Initial assessment
In an infant with suspected acute bronchiolitis, the assessment should begin by confirming the typical clinical presentation. The illness usually starts with symptoms of an upper respiratory tract infection, including rhinorrhoea, nasal obstruction and cough, followed by the progressive onset of breathing difficulty. Physical examination may reveal tachypnoea, increased work of breathing, crackles and, in some cases, wheezing.
Bronchiolitis is primarily a clinical diagnosis. Additional investigations, chest radiography and laboratory tests should not be performed routinely, as they rarely alter management and may lead to unnecessary interventions. Assessment should focus on simple, objective parameters: general condition, respiratory rate, work of breathing, feeding, hydration and peripheral oxygen saturation. Whenever possible, SpO₂ should be measured after nasal clearance.
Severity assessment
Following the initial assessment, it is essential to stratify disease severity. Most cases are mild and can be managed in the community, but some infants may deteriorate rapidly, particularly between the third and fifth days of illness.
Particular attention should be paid to signs such as marked tachypnoea, severe chest recession, nasal flaring, grunting, episodes of apnoea, cyanosis, reduced responsiveness, lethargy, signs of dehydration or a marked reduction in oral intake.
Risk factors
The presence of risk factors should lower the threshold for referral. Particularly relevant factors include age under 6–12 weeks, prematurity, chronic lung disease, haemodynamically significant congenital heart disease, immunodeficiency, neurological or neuromuscular disease, and Down syndrome.
In these groups, even apparently moderate illness may warrant hospital observation because of the increased risk of clinical deterioration.
Treatment
The treatment of bronchiolitis is primarily supportive. It includes nasal clearance with saline solution, smaller and more frequent feeds, maintenance of adequate hydration, fever control and monitoring for signs of deterioration.
Caregiver education is a central part of management and should include an explanation of the expected course, warning signs and the possibility that cough may persist for several weeks.
Therapies not routinely recommended
Pharmacological therapies should not be used routinely. Antibiotics, bronchodilators, corticosteroids, cough suppressants, expectorants, antihistamines, decongestants, humidifiers and chest physiotherapy have not shown consistent benefit in most cases.
The use of these interventions may increase costs and adverse effects and lead to unnecessary treatment without proven improvement in clinical outcomes.
Hospital respiratory support
In hospital, oxygen therapy may be required in the presence of persistent hypoxaemia. High-flow nasal cannula therapy (HFNC) may be considered in infants with significant work of breathing or clinical deterioration despite conventional oxygen therapy.
The aim is to reduce the work of breathing and improve oxygenation, and it is used mainly in moderate to severe cases.
Conclusion
In summary, the management of bronchiolitis follows a straightforward sequence: confirm the clinical diagnosis, assess severity after nasal clearance, identify risk factors, decide between home monitoring and hospital referral, and provide appropriate supportive care.
This approach helps avoid unnecessary interventions and enables early recognition of infants at greater risk of deterioration.
