis. Chest. 2007 Mar. 131(3):788-95. [Medline].
Chapman J, Abbott E, Alber DG, Baxter RC, Bithell SK, Henderson EA. RSV604, a novel inhibitor of respiratory syncytial virus replication. Antimicrob Agents Chemother. 2007 Sep. 51(9):3346-53. [Medline].
Chavez-Bueno S, Mejias A, Jafri HS, Ramilo O. Respiratory syncytial virus: old challenges and new approaches. Pediatr Ann. 2005 Jan. 34(1):62-8. [Medline].
Davis IC, Lazarowski ER, Chen FP, Hickman-Davis JM, Sullender WM, Matalon S. Post-infection A77-1726 blocks pathophysiologic sequelae of respiratory syncytial virus infection. Am J Respir Cell Mol Biol. 2007 Oct. 37(4):379-86. [Medline].
Maggon K, Barik S. New drugs and treatment for respiratory syncytial virus. Rev Med Virol. 2004 May-Jun. 14(3):149-68. [Medline].
Johnson DW, Adair C, Brant R, Holmwood J, Mitchell I. Differences in admission rates of children with bronchiolitis by pediatric and general emergency departments. Pediatrics. 2002 Oct. 110(4):e49. [Medline].
Leclerc F, Riou Y, Martinot A, Storme L, Hue V, Flurin V. Inhaled nitric oxide for a severe respiratory syncytial virus infection in an infant with bronchopulmonary dysplasia. Intensive Care Med. 1994 Aug. 20(7):511-2. [Medline].
Langley JM, LeBlanc JC, Wang EE, Law BJ, MacDonald NE, Mitchell I. Nosocomial respiratory syncytial virus infection in Canadian pediatric hospitals: a Pediatric Investigators Collaborative Network on Infections in Canada Study. Pediatrics. 1997 Dec. 100(6):943-6. [Medline].
Christakis DA, Cowan CA, Garrison MM, Molteni R, Marcuse E, Zerr DM. Variation in inpatient diagnostic testing and management of bronchiolitis. Pediatrics. 2005 Apr. 115(4):878-84. [Medline].
Boschert S. Bronchiolitis Care Improves With Peer Networking. Pediatric News. 2012. 46(May):11.
Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for medical management of bronchiolitis in infants less than 1 year of age presenting with a first time episode. National Guideline Clearinghouse. Available at http://guideline.gov/summary/summary.aspx?doc_id=9528. Accessed: February 28, 2010.
Perlstein PH, Kotagal UR, Bolling C, et al. Evaluation of an evidence-based guideline for bronchiolitis. Pediatrics. 1999 Dec. 104(6):1334-41. [Medline].
Perlstein PH, Kotagal UR, Schoettker PJ, Atherton HD, Farrell MK, Gerhardt WE. Sustaining the implementation of an evidence-based guideline for bronchiolitis. Arch Pediatr Adolesc Med. 2000 Oct. 154(10):1001-7. [Medline].
Voets S, van Berlaer G, Hachimi-Idrissi S. Clinical predictors of the severity of bronchiolitis. Eur J Emerg Med. 2006 Jun. 13(3):134-8. [Medline].
McKiernan C, Chua LC, Visintainer PF, Allen H. High flow nasal cannulae therapy in infants with bronchiolitis. J Pediatr. 2010 Apr. 156(4):634-8. [Medline].
Tie SW, Hall GL, Peter S, Vine J, Verheggen M, Pascoe EM, et al. Home oxygen for children with acute bronchiolitis. Arch Dis Child. 2009 Aug. 94(8):641-3. [Medline].
Kepreotes E, Whitehead B, Attia J, Oldmeadow C, Collison A, Searles A, et al. High-flow warm humidified oxygen versus standard low-flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomised controlled trial. Lancet. 2017 Mar 4. 389 (10072):930-939. [Medline].
Arnold JH, Hanson JH, Toro-Figuero LO, Gutierrez J, Berens RJ, Anglin DL. Prospective, randomized comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure. Crit Care Med. 1994 Oct. 22(10):1530-9. [Medline].
Arensman RM, Statter MB, Bastawrous AL, Madonna MB. Modern treatment modalities for neonatal and pediatric respiratory failure. Am J Surg. 1996 Jul. 172(1):41-7. [Medline].
Beasley JM, Jones SE. Continuous positive airway pressure in bronchiolitis. Br Med J (Clin Res Ed). 1981 Dec 5. 283(6305):1506-8. [Medline].
