Bronchiolitis – causes, symptoms, treatment, complications

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Bronchiolitis is a common lung infection in young children and infants. It causes inflammation and congestion of the bronchioles. Bronchiolitis is almost always caused by a virus. Typically, the peak period of bronchiolitis is in the winter months. Bronchiolitis begins with cold-like symptoms, but then progresses to coughing, wheezing and sometimes difficulty breathing. Symptoms of bronchiolitis can last from several days to weeks. Most children feel better with home care. However, a small percentage of children require hospitalization.

Inflammation of the bronchioles can block oxygen in the airways, leading to symptoms such as coughing or difficulty breathing. Generally, bronchiolitis is a mild condition, but severe cases can lead to lung failure.

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Inflammation of the bronchioles affects the smaller airways (bronchioles). Bronchitis usually affects older children and adults, while bronchiolitis is more common in younger children.

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What are the types of bronchiolitis?

Diffuse bronchiolitis

Diffuse bronchiolitis is a rare disease whose causes are not yet well understood (although there is much talk about the genetic makeup). This type of bronchitis is characterized by the appearance of shortness of breath and purulent sputum. The sinuses are also affected. The disease progresses slowly, but lung function damage is only a matter of time.

Diffuse bronchiolitis is very difficult to diagnose as the symptoms are similar to almost any lung disease. Treatment usually lasts several weeks or months and is based on the administration of antibiotics, which slow down the development of the disease (however, the patient must be under a doctor’s care for the rest of his life).

Obstructive bronchiolitis

In a patient with obstructive bronchiolitis, the lumen of the bronchioles becomes gradually narrowing, which leads to symptoms such as persistent and dry cough, shortness of breath and breathing problems. There may be several reasons for the onset of the disease: contact with toxic fumes; a consequence of an untreated respiratory infection (especially in children), complication after lung transplantation; the consequence of rheumatological diseases (arthritis, lupus erythematosus); a side effect of taking certain medications.

The diagnosis is made through tests such as a chest X-ray, spirometry, and a basic GP examination. Occasionally it may be necessary to perform a lung biopsy. Treatment is usually based on the administration of cough suppressants. Sometimes they also include immunosuppressants and corticosteroids. Similarly, in the previous example, a large proportion of patients must remain under the care of a specialist for many years, sometimes for the rest of their lives.

Papular bronchiolitis

In the case of this type of bronchiolitis, there is an overgrowth of the so-called lymph nodes in the lungs (part of the lymphatic system). Papular bronchiolitis is usually a consequence of rheumatoid arthritis or systemic lupus. It is also diagnosed in the case of HIV infection. The diagnosis is not the easiest one, because the symptoms are similar to any other respiratory disease. The examinations include chest X-ray, sometimes computed tomography, and spirometry. Treatment consists of taking bronchodilators and glucocorticosteroids.

Some patients fully recover, but others may require specialist care for the rest of their lives. Possible complications of the disease are bronchoconstriction and more frequent respiratory infections.

Acute bronchiolitis

The hallmark of acute bronchiolitis is edema and epithelial necrosis. In children, the disease is usually caused by infection with RSV. In adults, this may be because of ingestion or inhalation of toxic gases. Symptoms include rapid breathing, prolonged exhalation, and wheezing. Treatment is based on the facilitation of breathing, oxygen administration, fluid replacement and nutrition (the disease is usually mild).

Bronchiolitis – risk factors

Bronchiolitis usually affects children under 2 years of age. Babies under 3 months of age are at greatest risk of developing bronchiolitis because their lungs and immune systems are not fully developed yet.

Other factors that are associated with an increased risk of bronchiolitis in infants and with more severe cases are:

1. Premature birth;
2. Heart or lung disease;
3. Weakened immune system;
4. Exposure to tobacco smoke;
5. Never breastfed (breastfed babies get the immune benefits from the mother);
6. Contact with many children, for example in a childcare facility;
7. Spending time in crowded environments;
8. Having siblings attending school or using childcare services and bringing an infection into your home.

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Your baby may show more serious symptoms, including:

1. Grunting noises;
2. Problems with sucking and swallowing, which makes feeding difficult, in addition to poor appetite;
3. Attempts to breathe so forcefully that the baby’s chest reclines (the skin is tightly pulled over the chest and looks like it’s going in);
4. Bluish lips, fingertips or toes;
5. General lethargy.

If we notice such symptoms in our child, we should immediately call our doctor or take the child to the emergency room. This also applies if the baby shows signs of dehydration, such as dry mouth, infrequent urination, and crying without tears. Dehydration is a very serious condition in a young child.

Also check: Is wheezing a symptom of an illness?

Infants hospitalized with bronchiolitis caused by respiratory syncytial virus and rhinovirus (the virus that is the most common cause of the common cold) have an increased risk of recurring wheezing in the first 10 years of life. Some studies have also reported an increased risk of asthma following an episode of bronchiolitis, although it is unclear whether the risk of asthma is increased due to bronchiolitis or other risk factors (e.g. genetic predisposition to asthma, environmental irritants such as cigarette smoke).

