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Peds Geek M.D.

Bronchiolitis and RSV: What Helps, What Doesn't

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Young child in hospital

Right now, we’re in the thick of bronchiolitis season. I’m seeing it on a daily basis in clinic, and the hospital is frequently full, in part because of this disease. There’s a lot of worry, frustration, and confusion about bronchiolitis, so I’m going to try to clear the air, so to speak.

Bronchiolitis Is Not Bronchitis

Bronchiolitis and bronchitis sound so similar that they are easy to mix up, but they’re fairly distinct. Bronchitis is usually caused by a viral infection of the larger airways, while bronchiolitis is mainly a problem of the bronchioles – smaller branching airways in the lungs. Bronchiolitis has a distinctive set of symptoms, and the biggest symptom is the production of lots and lots of wet mucus. This is the biggest problem with bronchiolitis, that the mucus makes it hard for kids to move air through their airways. Some kids wheeze with bronchiolitis, but most do not.

What is RSV?

RSV (Respiratory Syncytial Virus) is just the name for the most common virus that causes bronchiolitis. We can test for RSV easily, but testing doesn’t mean much except that we are a little more confident in what we are dealing with. If a child looks and acts like bronchiolitis, the care is the same whether they are positive for RSV or not. As Doc Smitty over at Cook’s Children discusses, it’s just not that important to test.

Most kids get bronchiolitis at some point, but the younger you are, the harder it can be on you. It’s a frustrating illness because there’s no traditional vaccine for it, and because it is caused by a virus, not bacteria, antibiotics just aren’t any good. This is one of those illnesses that makes kids miserable, and is hard to watch, but there just isn’t a medicine that makes it get better faster. It’s a lot of waiting and supporting the body while it fights the disease off by itself.

What can you do at home?

  • Suction, suction, suction! Suctioning the nose and mouth is the mainstay of treatment for bronchiolitis. The better you can keep the airway clear, the better the child can breathe. You can use the traditional bulb suction, but there are a lot of products out there than might do better. Many of my parents swear by the NoseFrida, though a number are grossed-out by the fact that you’re basically using your mouth to suck through a tube to get your baby’s snot out. Isn't parenting great?
  • Humidified air can loosen the mucus and make it easier to remove, and not block your child’s breathing as much.
  • Watch for signs of dehydration or increased work of breathing. If your child is worsening, you should talk to your child’s doctor. If your child appears dehydrated, or is working harder to breathe, using extra rib muscles or flaring their nostrils with each breath, it’s time to go to the emergency room.
  • Do not use cough medicines. If your child has asthma, you can talk to your child’s doctor about whether to try your child’s asthma medication, but most cases of bronchiolitis don’t improve with inhalers or nebulizers. 
  • Prevent the spread by practicing good hygiene. This disease is spread by saliva and mucus, so make sure hands are washed frequently, noses are covered when coughing, and you’re not taking your child out in public while they are coughing or febrile.

In The Hospital

About three percent of infants with bronchiolitis need care in the hospital. Premature babies, and infants with other medical conditions, are more likely to be hospitalized. Bronchiolitis caused by RSV is more likely to need hospitalization than bronchiolitis from other viruses. Now this can a very frustrating kind of hospital stay, because even on the floor, there isn't a magic way that makes kids get better faster. A lot of inpatient care for this illness still involves supporting the body while the child fights off the illness themselves.

The hospital team can:

  • Do deep suctioning with a machine to remove the mucus that is obstructing the airway, so that your child can breathe more easily.
  • Provide oxygen if it's needed, so that the air that gets to the lungs has more oxygen for the body, and the child can breathe a little easier.
  • Give the body fluids or nutrition either through a tube through the nose to the stomach, or with an IV, if needed. Eating requires a lot of energy, and it can be hard to breathe at the same time. This can give the body the chance to take a break from that stress and focus on breathing.
  • Monitor for complications and intervene if any develop. Kids with bronchiolitis can develop secondary infections like pneumonias that need additional care. Or they may need more help breathing if things get worse

I know families can get frustrated and feel the doctors aren't doing enough, when really they are doing everything that has been shown to be helpful. 

Some things that aren’t shown to be helpful in most cases of bronchiolitis include:

  • Antibiotics. Unless the doctor suspects there's a bacterial infection at the same time, like an ear infection or pneumonia, antibiotics just won’t help your child get better. We all want antibiotics to fix things like this, but in this case it won’t help, and may cause problems, like antibiotic resistance or side effects.
  • Steroids. Medications like prednisone, which we give commonly for asthma exacerbations, aren't shown to be helpful either, even though children can sometimes wheeze with bronchiolitis
  • Bronchodilators. Airway-opening medications like albuterol, which in the past had given for bronchiolitis on a trial basis, are not shown in the literature to be helpful.

The AAP recommends against all these things except in special circumstances. You can read more about these recommendations here.

It's very normal to want to have as much as possible done for your sick child when they are in the hospital, but some things just don't help and may have side effects, which is why hospital pediatricians follow expert guidelines for the treatment of diseases like bronchiolitis. They want your child to get better as much as you do. 

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