Gavin R, Anderson B, Percival T. Management of severe bronchiolitis: indications for ventilator support. N Z Med J. 1996 Apr 26. 109(1020):137-9. [Medline].
Khan JY, Kerr SJ, Tometzki A, Tyszczuk L, West J, Sosnowski A. Role of ECMO in the treatment of respiratory syncytial virus bronchiolitis: a collaborative report. Arch Dis Child Fetal Neonatal Ed. 1995 Sep. 73(2):F91-4. [Medline]. [Full Text].
Möller JC, Schaible TF, Reiss I, Artlich A, Gortner L. Treatment of severe non-neonatal ARDS in children with surfactant and nitric oxide in a "pre-ECMO"-situation. Int J Artif Organs. 1995 Oct. 18(10):598-602. [Medline].
Ventre K, Haroon M, Davison C. Surfactant therapy for bronchiolitis in critically ill infants. Cochrane Database Syst Rev. 2006. 3:CD005150. [Medline].
Jat KR, Chawla D. Surfactant therapy for bronchiolitis in critically ill infants. Cochrane Database Syst Rev. 2015 Aug 24. 8:CD009194. [Medline].
Cambonie G, Milesi C, Fournier-Favre S, Counil F, Jaber S, Picaud JC. Clinical effects of heliox administration for acute bronchiolitis in young infants. Chest. 2006 Mar. 129(3):676-82. [Medline].
Hollman G, Shen G, Zeng L, Yngsdal-Krenz R, Perloff W, Zimmerman J. Helium-oxygen improves Clinical Asthma Scores in children with acute bronchiolitis. Crit Care Med. 1998 Oct. 26(10):1731-6. [Medline].
Liet JM, Millotte B, Tucci M, Laflammme S, Hutchison J, Creery D. Noninvasive therapy with helium-oxygen for severe bronchiolitis. J Pediatr. 2005 Dec. 147(6):812-7. [Medline].
Martinon-Torres F, Rodriguez-Nunez A, Martinon-Sanchez JM. Heliox therapy in infants with acute bronchiolitis. Pediatrics. 2002 Jan. 109(1):68-73. [Medline].
Martinon-Torres F, Rodriguez-Nunez A, Martinon-Sanchez JM. Nasal continuous positive airway pressure with heliox in infants with acute bronchiolitis. Respir Med. 2006 Aug. 100(8):1458-62. [Medline].
Martinon-Torres F, Rodriguez-Nunez A, Martinon-Sanchez JM. Nasal continuous positive airway pressure with heliox versus air oxygen in infants with acute bronchiolitis: a crossover study. Pediatrics. 2008 May. 121(5):e1190-5. [Medline].
Paret G, Dekel B, Vardi A, Szeinberg A, Lotan D, Barzilay Z. Heliox in respiratory failure secondary to bronchiolitis: a new therapy. Pediatr Pulmonol. 1996 Nov. 22(5):322-3. [Medline].
Kellner JD, Ohlsson A, Gadomski AM, Wang EE. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2000. CD001266. [Medline].
Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010 Dec 8. CD001266. [Medline].
Schuh S, Johnson D, Canny G, Reisman J, Shields M, Kovesi T. Efficacy of adding nebulized ipratropium bromide to nebulized albuterol therapy in acute bronchiolitis. Pediatrics. 1992 Dec. 90(6):920-3. [Medline].
Hammer J, Numa A, Newth CJ. Albuterol responsiveness in infants with respiratory failure caused by respiratory syncytial virus infection. J Pediatr. 1995 Sep. 127(3):485-90. [Medline].
Derish M, Hodge G, Dunn C, Ariagno R. Aerosolized albuterol improves airway reactivity in infants with acute respiratory failure from respiratory syncytial virus. Pediatr Pulmonol. 1998 Jul. 26(1):12-20. [Medline].
Langley JM, Smith MB, LeBlanc JC, Joudrey H, Ojah CR, Pianosi P. Racemic epinephrine compared to salbutamol in hospitalized young children with bronchiolitis; a randomized controlled clinical trial [ISRCTN46561076]. BMC Pediatr. 2005. 5(1):7. [Medline].
Menon K, Sutcliffe T, Klassen TP. A randomized trial comparing the efficacy of epinephrine with salbutamol in the treatment of acute bronchiolitis. J Pediatr. 1995 Jun. 126(6):1004-7. [Medline].
Wainwright C, Altamirano L, Cheney M, Cheney J, Barber S, Price D. A multicenter, randomized, double-blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med. 2003 Jul 3. 349(1):27-35. [Medline].
