UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Bronchiolitis in infants and children: Clinical features and diagnosis

Authors
Pedro A Piedra, MD
Ann R Stark, MD
Section Editors
Gregory Redding, MD
Morven S Edwards, MD
Deputy Editor
Mary M Torchia, MD

INTRODUCTION

Bronchiolitis, a lower respiratory tract infection that primarily affects the small airways (bronchioles), is a common cause of illness and hospitalization in infants and young children.

The microbiology, epidemiology, clinical features, and diagnosis of bronchiolitis will be presented here. The treatment, outcome, and prevention of bronchiolitis in children; respiratory syncytial virus; and the emergent evaluation of children with acute respiratory distress are discussed separately:

(See "Bronchiolitis in infants and children: Treatment; outcome; and prevention".)

(See "Respiratory syncytial virus infection: Clinical features and diagnosis" and "Respiratory syncytial virus infection: Treatment" and "Respiratory syncytial virus infection: Prevention".)

(See "Emergency evaluation and immediate management of acute respiratory distress in children".)

                           

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Thu Nov 03 00:00:00 GMT 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Bordley WC, Viswanathan M, King VJ, et al. Diagnosis and testing in bronchiolitis: a systematic review. Arch Pediatr Adolesc Med 2004; 158:119.
  2. Fitzgerald DA, Kilham HA. Bronchiolitis: assessment and evidence-based management. Med J Aust 2004; 180:399.
  3. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 2014; 134:e1474.
  4. Wainwright C, Altamirano L, Cheney M, et al. A multicenter, randomized, double-blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med 2003; 349:27.
  5. Plint AC, Johnson DW, Patel H, et al. Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med 2009; 360:2079.
  6. Colby TV. Bronchiolitis. Pathologic considerations. Am J Clin Pathol 1998; 109:101.
  7. Aherne W, Bird T, Court SD, et al. Pathological changes in virus infections of the lower respiratory tract in children. J Clin Pathol 1970; 23:7.
  8. Wohl ME, Chernick V. State of the art: bronchiolitis. Am Rev Respir Dis 1978; 118:759.
  9. Mansbach JM, Piedra PA, Teach SJ, et al. Prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis. Arch Pediatr Adolesc Med 2012; 166:700.
  10. Mansbach JM, McAdam AJ, Clark S, et al. Prospective multicenter study of the viral etiology of bronchiolitis in the emergency department. Acad Emerg Med 2008; 15:111.
  11. Midulla F, Scagnolari C, Bonci E, et al. Respiratory syncytial virus, human bocavirus and rhinovirus bronchiolitis in infants. Arch Dis Child 2010; 95:35.
  12. Meissner HC. Viral Bronchiolitis in Children. N Engl J Med 2016; 374:62.
  13. Skjerven HO, Megremis S, Papadopoulos NG, et al. Virus Type and Genomic Load in Acute Bronchiolitis: Severity and Treatment Response With Inhaled Adrenaline. J Infect Dis 2016; 213:915.
  14. Allander T, Tammi MT, Eriksson M, et al. Cloning of a human parvovirus by molecular screening of respiratory tract samples. Proc Natl Acad Sci U S A 2005; 102:12891.
  15. Calvo C, García-García ML, Pozo F, et al. Clinical characteristics of human bocavirus infections compared with other respiratory viruses in Spanish children. Pediatr Infect Dis J 2008; 27:677.
  16. Richard N, Komurian-Pradel F, Javouhey E, et al. The impact of dual viral infection in infants admitted to a pediatric intensive care unit associated with severe bronchiolitis. Pediatr Infect Dis J 2008; 27:213.
  17. Stempel HE, Martin ET, Kuypers J, et al. Multiple viral respiratory pathogens in children with bronchiolitis. Acta Paediatr 2009; 98:123.
  18. Miron D, Srugo I, Kra-Oz Z, et al. Sole pathogen in acute bronchiolitis: is there a role for other organisms apart from respiratory syncytial virus? Pediatr Infect Dis J 2010; 29:e7.
