The use of ipratropium bromide in this population is controversial, but it appears to be somewhat effective as an adjunct therapy. It is also useful in infants with significant tracheal and bronchial malacia who may be made worse by ?-2 agonists such as albuterol because of the subsequent decrease in smooth muscle tone.
A trial of inhaled steroids may be warranted in a patient who has responded to multiple courses of oral steroids, has moderate to severe wheezing, or a significant history of atopy including food allergy or eczema. Inhaled steroids are appropriate for maintenance therapy in patients with known reactive airways but are controversial when used for episodic or acute illnesses.
Oral steroids are generally reserved for atopic wheezing infants thought to have asthma that is refractory to other medications. Their use in first-time wheezing infants or those infants that do not warrant hospitalization is controversial.
Infants with acute bronchiolitis who are experiencing respiratory distress should be hospitalized; the mainstay of treatment is supportive. If hypoxemic, the child should receive cool humidified oxygen. Sedatives are to be avoided because they may depress respiratory drive. The infant is sometimes more comfortable if sitting with head and chest elevated at a 30-degree angle with neck extended. The risk of aspiration of oral feedings may be high in infants with bronchiolitis, owing to tachypnea and the increased work of breathing. The infant may be fed through a nasogastric tube. If there is any risk for further respiratory decompensation potentially necessitating tracheal intubation, however, the infant should not be fed orally but be maintained with parenteral fluids. Frequent suctioning of nasal and oral secretions often provides relief of distress or cyanosis. Oxygen is indicated in all infants with hypoxia.
A number of agents have been proposed as adjunctive therapies for bronchiolitis. Bronchodilators produce modest short-term improvement in clinical features, but the statistical improvement in clinical scoring systems seen with them is not always clinically significant. Several studies have included both infants with 1st-time wheezing and those with recurrent wheezing, complicating interpretation of the data. Nebulized epinephrine may be more effective than ?-agonists. A trial dose of inhaled bronchodilator may be reasonable, with further therapy predicated on response in the individual patient. Corticosteroids, whether parenteral, oral, or inhaled, have been used for bronchiolitis despite conflicting and often negative studies. Differences of diagnostic criteria, measures of effect, timing and route of administration, and severity of illness complicate these studies. Corticosteroids are not recommended in previously healthy infants with RSV. Ribavirin, an antiviral agent administered by aerosol, has been used for infants with congenital heart disease or chronic lung disease. There is no convincing evidence of a positive impact on clinically important outcomes such as mortality and duration of hospitalization. Antibiotics have no value unless there is secondary bacterial pneumonia. Likewise, there is no support for RSV immunoglobulin administration during acute episodes of RSV bronchiolitis.