Lowell DI, Lister G, Von Koss H, McCarthy P. Wheezing in infants: the response to epinephrine. Pediatrics. 1987 Jun. 79(6):939-45. [Medline].
Henderson AJ, Arnott J, Young S, Warshawski T, Landau LI, LeSouef PN. The effect of inhaled adrenaline on lung function of recurrently wheezy infants less than 18 months old. Pediatr Pulmonol. 1995 Jul. 20(1):9-15. [Medline].
Kristjansson S, Lodrup Carlsen KC, Wennergren G, Strannegard IL, Carlsen KH. Nebulised racemic adrenaline in the treatment of acute bronchiolitis in infants and toddlers. Arch Dis Child. 1993 Dec. 69(6):650-4. [Medline].
Ralston S, Hartenberger C, Anaya T, Qualls C, Kelly HW. Randomized, placebo-controlled trial of albuterol and epinephrine at equipotent beta-2 agonist doses in acute bronchiolitis. Pediatr Pulmonol. 2005 Oct. 40(4):292-9. [Medline].
Sanchez I, De Koster J, Powell RE, Wolstein R, Chernick V. Effect of racemic epinephrine and salbutamol on clinical score and pulmonary mechanics in infants with bronchiolitis. J Pediatr. 1993 Jan. 122(1):145-51. [Medline].
Wohl ME, Chernick V. Treatment of acute bronchiolitis. N Engl J Med. 2003 Jul 3. 349(1):82-3. [Medline].
Hartling L, Fernandes RM, Bialy L, Milne A, Johnson D, Plint A, et al. Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis. BMJ. 2011 Apr 6. 342:d1714. [Medline].
Plint AC, Johnson DW, Patel H, Wiebe N, Correll R, Brant R, et al. Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med. 2009 May 14. 360(20):2079-89. [Medline].
Livni G, Rachmel A, Marom D, Yaari A, Tirosh N, Ashkenazi S. A randomized, double-blind study examining the comparative efficacies and safety of inhaled epinephrine and nasal decongestant in hospitalized infants with acute bronchiolitis. Pediatr Infect Dis J. 2010 Jan. 29(1):71-3. [Medline].
Reassessment of the indications for ribavirin therapy in respiratory syncytial virus infections. American Academy of Pediatrics Committee on Infectious Diseases. Pediatrics. 1996 Jan. 97(1):137-40. [Medline].
Ventre K, Randolph AG. Ribavirin for respiratory syncytial virus infection of the lower respiratory tract in infants and young children. Cochrane Database Syst Rev. 2007 Jan 24. CD000181. [Medline].
Randolph AG, Wang EE. Ribavirin for respiratory syncytial virus lower respiratory tract infection. A systematic overview. Arch Pediatr Adolesc Med. 1996 Sep. 150(9):942-7. [Medline].
Corneli HM, Zorc JJ, Mahajan P, et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med. 2007 Jul 26. 357(4):331-9. [Medline].
Daugbjerg P, Brenøe E, Forchhammer H, Frederiksen B, Glazowski MJ, Ibsen KK. A comparison between nebulized terbutaline, nebulized corticosteroid and systemic corticosteroid for acute wheezing in children up to 18 months of age. Acta Paediatr. 1993 Jun-Jul. 82(6-7):547-51. [Medline].
Davison C, Ventre KM, Luchetti M, Randolph AG. Efficacy of interventions for bronchiolitis in critically ill infants: a systematic review and meta-analysis. Pediatr Crit Care Med. 2004 Sep. 5(5):482-9. [Medline].
De Boeck K, Van der Aa N, Van Lierde S, Corbeel L, Eeckels R. Respiratory syncytial virus bronchiolitis: a double-blind dexamethasone efficacy study. J Pediatr. 1997 Dec. 131(6):919-21. [Medline].
Springer C, Bar-Yishay E, Uwayyed K, Avital A, Vilozni D, Godfrey S. Corticosteroids do not affect the clinical or physiological status of infants with bronchiolitis. Pediatr Pulmonol. 1990. 9(3):181-5. [Medline].
Bronchiolitis is an acute infectious disease of the lower respiratory tract that occurs primarily in the very young, most commonly infants between 2 and 6 months old. It is a clinical diagnosis based upon:
- Breathing difficulties
- Decreased feeding
- Apnoeas in the very young
- Wheeze or crepitations on auscultation
It is usually due to a viral infection of the bronchioles. Respiratory syncytial virus (RSV) is the most common pathogen, causing 50-90% of cases. A combination of increased production of mucus, cell debris and oedema produces narrowing and obstruction of small airways.
