Bronchiolitis: Is the nebulized albuterol party is over

by: Daniel Wood, PA-C

You are precepting a PA student and she is presenting to you the next patient.

Juliette is an 18 month old with a prior 2 day history of nasal congestion and cough and a 1 day history of increasing cough and subcostal retractions.  She presents with a respiratory rate in the low 40’s with slight subcostal retractions and nasal flaring wheezing and fine crackles.   The student has the working diagnosis of bronchiolitis.  When formulating her treatment plan she remembers from her last rotation that the previous provider gave albuterol and oral steroids. She asks you the following questions:

Would you test the toddler for RSV?

Would you recommend a nebulized albuterol treatment?

What are treatments that are helpful in a child with bronchiolitis?

RSV qualitative testing is not indicated to be routinely tested in children with symptoms consistent with RSV.  This will give you an answer of yes or no answer to your question that you already know.  In addition. PCR may be positive post-infection for several weeks later.  Viral testing maybe helpful in babies less than a month of life, where the presence of RSV virus is associated with apnea.

Should bronchodilators be used in children with bronchiolitis?  The short answer to the question is that the American Academy of Pediatrics, the UK’s National Institute for Health and Care Excellence, and the Canadian Pediatric Society currently recommend against them.  It can be confusing because in continental Europe and Australia, the language typically used is not routinely recommended.

So what then is helpful for children with bronchiolitis?  Your best friends are nasal suctioning and hydration and nutrition.

Resources: Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S 3rd, Hernandez-Cancio S; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014 Nov;134(5):e1474-502.

You can see Daniel Wood, PA-C speak at the GAPA 2019 Summer Conference in Hilton Head Island, SC.

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