When your baby wheezes for the first time, it can be difficult to tell if it’s caused by bronchiolitis or asthma. Most cases of wheezing for the first time are caused by a virus. A history of recurring wheezing episodes and a family or personal history of asthma, nasal allergies or eczema help to make a diagnosis of asthma. Viruses often trigger asthma attacks in children with asthma.

After developing bronchiolitis, some infants will have recurring episodes of wheezing during childhood. These wheezing episodes are caused by viruses and may respond to the same treatments that are used for children with asthma.

Gastric reflux with aspiration of gastric contents may also cause a clinical picture of bronchiolitis; multiple episodes in an infant could be a clue to this diagnosis. Foreign body aspiration sometimes causes wheezing and should be considered if the onset is sudden and not associated with symptoms of an upper respiratory tract infection. Heart failure with a known left-to-right shunt, which manifests itself at 2 to 3 months of age, may also be confused with bronchiolitis.

Whenever we find that a child has breathing difficulties, we should consult a doctor. It is he who will be able to distinguish one type of breathing problem from another.

See also: Foreign bodies in the respiratory tract

Tests and x-rays are usually not needed to diagnose bronchiolitis. The doctor can usually identify the problem by observing the baby and auscultating the lungs with a stethoscope. Patients suspected of having bronchiolitis should receive pulse oximetry to assess oxygenation.

If your child is at risk of developing severe bronchiolitis, if symptoms worsen, or if another problem is suspected, your doctor may order tests, including:

1. Chest x-ray. Your doctor may ask for a chest X-ray to look for signs of pneumonia.
2. Viral Research. The doctor may take a mucus sample from your child to test for the presence of a virus that causes bronchiolitis. This is done with a cotton ball that is gently inserted into your nose.
3. Blood tests. Occasionally, blood tests may be used to check your baby’s white blood cell count. An increase in the number of white blood cells is usually a sign that your body is fighting an infection. A blood test can also determine if the oxygen level in your baby’s bloodstream has dropped.

The doctor may also ask us about signs of dehydration, especially if our child refuses to drink or eat, or is vomiting. Signs of dehydration include sunken eyes, dry mouth and dry skin, lethargy, and little or no urination.

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Bronchiolitis – prognosis

The prognosis is very good. Most babies recover within 3 to 5 days without sequelae, although wheezing and coughing may last for 2 to 4 weeks. Mortality is <0,1% when medical care is appropriate. The incidence of asthma in children with bronchiolitis in early childhood is suspected to be increased, but the relationship is controversial as children who develop asthma later may be more severely affected by RSV and therefore see their doctor more often. Incidence appears to decrease with increasing age of children.

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Bronchiolitis – treatment

Inflammation of the bronchioles usually lasts for two to three weeks. Most children with bronchiolitis can be looked after at home. It is important to be alert to changes in breathing difficulties, such as fighting for each breath, not being able to speak or cry because of difficulty breathing, or grunting with each breath.

Since viruses cause bronchiolitis, antibiotics – which are used to treat infections caused by bacteria – are not effective against them. Bacterial infections, such as pneumonia or an ear infection, can occur along with bronchiolitis, and your doctor may prescribe an antibiotic for this infection.

Drugs that open the airways (bronchodilators) have been found not to be routinely helpful and are not usually given for bronchiolitis. In severe cases, your doctor may decide to try sulbutamol treatment with a nebuliser to see if this helps.

Oral corticosteroids and tapping the chest to loosen mucus (chest physiotherapy) have not been effective in treating bronchiolitis and are not recommended.

Bronchiolitis – inpatient care

A small percentage of children may require hospital care to manage their condition. Children with conditions such as heart disease, immunodeficiency or bronchopulmonary dysplasia that put them at high risk of severe or complicated disease should also be considered candidates for hospitalization.

In hospitalized children, 30-40% of the oxygen delivered through the nasal cannula or face mask is usually sufficient to maintain oxygen saturation> 90%. Tracheal intubation is indicated in the event of severe recurrent apnea, hypoxemia unresponsive to oxygen therapy, CO2 retention, or when the child is unable to remove bronchial secretions. High flow nasal cannula [HFNC] oxygen therapy, CPAP (Continuous Positive Airway Pressure) therapy, or both, are often used to avoid intubation in patients at risk of respiratory failure.

Hydration can be maintained by feeding frequently with small clear fluids. Sick children should be given intravenous fluids initially, and hydration levels should be monitored based on urine output, specific gravity, and serum electrolytes.

There is evidence that systemic corticosteroids are beneficial when given very early in the disease in children with underlying corticosteroid-responsive conditions (e.g., bronchopulmonary dysplasia, asthma), but are of no benefit in previously healthy infants.

Antibiotics should be discontinued unless a secondary bacterial infection occurs (rare sequelae).

