Clinical Review

Acute bronchiolitis

BMJ 2007; 335 doi: http://dx.doi.org/10.1136/bmj.39374.600081.AD (Published 15 November 2007)
Cite this as: BMJ 2007;335:1037

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  1. Andrew Bush, professor of paediatric respirology1,
  2. Anne H Thomson, consultant in paediatric respiratory medicine2
  1. 1Imperial School of Medicine at National Heart and Lung Institute, London SW3 6NP
  2. 2Oxford Children's Hospital, Oxford OX3 9DU
  1. Correspondence to: A Bush, Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London SW3 6NPa.bush{at}rbh.nthames.nhs.uk

    Summary points

    • • Bronchiolitis caused by respiratory syncytial virus is an important and seasonal cause of respiratory morbidity in the first year of life

    • • No effective preventive or therapeutic strategies exist, and supportive management is offered

    • • Unnecessary investigations and ineffective treatment must be avoided

    • • Many infants have medium to long term post-bronchiolitic symptoms, which should not be confused with true asthma and which do not respond to any current treatments

    Acute bronchiolitis is a clinical diagnosis. A UK Delphic process reached a 90% consensus that bronchiolitis “is a seasonal viral illness, characterised by fever, nasal discharge and dry, wheezy cough. On examination, there are fine inspiratory crackles and/or high-pitched expiratory wheeze.”1 Internationally, the definition is sometimes broadened to include a first episode of acute viral wheeze. It is an annual and major cause of morbidity in infancy. Acute bronchiolitis is a very common serious respiratory illness in children. Inappropriate treatment is often prescribed, and the relation between such treatment and subsequent asthma is unclear. This review focuses on management in the community and hospital ward.

    What causes acute bronchiolitis?

    Respiratory syncytial virus (RSV) is responsible for about 80% of cases. Other causative agents include human metapneumovirus; rhinovirus; adenovirus (more likely to be followed by serious sequelae, such as obliterative bronchiolitis); influenza and para-influenza viruses; and enteroviruses. Diagnosing RSV is important for preventing cross infection in hospital and for epidemiological information but does not affect acute management.

    Sources and selection criteria

    We searched PubMed and the Cochrane database using the term “bronchiolitis” and hand selected what we deemed to be clinically relevant articles. We also used the evidence based, SIGN (Scottish Intercollegiate Guidelines Network) guidelines,2 which we recommend to readers. We drew on our personal archives of references.

    Who gets acute bronchiolitis and how common is it?

    Acute bronchiolitis is largely a disease of the first year of life; 2-3% of infants aged <1 year …

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