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Bronchiolitis

 

Definition

Bronchiolitis is swelling and mucus buildup in the smallest air passages in the lungs (bronchioles), usually due to a viral infection.

Causes

Bronchiolitis usually affects children under the age of 2, with a peak age of 3 - 6 months. It is a common, and sometimes severe illness. Respiratory syncytial virus (RSV) is the most common cause. Other viruses that can cause bronchiolitis include:

The virus is transmitted from person to person by direct contact with nasal fluids, or by airborne droplets. Although RSV generally causes only mild symptoms in an adult, it can cause severe illness in an infant.

Bronchiolitis is seasonal and appears more often in the fall and winter months. It is a very common reason for infants to be hospitalized during winter and early spring. It is estimated that by their first year, more than half of all infants have been exposed to RSV.

Risk factors include:

  • Exposure to cigarette smoke
  • Age younger than 6 months old
  • Living in crowded conditions
  • Lack of breast-feeding
  • Prematurity (being born before 37 weeks gestation)
Symptoms

Some children have infections with few or minor symptoms.

Bronchiolitis begins as a mild upper respiratory infection. Over a period of 2 - 3 days, it can develop into increasing respiratory distress with wheezing and a "tight" wheezy cough.

The infant's breathing rate may increase (tachypnea), and the infant may become irritable or anxious-looking. If the disease is severe enough, the infant may turn bluish (cyanotic), which is an emergency.

As the effort of breathing increases, parents may see the child's nostrils flaring with each breath and the muscles between the ribs retracting (intercostal retractions) as the child tries to breathe in air. This can be exhausting for the child, and very young infants may become so tired that they have difficulty maintaining breathing.

Symptoms include:

  • Bluish skin due to lack of oxygen (cyanosis)
  • Cough, wheezing, shortness of breath, or difficulty breathing
  • Fever
  • Intercostal retractions
  • Nasal flaring in infants
  • Rapid breathing (tachypnea)
Signs and tests

Signs include:

  • Decreased blood oxygen
  • Wheezing and crackling sounds heard through stethoscope exam of chest

Tests include:

  • Blood gases
  • Chest x-ray
  • Nasal fluid cultures (to determine which virus is present)
Support Groups

Expectations (prognosis)

Usually, the symptoms get better within a week, and breathing difficulty usually improves by the third day. The mortality rate is less than 1%.

Calling your health care provider

Call your health care provider immediately, or go to the emergency room if the child with bronchiolitis:

  • Becomes lethargic
  • Develops a bluish color in the skin, nails, or lips
  • Develops rapid, shallow breathing
  • Has a cold that suddenly worsens
  • Has difficulty breathing
  • Flares nostrils or retracts chest muscles in an effort to breathe
Complications
  • Airway disease, including asthma, later in life
  • Respiratory failure
  • Additional infection, such as pneumonia
Treatments

Sometimes, no treatment is necessary.

Supportive therapy can include:

  • Chest clapping
  • Drinking enough fluids. Breast milk or formula are okay for children younger than 12 months. Offer warm lemonade or apple juice if your child is over 4 months.
  • Breathing moist (wet) air helps loosen the sticky mucus that may be choking your child. You can use a humidifier to moisten the air your child is breathing. Follow the directions that come with the humidifier.
  • Getting plenty of rest
  • Do not let anyone smoke in the house, car, or anywhere near your child.

Antibiotics are not effective against viral infections. Most medications have little effect on bronchiolitis. Children in the hospital may need oxygen therapy and fluids given through a vein (IV) to stay hydrated.

In extremely ill children, antiviral medications (such as ribavirin) are used in rare cases.

Prevention

Most cases of bronchiolitis are not easily preventable because the viruses that cause the disorder are common in the environment. Careful attention to hand washing, especially around infants, can help prevent the spread of respiratory viruses.

Family members with an upper respiratory infection should be especially careful around infants. Wash your hands often, especially before handling the child.

At this date, there is no RSV vaccine available. However, there is an effective product, called palivizumab (Synagis), for infants who are at high risk of developing severe disease from RSV. Ask your child's doctor whether this medication is right for your child.

References

Watts KD, Goodman DM. Wheezing, bronchiolitis, and bronchitis. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 388.

American Academy of Pediatrics Subcommittee on the Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118:1774-1793.


Review Date: 11/2/2009
Reviewed By: Neil K. Kaneshiro, MD, MHA, Clinical Assistant Professor of Pediatrics, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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