BRONCHIOLITIS

INTRODUCTION
Acute bronchiolitis, a common disease of the lower respiratory tract of infants,
results from inflammatory obstruction of the small airways. It occurs during the first 2
yr of life, with a peak incidence at approximately 6 mo of age, and in many localities,
it is the most frequent cause of hospitalization of infants. The incidence is highest
during the winter and early spring. The illness occurs sporadically and epidemically.

ETIOLOGY AND EPIDEMIOLOGY

Acute bronchiolitis is predominantly a viral illness. The respiratory syncytial
virus (RSV) is the causative agent in more than 50% of cases; parainfluenza 3 virus,
mycoplasma, some adenoviruses, and occasionally other viruses produce most of the
remaining cases. Adenovirus may be associated with long-term complications,
including bronchiolitis obliterans and unilateral hyperlucent lung syndrome (Swyer-
James syndrome). There is no firm evidence that bacteria cause bronchiolitis.
Occasionally, bacterial bronchopneumonia may be confused clinically with
bronchiolitis.
Bronchiolitis occurs most commonly in male infants between 3 and 6 mo of
age who have not been breast-fed and who live in crowded conditions. The source of
the viral infection is usually a family member with minor respiratory illness. Older
children and adults tolerate bronchiolar edema better than infants and do not develop
the clinical picture of bronchiolitis even when the smaller airways of their respiratory
tract are infected by a virus.
In one report, sophisticated pulmonary function studies were performed for a
large population of normal infants. The follow-up analysis revealed that wheezy
respiratory illnesses were significantly more common among infants whose initial
total respiratory conductance was in the lowest third of those tested. Diminished lung
function may play a role in determining which infants with viral infection develop
bronchiolitis.
Infants whose mothers smoke cigarettes are more likely to develop
bronchiolitis than infants of nonsmoking mothers. Despite the known risks of
respiratory infections from child care, infants who stay home with mothers who are
heavy smokers are more likely to develop bronchiolitis than infants who attend day
care centers.

PATHOPHYSIOLOGY
Acute bronchiolitis is characterized by bronchiolar obstruction due to edema
and accumulation of mucus and cellular debris and by invasion of the smaller
bronchial radicles by virus. Because resistance to airflow in a tube is inversely related
to the fourth power of the radius, even minor thickening of the bronchiolar wall in
infants may profoundly affect airflow. Resistance in the small air passages is
increased during the inspiratory and expiratory phases, but because the radius of an
airway is smaller during expiration, the resultant ball valve respiratory obstruction
leads to early air trapping and overinflation. Atelectasis may occur when an
obstruction becomes complete and trapped air is absorbed.
 The pathologic process impairs the normal exchange of gases in the lung.
Ventilation perfusion mismatch results in hypoxemia, which occurs early in the
course. Carbon dioxide retention (i.e., hypercapnia) does not usually occur except in
severely affected patients. The higher the respiratory rate, the lower is the arterial
oxygen tension. Hypercapnia usually does not occur until respirations exceed 60/min;
it then increases in proportion to the tachypnea.

CLINICAL MANIFESTATIONS
Most affected infants have a history of exposure to older children or adults
with minor respiratory diseases within the week preceding the onset of illness. The
infant first has a mild upper respiratory tract infection with serous nasal discharge and
sneezing. These symptoms usually last several days and may be accompanied by
diminished appetite and fever of 38.5–39ºC (101–102ºF), although the temperature
may range from subnormal to markedly elevated. The gradual development of
respiratory distress is characterized by paroxysmal wheezy cough, dyspnea, and
irritability. Breast- or bottle-feeding may be particularly difficult, because the rapid
respiratory rate may not permit time for sucking and swallowing. In mild cases,
symptoms disappear in 1–3 days. In the more severely affected patients, symptoms
may develop within several hours, and the course is protracted. Other systemic
manifestations, such as vomiting and diarrhea, are usually absent.
An examination reveals a tachypneic infant, often in extreme distress.
Respirations range from 60–80/min; severe air hunger and cyanosis may occur. The
alae nasi flare, and use of the accessory muscles of respiration results in intercostal
and subcostal retractions, which are shallow because of the persistent distention of the
lungs by the trapped air. The depression of the liver and spleen by the overinflated
lungs may result in their being palpable below the costal margin. Widespread fine
crackles may be heard at the end of inspiration and in early expiration. The expiratory
phase of breathing is prolonged, and wheezes are usually audible. In the most severe
cases, breath sounds are barely audible when bronchiolar obstruction is almost
complete.
Roentgenographic examination reveals hyperinflation of the lungs and an
increased anteroposterior diameter on lateral view. Scattered areas of consolidation
are found in about 30% of patients and are caused by atelectasis secondary to
obstruction or by inflammation of the alveoli. Early bacterial pneumonia cannot be
excluded on radiographic grounds alone.
The white blood cell and differential cell counts are usually within normal
limits. Lymphopenia, commonly associated with many viral illnesses, is usually not
found. Nasopharyngeal cultures reveal normal bacterial flora. Virus may be
demonstrated in nasopharyngeal secretions by antigen detection (e.g., enzyme
immunoassay) or by culture.
DIFFERENTIAL DIAGNOSIS
The condition most commonly confused with acute bronchiolitis is asthma.
One or more of the following favors the diagnosis of asthma: a family history of
asthma, repeated episodes in the same infant, sudden onset without preceding
infection, markedly prolonged expiration, eosinophilia, and an immediate favorable
response to the administration of a single dose of aerosolized albuterol. Repeated
attacks represent an important differential point: fewer than 5% of recurrent attacks of
clinical bronchiolitis have viral infections as a cause. Other entities that may be
confused with acute bronchiolitis are congestive heart failure, a foreign body in the
trachea, pertussis, organophosphate poisoning, cystic fibrosis, and bacterial
bronchopneumonias associated with generalized obstructive pulmonary overinflation.