  19. Piotrowska Z, Vázquez M, Shapiro ED, et al. Rhinoviruses are a major cause of wheezing and hospitalization in children less than 2 years of age. Pediatr Infect Dis J 2009; 28:25.
  20. Jacques J, Bouscambert-Duchamp M, Moret H, et al. Association of respiratory picornaviruses with acute bronchiolitis in French infants. J Clin Virol 2006; 35:463.
  21. Counihan ME, Shay DK, Holman RC, et al. Human parainfluenza virus-associated hospitalizations among children less than five years of age in the United States. Pediatr Infect Dis J 2001; 20:646.
  22. Greensill J, McNamara PS, Dove W, et al. Human metapneumovirus in severe respiratory syncytial virus bronchiolitis. Emerg Infect Dis 2003; 9:372.
  23. Edwards KM, Zhu Y, Griffin MR, et al. Burden of human metapneumovirus infection in young children. N Engl J Med 2013; 368:633.
  24. Kuypers J, Martin ET, Heugel J, et al. Clinical disease in children associated with newly described coronavirus subtypes. Pediatrics 2007; 119:e70.
  25. Kristoffersen AW, Nordbø SA, Rognlien AG, et al. Coronavirus causes lower respiratory tract infections less frequently than RSV in hospitalized Norwegian children. Pediatr Infect Dis J 2011; 30:279.
  26. Lau SK, Woo PC, Li KS, et al. Severe acute respiratory syndrome coronavirus-like virus in Chinese horseshoe bats. Proc Natl Acad Sci U S A 2005; 102:14040.
  27. Arnold JC, Singh KK, Spector SA, Sawyer MH. Human bocavirus: prevalence and clinical spectrum at a children's hospital. Clin Infect Dis 2006; 43:283.
  28. Allander T, Jartti T, Gupta S, et al. Human bocavirus and acute wheezing in children. Clin Infect Dis 2007; 44:904.
  29. Regamey N, Frey U, Deffernez C, et al. Isolation of human bocavirus from Swiss infants with respiratory infections. Pediatr Infect Dis J 2007; 26:177.
  30. Kapoor A, Simmonds P, Slikas E, et al. Human bocaviruses are highly diverse, dispersed, recombination prone, and prevalent in enteric infections. J Infect Dis 2010; 201:1633.
  31. Mansbach JM, Pelletier AJ, Camargo CA Jr. US outpatient office visits for bronchiolitis, 1993-2004. Ambul Pediatr 2007; 7:304.
  32. Hasegawa K, Tsugawa Y, Brown DF, et al. Trends in bronchiolitis hospitalizations in the United States, 2000-2009. Pediatrics 2013; 132:28.
  33. Shay DK, Holman RC, Newman RD, et al. Bronchiolitis-associated hospitalizations among US children, 1980-1996. JAMA 1999; 282:1440.
  34. Pelletier AJ, Mansbach JM, Camargo CA Jr. Direct medical costs of bronchiolitis hospitalizations in the United States. Pediatrics 2006; 118:2418.
  35. Shaw KN, Bell LM, Sherman NH. Outpatient assessment of infants with bronchiolitis. Am J Dis Child 1991; 145:151.
  36. Wang EE, Law BJ, Stephens D. Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) prospective study of risk factors and outcomes in patients hospitalized with respiratory syncytial viral lower respiratory tract infection. J Pediatr 1995; 126:212.
  37. MacDonald NE, Hall CB, Suffin SC, et al. Respiratory syncytial viral infection in infants with congenital heart disease. N Engl J Med 1982; 307:397.
  38. Hall CB, Powell KR, MacDonald NE, et al. Respiratory syncytial viral infection in children with compromised immune function. N Engl J Med 1986; 315:77.
  39. Meissner HC. Selected populations at increased risk from respiratory syncytial virus infection. Pediatr Infect Dis J 2003; 22:S40.
  40. Mansbach JM, Piedra PA, Stevenson MD, et al. Prospective multicenter study of children with bronchiolitis requiring mechanical ventilation. Pediatrics 2012; 130:e492.
  41. Hasegawa K, Pate BM, Mansbach JM, et al. Risk factors for requiring intensive care among children admitted to ward with bronchiolitis. Acad Pediatr 2015; 15:77.