It is the most common cause of hospitalisation in infants and of acute respiratory failure in paediatric intensive care units (PICUs) in the UK. 
There is a significant discrepancy between the use of 'bronchiolitis' in the UK and in the USA and other parts of Europe. In the UK, the term describes an illness in infants, beginning as an upper respiratory tract infection (URTI) that evolves with signs of respiratory distress, cough, wheeze, air trapping and bilateral crepitations. In North America, bronchiolitis is used to describe a wheezing illness associated with an URTI in children up to the age of 2 (whilst this would be described as a 'viral-induced wheeze' in the UK). This causes difficulties in interpreting results of clinical trials, as the populations may display considerable heterogeneity.
- Respiratory syncytial virus (RSV)
- Human metapneumovirus (hMPV) - causes a similar spectrum of illness to RSV and is thought to be the second most common cause
- Adenovirus - occasionally causes a similar syndrome with a more virulent course
- Parainfluenza virus
- Other less common causes include:
- Mycoplasma pneumoniae
- Influenza virus
- Chlamydophila pneumoniae
- Peak incidence of RSV infections is in the winter months (November to March), although the size of the peak varies from winter to winter.
- Prevalence may be higher in urban areas.
- By their first birthday over 60% of children have been infected and, by 2 years of age, over 80%. The antibodies that develop following early childhood infection do not prevent further RSV infections throughout life.
- One study used Hospital Episode Statistics to identify all children aged below 2 years who were discharged from hospital with a primary code of bronchiolitis in England, between 1 April 2007 and 31 March 2010. This reported a total of 75,318 admissions during the study period.
- Hospital admission rates have increased over a period of ten years. The cause for this is unknown but may in part be due to improved survival rates for preterm infants.
- An English study found that 88% of infants admitted with RSV bronchiolitis were born at term, with no risk factors for severe RSV infection. The study showed that admissions occurred at a much earlier age than previously reported and the majority were admitted for just one day.
Environmental and social risk factors:
- Older siblings
- Nursery attendance
- Passive smoke, particularly maternal
Breast-feeding is considered protective and should be encouraged for this and other reasons.
Risk factors for severe disease and/or complications:
- Prematurity (<37 weeks)
- Low birth weight
- Age less than 12 weeks
- Chronic lung disease (eg, cystic fibrosis, bronchopulmonary dysplasia)
- Congenital heart disease
- Neurological disease with hypotonia and pharyngeal dis-co-ordination
- Insulin-dependent diabetes
- Congenital defects of the airways
- Down's syndrome
- Early symptoms are those of a viral URTI, including mild rhinorrhoea, cough and fever. Fever >39°C is unusual and should prompt a thorough examination and further investigations to exclude other possible causes.
- Adults, older children and many infants do not progress to any further symptoms.
- For the 40% of infants and young children who progress to lower respiratory tract involvement, paroxysmal cough and dyspnoea develop within 1-2 days.
- Other common symptoms include the following: wheeze, cyanosis, vomiting, irritability and poor feeding.
- Apnoeas may occur, especially in young infants.
Follow the National Institute for Health and Care Excellence (NICE) guidance for the assessment of feverish illness in children (in those aged under 5 years):
- Look for tachypnoea, tachycardia, fever, cyanosis and signs of dehydration. It is unusual for a child to appear 'toxic' (suggested by drowsiness, lethargy, pallor, mottled skin) and this should prompt urgent action in terms of the need for immediate treatment and exclusion of other potential causes.
- Mild conjunctivitis, pharyngitis.
- Evidence of increased respiratory work: intercostal, subcostal and supraclavicular recession, nasal flaring.
- Widespread fine inspiratory crackles are considered a key finding in the UK, whilst high-pitched expiratory wheezing is commonly present but not essential to a diagnosis. American definitions put more emphasis on the presence of wheeze.
- Liver and spleen may be palpable due to hyperinflation of the lungs.
- Pulse oximetry.
- Nasopharyngeal aspirate for:
- RSV rapid testing - to enable isolation or cohort arrangements and to prevent further, unnecessary testing.
- Viral cultures for RSV, influenza A and B, parainfluenza and adenovirus can also be undertaken.