COURSE AND PROGNOSIS

The most critical phase of illness occurs during the first 48–72 hr after the
onset of cough and dyspnea. During this period, the infant appears desperately ill,
apneic spells occur in the very young infant, and respiratory acidosis is likely to be
noticed. After the critical period, improvement occurs rapidly and often dramatically.
Recovery is complete in a few days. The case fatality rate is below 1%; death may
result from prolonged apneic spells, severe uncompensated respiratory acidosis, or
profound dehydration secondary to the loss of water vapor from tachypnea and the
inability to drink fluids. Infants with conditions such as congenital heart disease,
bronchopulmonary dysplasia, immunodeficiency diseases, or cystic fibrosis have a
greater morbidity rate and have a slightly increased mortality rate. The mortality rate
is not as great in these "high-risk" infants as it once was. Estimates of mortality
among infants with these high-risk conditions who contract RSV bronchiolitis have
decreased from 37% in 1982 to 3.5% in 1988. Bacterial complications, such as
bronchopneumonia or otitis media, are uncommon. Cardiac failure during
bronchiolitis is rare, except in children with underlying heart disease.
A significant proportion of infants with bronchiolitis have hyper-reactive
airways during later childhood, but the relation of these two entities, if any, is not
understood. The suggestion that a single episode of bronchiolitis may result in very-
long-term small airway abnormality requires further investigation. These
abnormalities may be partially explained by the finding that infants with low total
respiratory conductance are more likely to develop bronchiolitis in response to viral
respiratory infection. The infants with bronchiolitis who develop reactive airways are
more likely to have a family history of asthma and allergy, a prolonged acute episode
of bronchiolitis, and exposure to cigarette smoke.

TREATMENT
Infants with respiratory distress should be hospitalized, but only supportive
treatment is indicated. The patient is commonly placed in an atmosphere of cool,
humidified oxygen to relieve hypoxemia and reduce insensible water loss from
tachypnea; this treatment relieves the dyspnea and cyanosis and allays anxiety and
restlessness. Sedatives should be avoided whenever possible because of potential
depression of respiration. The infant is usually more comfortable sitting at a 30 to 40
degree angle or with the head and chest slightly elevated so that the neck is somewhat
extended. Oral intake must often be supplemented or replaced by parenteral fluids to
offset the dehydrating effect of tachypnea. Electrolyte balance and pH should be
adjusted by suitable intravenous solutions.
 Ribavirin (Virazole), an antiviral agent, has been available for the treatment of
RSV infection since 1985. Several controlled trials using high-risk patients showed an
improvement in oxygenation and decreased viral shedding. Its use has been
recommended for infants with congenital heart disease or bronchopulmonary
dysplasia by the Committee on Infectious Diseases of American Academy of
Pediatrics (AAP). One study of intubated infants randomized to ribavirin or placebo
showed a better outcome for the ribavirin-treated group. Despite these apparently
favorable studies and the AAP recommendation, the use of ribavirin remains
controversial, even in desperately ill infants. The study of intubated infants, for
example, employed water (a known bronchoconstrictor) rather than saline as the
placebo, raising important questions about its validity. There has been no convincing
evidence of its impact on the duration of hospitalization, requirement for supportive
therapies such as oxygen or mechanical ventilation, or mortality. There appears to be
generally excellent outcome for even some high-risk infants not treated with ribavirin.
Antibiotics have no therapeutic value unless there is secondary bacterial pneumonia.
The low incidence of bacterial complications is not reduced further by antibiotic
therapy. Corticosteroids are not beneficial and may be harmful under certain
conditions. However, corticosteroids have not been evaluated in patients with severe
adenovirus bronchiolitis in whom long-term severe sequelae (e.g., necrotizing lesions)
might be more likely. Bronchodilating aerosolized drugs (e.g., albuterol) are
frequently used empirically; studies are divided between those that demonstrate
benefit and those that demonstrate no benefit or even harm. Epinephrine or other
adrenergic agents have a theoretical basis for use, and in two studies, aerosolized
epinephrine provided some benefit to infants with bronchiolitis. Chinese herbs have
been shown in one study to decrease symptom duration by 2.6 days. Because the
obstruction occurs at the bronchiolar level, tracheostomy is not beneficial and
involves substantial risks that are not justified in these acutely ill infants. Some
patients may progress rapidly to respiratory failure, requiring ventilatory assistance.

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