  42. Holman RC, Curns AT, Cheek JE, et al. Respiratory syncytial virus hospitalizations among American Indian and Alaska Native infants and the general United States infant population. Pediatrics 2004; 114:e437.
  43. McConnochie KM, Roghmann KJ. Parental smoking, presence of older siblings, and family history of asthma increase risk of bronchiolitis. Am J Dis Child 1986; 140:806.
  44. Figueras-Aloy J, Carbonell-Estrany X, Quero J, IRIS Study Group. Case-control study of the risk factors linked to respiratory syncytial virus infection requiring hospitalization in premature infants born at a gestational age of 33-35 weeks in Spain. Pediatr Infect Dis J 2004; 23:815.
  45. Choudhuri JA, Ogden LG, Ruttenber AJ, et al. Effect of altitude on hospitalizations for respiratory syncytial virus infection. Pediatrics 2006; 117:349.
  46. Florin TA, Plint AC, Zorc JJ. Viral bronchiolitis. Lancet 2016.
  47. Swingler GH, Hussey GD, Zwarenstein M. Duration of illness in ambulatory children diagnosed with bronchiolitis. Arch Pediatr Adolesc Med 2000; 154:997.
  48. Patel H, Gouin S, Platt RW. Randomized, double-blind, placebo-controlled trial of oral albuterol in infants with mild-to-moderate acute viral bronchiolitis. J Pediatr 2003; 142:509.
  49. Petruzella FD, Gorelick MH. Duration of illness in infants with bronchiolitis evaluated in the emergency department. Pediatrics 2010; 126:285.
  50. Plint AC, Johnson DW, Wiebe N, et al. Practice variation among pediatric emergency departments in the treatment of bronchiolitis. Acad Emerg Med 2004; 11:353.
  51. Thompson M, Vodicka TA, Blair PS, et al. Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013; 347:f7027.
  52. Jartti T, Aakula M, Mansbach JM, et al. Hospital length-of-stay is associated with rhinovirus etiology of bronchiolitis. Pediatr Infect Dis J 2014; 33:829.
  53. McMillan JA, Tristram DA, Weiner LB, et al. Prediction of the duration of hospitalization in patients with respiratory syncytial virus infection: use of clinical parameters. Pediatrics 1988; 81:22.
  54. Green M, Brayer AF, Schenkman KA, Wald ER. Duration of hospitalization in previously well infants with respiratory syncytial virus infection. Pediatr Infect Dis J 1989; 8:601.
  55. Dawson KP, Mogridge N. Acute bronchiolitis: a three year study. N Z Med J 1989; 102:528.
  56. Robbins JM, Kotagal UR, Kini NM, et al. At-home recovery following hospitalization for bronchiolitis. Ambul Pediatr 2006; 6:8.
  57. Wright PF, Gruber WC, Peters M, et al. Illness severity, viral shedding, and antibody responses in infants hospitalized with bronchiolitis caused by respiratory syncytial virus. J Infect Dis 2002; 185:1011.
  58. Willson DF, Landrigan CP, Horn SD, Smout RJ. Complications in infants hospitalized for bronchiolitis or respiratory syncytial virus pneumonia. J Pediatr 2003; 143:S142.
  59. Pinnington LL, Smith CM, Ellis RE, Morton RE. Feeding efficiency and respiratory integration in infants with acute viral bronchiolitis. J Pediatr 2000; 137:523.
  60. Kneyber MC, Brandenburg AH, de Groot R, et al. Risk factors for respiratory syncytial virus associated apnoea. Eur J Pediatr 1998; 157:331.
  61. Bruhn FW, Mokrohisky ST, McIntosh K. Apnea associated with respiratory syncytial virus infection in young infants. J Pediatr 1977; 90:382.
  62. Hall CB, Kopelman AE, Douglas RG Jr, et al. Neonatal respiratory syncytial virus infection. N Engl J Med 1979; 300:393.
  63. Willwerth BM, Harper MB, Greenes DS. Identifying hospitalized infants who have bronchiolitis and are at high risk for apnea. Ann Emerg Med 2006; 48:441.
  64. Schroeder AR, Mansbach JM, Stevenson M, et al. Apnea in children hospitalized with bronchiolitis. Pediatrics 2013; 132:e1194.
  65. Ricart S, Rovira N, Garcia-Garcia JJ, et al. Frequency of apnea and respiratory viruses in infants with bronchiolitis. Pediatr Infect Dis J 2014; 33:988.