Other investigations that are not recommended for typical acute bronchiolitis include:
- CXR: bronchiolitis produces:
- Nonspecific hyperinflation and patchy infiltrates
- Focal atelectasis
- Air trapping
- Flattened diaphragm
- Increased anteroposterior diameter
- Peribronchial cuffing
- Electrolytes and renal function: only perform if the child is dehydrated or on IV fluids.
- Blood and urine culture: consider if pyrexia >38.5°C or the child has a 'toxic' appearance.
- Arterial blood gases: may be required in the severely ill patients, especially in those who may need mechanical ventilation.
- Most infants with acute bronchiolitis will have mild, self-limiting illness and can be managed at home. Supportive measures are the mainstay of treatment, with attention to fluid input, nutrition and temperature control.
- Within general practice, a doctor's role is to assess current severity of illness and, for those with mild-to-moderate disease, to support and monitor. Consider whether the presentation is in the early stages of disease, when a child is more likely to get worse before improving. Careful safety netting is important, teaching parents to spot deterioration and to seek medical review should this occur.
- For the majority, bronchiolitis lasts 7-10 days, with 50% asymptomatic by two weeks and only a small subgroup still symptomatic at four weeks.
Hospital referral is suggested where there is:
- Poor feeding (<50% usual intake over the previous 24 hours) which is inadequate to maintain hydration
- History of apnoea
- Respiratory rate >70 breaths/minute
- Nasal flaring or grunting
- Severe chest wall recession
- Saturations ≤94%
- Uncertainty regarding diagnosis
- Where home care or rapid review cannot be assured
The threshold for admission should be lower in those with significant comorbidities, premature infants and those under 3 months old.
PICU admission is necessary if the child has increasing severe respiratory distress with desaturation or apnoea whilst receiving 50% oxygen. Continuous positive airway pressure (CPAP) or intubation may be required in these cases, although one study found that the majority of children could be managed with non-invasive ventilation outside the PICU setting.
- Even amongst hospitalised children, supportive care is the mainstay of treatment, including oxygen and nasogastric feeding where necessary.
- Other treatments have shown inconsistent or little evidence of benefit:
- Bronchodilators: modest short-term improvement in clinical scores but no reduction in the rate or duration of hospitalisation.
- Corticosteroids: trials have consistently failed to provide evidence of benefit. A large multicentre randomised controlled trial (RCT), comparing the use of a single dose of oral dexamethasone with placebo in children diagnosed with bronchiolitis in Emergency Departments, failed to show any significant differences in the rates of hospital admission, respiratory status after four hours or longer-term outcomes.
- Racemic adrenaline (epinephrine) - racemic = 1:1 mixture of the dextrorotatory and levorotatory isomers: one study reported that inhaled racemic adrenaline (epinephrine) was no better than inhaled saline.
- Hypertonic (3%) saline: thought to act by unblocking mucous plugs and reducing airways obstruction. A Cochrane Review concluded that there was evidence its use did reduce length of hospital stay and clinical severity scores.A later study found no difference in clinical outcome between 3% and 0.9% saline.
- Antibiotics: there is minimal evidence to support their use, except in a small subset of patients with respiratory failure.
- Ribavirin: may reduce the need for mechanical ventilatory support and the number of days in hospital but there is no clear evidence of clinically relevant benefits (eg, preventing respiratory deterioration or mortality).
- Chest physiotherapy does not improve the severity of the disease, respiratory parameters, or reduce length of hospital stay or oxygen requirements in hospitalised infants with acute bronchiolitis not on mechanical ventilation.
- Most children with bronchiolitis make a full recovery.
- Mechanical ventilation is required for some patients but one study found that the majority can be managed without.
- In the UK, RSV-related mortality rate in those aged under 1 year is 8.4/100,000 population.
- Most deaths occur in infants younger than 6 months or in those with underlying cardiac or pulmonary disease.
- There is an association between bronchiolitis and subsequent reactive airways disease - approximately 34-50% wheeze following bronchiolitis. The underlying mechanism by which RSV or other agents, such as rhinovirus, cause reactive airways disease is unknown.
A vaccine is available for babies most at risk of developing severe, and occasionally fatal, RSV infection. These will be very young infants born prematurely who have predisposing conditions such as chronic lung disease, congenital heart disease or children who are immunodeficient. It is usually given in secondary care.
Recent years have seen the development of agents which provide passive immunity to RSV: RSV immunoglobulin (RSV-Ig) which has been superseded by palivizumab, a monoclonal antibody. It has been shown to reduce RSV-related hospitalisation and intensive care admissions significantly. The Joint Committee on Vaccination and Immunisation recommends that it should be used by those at high risk of severe RSV disease:
- Children aged under 2 years with chronic lung disease, who have required at least 28 days of supplemental oxygen from birth or who are receiving home oxygen.