Bronchodilators are not equally effective, but a significant subset of children may respond with a short-term improvement. This is especially true for babies who have previously had wheezing. Hospital stays are unlikely to be shorter.

Ribavirin, an antiviral drug with in vitro activity against respiratory syncytial virus (RSV), influenza and measles, is unlikely to be clinically effective and is no longer recommended, except in immunocompromised children with severe RSV infection; it is also potentially toxic to hospital staff. RSV immunoglobulin has been tried, but it is not effective.

Prevention of RSV infection by passive immunoprophylaxis with an anti-RSV monoclonal antibody (palivizumab) reduces hospitalization rates, but is costly and is indicated primarily in high-risk infants.

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Inflammation of the bronchioles – complications

Ear infection is a common complication of bronchiolitis. Another less common complication is bacterial pneumonia.

Severe complications of bronchiolitis can include:

1. Blueness of the lips or skin (cyanosis) caused by lack of oxygen;
2. Breaks in breathing (apnea), which are most common in premature babies and infants in the first two months of life;
3. Dehydration;
4. Low oxygen levels and respiratory failure.

In this case, the child may need to be hospitalized. Severe respiratory failure may require insertion of a tube into the windpipe (tracheotomy) to help the child breathe until the infection has passed.

If your baby was born prematurely, has heart or lung problems, or has a weak immune system, you should carefully watch for signs of bronchiolitis. The infection can become severe quickly. In these cases, the child will usually need to be hospitalized.

Bronchiolitis is the leading cause of infant hospitalization in the US, with approximately 100 hospital admissions annually. While bronchiolitis is manageable, it can also be life-threatening in rare cases, such as when it causes respiratory failure. In the United States, fewer than 000 children die of bronchiolitis each year. Worldwide, this number is around 100 per year.

1. Moisten the air. If the air in our baby’s room is dry, a humidifier or cold mist evaporator can moisten the air and relieve nasal congestion and coughing. Remember to keep the humidifier clean to prevent the growth of bacteria and mold.
2. Keep your baby upright. Standing upright usually makes breathing easier.
3. Let your child drink fluids. To prevent dehydration, give your child plenty of clear fluids such as water or juice to drink. Our baby may drink more slowly than usual because of a stuffy nose and breathing problems. It will be easier for us to give smaller amounts of food or liquids at a time, but to increase the amount of feeding the baby.
4. Try nasal saline drops to relieve nasal congestion. We can buy these drops without a prescription. They are effective, safe and will not irritate even children’s noses. To use them, pour a few drops into one nostril, and then immediately suck the secretion into that nostril (but do not push the pears too deep). Repeat the process in the other nostril.
5. Consider pain medications. To treat fever or pain, ask your doctor to give your child over-the-counter antipyretic and pain relievers such as acetaminophen or ibuprofen as a safer alternative to aspirin. Aspirin is not recommended in children due to the risk of Reye’s syndrome, a rare but potentially life-threatening condition. Children and adolescents after chickenpox or flu-like symptoms should never take aspirin as they have a higher risk of Reye’s syndrome.
6. Maintain a smoke-free environment. Smoke can aggravate the symptoms of a respiratory infection. If a family member smokes, ask him or her to smoke outside the home and outside the car. It is recommended to keep the child away from any airborne irritants, such as strong perfumes or strong-smelling cleansers.

Do not use over-the-counter medications, with the exception of antipyretics and painkillers, to treat cough and cold in children under 6 years of age. Also consider avoiding the use of these drugs in children under 12 years of age.

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Bronchiolitis – prevention

As bronchiolitis viruses spread from person to person, one of the best ways to prevent this is by washing your hands frequently – especially before touching your baby, or if you have a cold or other respiratory disease. It is appropriate to wear a face mask at this time.

If our child has bronchiolitis, let’s keep them at home until the disease has passed to avoid spreading it to other people.

Other common-sense ways to reduce infection include:

1. Limiting contact with people who have a fever or cold. If our baby is a newborn, especially a premature baby, avoid contact with a cold, especially in the first two months of life.
2. Cleaning and disinfecting surfaces. Let’s clean and disinfect surfaces and objects that people often touch, such as toys and door handles. This is especially true when a family member is sick.
3. Covering mouth and nose when coughing and sneezing. Cover your mouth and nose with a tissue. Then throw away the handkerchief and wash your hands, or use an alcohol-based hand sanitizer.
4. Using your own drinking glasses. We do not share glasses with others, especially if someone in our family is sick.
5. Frequent hand washing. We often wash our hands and the hands of the baby. Keep an alcohol-based hand sanitizer on hand for you and your baby when we’re out and about.
6. Breast-feeding. Respiratory tract infections are much less common in breastfed infants.

In some cases, children may be given palivizumab with an anti-RSV antibody (Synagis) to prevent RSV infections. This can happen if the doctor thinks our baby is at a higher risk of serious complications, especially if she has a congenital heart defect or is premature. As with any type of medication, you should discuss palivizumab with your doctor to understand how it works, how often and how much to be given, and any side effects it may have.

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