  66. Walsh P, Cunningham P, Merchant S, et al. Derivation of Candidate Clinical Decision Rules to Identify Infants at Risk for Central Apnea. Pediatrics 2015; 136:e1228.
  67. Hall CB, Powell KR, Schnabel KC, et al. Risk of secondary bacterial infection in infants hospitalized with respiratory syncytial viral infection. J Pediatr 1988; 113:266.
  68. Thorburn K, Harigopal S, Reddy V, et al. High incidence of pulmonary bacterial co-infection in children with severe respiratory syncytial virus (RSV) bronchiolitis. Thorax 2006; 61:611.
  69. Duttweiler L, Nadal D, Frey B. Pulmonary and systemic bacterial co-infections in severe RSV bronchiolitis. Arch Dis Child 2004; 89:1155.
  70. Quinonez RA, Garber MD, Schroeder AR, et al. Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value. J Hosp Med 2013; 8:479.
  71. Swingler GH, Hussey GD, Zwarenstein M. Randomised controlled trial of clinical outcome after chest radiograph in ambulatory acute lower-respiratory infection in children. Lancet 1998; 351:404.
  72. Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J Paediatr Child Health 1990; 26:209.
  73. Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr 2007; 150:429.
  74. Lina B, Valette M, Foray S, et al. Surveillance of community-acquired viral infections due to respiratory viruses in Rhone-Alpes (France) during winter 1994 to 1995. J Clin Microbiol 1996; 34:3007.
  75. Corrard F, de La Rocque F, Martin E, et al. Food intake during the previous 24 h as a percentage of usual intake: a marker of hypoxia in infants with bronchiolitis: an observational, prospective, multicenter study. BMC Pediatr 2013; 13:6.
  76. Shazberg G, Revel-Vilk S, Shoseyov D, et al. The clinical course of bronchiolitis associated with acute otitis media. Arch Dis Child 2000; 83:317.
  77. Andrade MA, Hoberman A, Glustein J, et al. Acute otitis media in children with bronchiolitis. Pediatrics 1998; 101:617.
  78. Welliver RC. Bronchiolitis and infectious asthma. In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 7th, Cherry JD, Harrison GJ, Kaplan SL, et al. (Eds), Elsevier Saunders, Philadelphia 2014. p.271.
  79. Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections. Pediatrics 2004; 113:1728.
  80. Viswanthan M, King V, Bordley C, et al. Management of bronchiolitis in infants and children. Evidence Report/Technology Assessment No. 69. ARHQ Publication No. 03-E014, Agency for Healthcare Research and Quality; US Department for Health and Human Services, Rockville, MD 2003.
  81. Purcell K, Fergie J. Lack of usefulness of an abnormal white blood cell count for predicting a concurrent serious bacterial infection in infants and young children hospitalized with respiratory syncytial virus lower respiratory tract infection. Pediatr Infect Dis J 2007; 26:311.
  82. Kuppermann N, Bank DE, Walton EA, et al. Risks for bacteremia and urinary tract infections in young febrile children with bronchiolitis. Arch Pediatr Adolesc Med 1997; 151:1207.
  83. Bilavsky E, Shouval DS, Yarden-Bilavsky H, et al. A prospective study of the risk for serious bacterial infections in hospitalized febrile infants with or without bronchiolitis. Pediatr Infect Dis J 2008; 27:269.
  84. Ralston S, Hill V, Waters A. Occult serious bacterial infection in infants younger than 60 to 90 days with bronchiolitis: a systematic review. Arch Pediatr Adolesc Med 2011; 165:951.
  85. Harris JA, Huskins WC, Langley JM, et al. Health care epidemiology perspective on the October 2006 recommendations of the Subcommittee on Diagnosis and Management of Bronchiolitis. Pediatrics 2007; 120:890.
  86. Antonow JA, Byington CL. Use of respiratory syncytial virus testing could safely eliminate many sepsis evaluations. Arch Pediatr Adolesc Med 1999; 153:1310.
  87. Smyth RL, Openshaw PJ. Bronchiolitis. Lancet 2006; 368:312.