- Infants less than 6 months old with a left-to-right shunt, haemodynamically significant congenital heart disease or pulmonary hypertension.
- Children aged under 2 years with severe congenital immunodeficiency.
The first dose should be administered before the start of the RSV season.
Disease transmission should be limited by:
- Hand washing
- Use of gloves, aprons or gowns when in direct contact with the patient
- Isolation of infected patients or nursing in cohorts, based on laboratory confirmation of RSV status
Bronchiolitis in children; Scottish Intercollegiate Guidelines Network - SIGN (2006)
Yanney M, Vyas H; The treatment of bronchiolitis. Arch Dis Child. 2008 Sep93(9):793-8. Epub 2008 Jun 6.
Respiratory Syncytial Virus (RSV), Public Health England
Haas LE, Thijsen SF, van Elden L, et al; Human metapneumovirus in adults. Viruses. 2013 Jan 85(1):87-110. doi: 10.3390/v5010087.
Cheung CR, Smith H, Thurland K, et al; Population variation in admission rates and duration of inpatient stay for bronchiolitis in England. Arch Dis Child. 2013 Jan98(1):57-9. doi: 10.1136/archdischild-2012-302277. Epub 2012 Dec 5.
Murray J et al; Changes in the severity and age of RSV bronchiolitis hospital admission among infants in England: a population-based birth cohort study, Neonatal Society Abstracts, 2011.
Butt M, Symington A, Janes M, et al; Respiratory syncytial virus prophylaxis in children with cardiac disease: a retrospective single-centre study. Cardiol Young. 2013 Apr 29:1-7.
Pockett RD, Campbell D, Carroll S, et al; A comparison of healthcare resource use for rotavirus and RSV between vulnerable children with co-morbidities and healthy children: a case control study. J Med Econ. 201316(4):560-5. doi: 10.3111/13696998.2013.774278. Epub 2013 Feb 22.
Bloemers BL, van Furth AM, Weijerman ME, et al; Down syndrome: a novel risk factor for respiratory syncytial virus Pediatrics. 2007 Oct120(4):e1076-81.
Feverish illness in children - Assessment and initial management in children younger than 5 years; NICE Guideline (Updated August 2017)
Lazner MR, Basu AP, Klonin H; Non-invasive ventilation for severe bronchiolitis: analysis and evidence. Pediatr Pulmonol. 2012 Sep47(9):909-16. doi: 10.1002/ppul.22513. Epub 2012 Feb 10.
Gadomski AM, Bhasale AL; Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2006 Jul 193:CD001266.
Fernandes RM, Bialy LM, Vandermeer B, et al; Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2010 Oct 6(10):CD004878.
Corneli HM, Zorc JJ, Mahajan P, et al; A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med. 2007 Jul 26357(4):331-9.
Skjerven HO, Hunderi JO, Brugmann-Pieper SK, et al; Racemic adrenaline and inhalation strategies in acute bronchiolitis. N Engl J Med. 2013 Jun 13368(24):2286-93. doi: 10.1056/NEJMoa1301839.
Zhang L, Mendoza-Sassi RA, Wainwright C, et al; Nebulized hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev. 2008 Oct 8(4):CD006458.
Sharma BS, Gupta MK, Rafik SP; Hypertonic (3%) Saline for Acute Viral Bronchiolitis: A Randomized Trial. Indian Pediatr. 2012 Dec 5. pii: S097475591200360.
Spurling GK, Doust J, Del Mar CB, et al; Antibiotics for bronchiolitis in children. Cochrane Database Syst Rev. 2011 Jun 15(6):CD005189. doi: 10.1002/14651858.CD005189.pub3.
Ventre K, Randolph AG; Ribavirin for respiratory syncytial virus infection of the lower respiratory tract in infants and young children. Cochrane Database Syst Rev. 2007 Jan 24(1):CD000181.
Roque i Figuls M, Gine-Garriga M, Granados Rugeles C, et al; Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev. 2012 Feb 152:CD004873. doi: 10.1002/14651858.CD004873.pub4.
Respiratory syncytial virus (RSV) immunisation programme; Service specification No.3, Public health functions to be exercised by the NHS Commissioning Board, November 2012
Respiratory syncytial virus: the green book, chapter 27a; Public Health England (March 2013)