  88. Hall CB. Diagnosis and testing in bronchiolitis: a systematic review. J Pediatr 2004; 145:417.
  89. Stollar F, Alcoba G, Gervaix A, Argiroffo CB. Virologic testing in bronchiolitis: does it change management decisions and predict outcomes? Eur J Pediatr 2014; 173:1429.
  90. Vogel AM, Lennon DR, Harding JE, et al. Variations in bronchiolitis management between five New Zealand hospitals: can we do better? J Paediatr Child Health 2003; 39:40.
  91. Adcock PM, Stout GG, Hauck MA, Marshall GS. Effect of rapid viral diagnosis on the management of children hospitalized with lower respiratory tract infection. Pediatr Infect Dis J 1997; 16:842.
  92. Doan QH, Kissoon N, Dobson S, et al. A randomized, controlled trial of the impact of early and rapid diagnosis of viral infections in children brought to an emergency department with febrile respiratory tract illnesses. J Pediatr 2009; 154:91.
  93. Doan Q, Enarson P, Kissoon N, et al. Rapid viral diagnosis for acute febrile respiratory illness in children in the Emergency Department. Cochrane Database Syst Rev 2014; :CD006452.
  94. Subramony A, Zachariah P, Krones A, et al. Impact of Multiplex Polymerase Chain Reaction Testing for Respiratory Pathogens on Healthcare Resource Utilization for Pediatric Inpatients. J Pediatr 2016; 173:196.
  95. Bourke T, Shields M. Bronchiolitis. BMJ Clin Evid 2011; 2011.
  96. American Academy of Pediatrics. Respiratory syncytial virus. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.667.
  97. Ahluwalia G, Embree J, McNicol P, et al. Comparison of nasopharyngeal aspirate and nasopharyngeal swab specimens for respiratory syncytial virus diagnosis by cell culture, indirect immunofluorescence assay, and enzyme-linked immunosorbent assay. J Clin Microbiol 1987; 25:763.
  98. Macfarlane P, Denham J, Assous J, Hughes C. RSV testing in bronchiolitis: which nasal sampling method is best? Arch Dis Child 2005; 90:634.
  99. Scottish Intercollegiate Guidelines Network. Bronchiolitis in children. A national clinical guideline. 2006. www.sign.ac.uk/pdf/sign91.pdf (Accessed on August 25, 2015).
  100. Mulholland EK, Olinsky A, Shann FA. Clinical findings and severity of acute bronchiolitis. Lancet 1990; 335:1259.
  101. Brooks AM, McBride JT, McConnochie KM, et al. Predicting deterioration in previously healthy infants hospitalized with respiratory syncytial virus infection. Pediatrics 1999; 104:463.
  102. Roback MG, Baskin MN. Failure of oxygen saturation and clinical assessment to predict which patients with bronchiolitis discharged from the emergency department will return requiring admission. Pediatr Emerg Care 1997; 13:9.
  103. Walsh EE, McConnochie KM, Long CE, Hall CB. Severity of respiratory syncytial virus infection is related to virus strain. J Infect Dis 1997; 175:814.
  104. Martinello RA, Chen MD, Weibel C, Kahn JS. Correlation between respiratory syncytial virus genotype and severity of illness. J Infect Dis 2002; 186:839.
  105. Klassen TP, Rowe PC, Sutcliffe T, et al. Randomized trial of salbutamol in acute bronchiolitis. J Pediatr 1991; 118:807.
  106. Groothuis JR, Woodin KA, Katz R, et al. Early ribavirin treatment of respiratory syncytial viral infection in high-risk children. J Pediatr 1990; 117:792.
  107. Englund JA, Piedra PA, Ahn YM, et al. High-dose, short-duration ribavirin aerosol therapy compared with standard ribavirin therapy in children with suspected respiratory syncytial virus infection. J Pediatr 1994; 125:635.
  108. Bekhof J, Reimink R, Brand PL. Systematic review: insufficient validation of clinical scores for the assessment of acute dyspnoea in wheezing children. Paediatr Respir Rev 2014; 15:98.
  109. Coffin SE. Bronchiolitis: in-patient focus. Pediatr Clin North Am 2005; 52:1047.
  110. Landau LI. Bronchiolitis and asthma: are they related? Thorax 1994; 49:293.