Because no definitive treatment for the specific virus exists, therapy is directed toward symptomatic relief and maintenance

of hydration and oxygenation. Medical therapies used to treat bronchiolitis in infants and young children are controversial. Although numerous medications and interventions have been used to treat bronchiolitis, at present, only oxygen appreciably improves the condition of young children with bronchiolitis.[9] Bronchodilator therapy to relax bronchial smooth muscle, though common, is not supported as routine practice by convincing evidence. If bronchodilator therapy is started, it may be continued in patients who demonstrate clinical improvement. Despite the prominent role that inflammation plays in the pathogenesis of airway obstruction, corticosteroids have not clearly been shown to be of significant benefit in improving the clinical status of patients with bronchiolitis.[118] However, in some countries they are used routinely. Beta-agonists and ipratropium bromide, an aerosolized anticholinergic agent, have not shown effectiveness in the management of infants with respiratory syncytial virus (RSV) and wheezing.[119, 120, 121, 122, 123] Nasal phenylephrine is not effective treatment in infants hospitalized for bronchiolitis.[124] The efficacy of pharmacotherapy in infants is difficult to determine because it can be a function of the pharmacologic agent, the route of administration, the clinical status of the patient, or the adequacy of the outcome measure used to demonstrate an effect. Recombinant human DNAse also had no clinical effects in infants who were not receiving ventilation.[125] Various immunotherapies are being introduced both to treat the acute disease and to prevent sequelae.[126,
127, 128, 129]

Guidelines for treatment

As a consequence of the lack of evidence-based support for medicinal interventions to treat bronchiolitis, admission rates and treatment approaches vary widely, particularly in the emergency department (ED).[130, 131] In a Canadian study, children evaluated in general EDs were admitted twice as often as those observed in pediatric EDs, even when age, gender, estimated family income, medical comorbidity, and clinical severity were controlled for.[132] A survey of members of the Emergency Medicine section of the American Academy of Pediatrics (AAP) found that 96% recommended bronchodilators and 8% recommended steroids.[5] Twice as many pediatric emergency physicians would admit a child with an oxygen saturation of 92% on pulse oximetry than would admit a child with a saturation of 94%, though a respiratory rate of 50 breaths/min as opposed to 65 breaths/min made little difference in the admission rate. A study of 30 large childrens hospitals in the United States found that 45% of patients received steroids and 25% received systemic antibiotics. Factors that contributed to longer stays included use of antibiotics, steroids, and bronchodilators. Undergoing chest radiography was a significant predictor of antibiotic administration.[133] These differences from recommendations and between practices have led to a call for national guidelines for the treatment of bronchiolitis. In 2006, the AAP, in conjunction with the American

Academy of Family Physicians (AAFP), the American College of Chest Physicians (ACCP), and the American Thoracic Society (ATS), published the following recommendations[5] :

Diagnosis and severity should be based on history and physical findings and not on laboratory and radiologic findings; risk factors should be assessed when decisions about evaluation and management are made Bronchodilators should not be routinely used; if a trial of an alpha-adrenergic or betaadrenergic medication is an option, the agent be continued only if a positive (and continued) response is documented Corticosteroids should not routinely be used Ribavirin should not be used Antibacterials should be used only upon proven coexistence of bacterial infection Hydration and the ability to take oral fluids should be assessed Supplemental oxygen should be supplied for saturations below 90% on pulse oximetry; saturation measurement is otherwise unnecessary Palivizumab prophylaxis should be administered to selected children Hand decontamination is indicated to prevent nosocomial spread Infants should not be exposed to secondary smoking, and breastfeeding is recommended Clinicians should inquire about use of complementary and alternative medicine therapies

A recent report from the Value in Inpatient Pediatrics Network, formed out of the AAP section on hospital medicine, found that using the AAP guidelines in a peer-to-peer collaborative manner among the participating hospitals in 14 states reduced the use of bronchodilators to treat pediatric bronchiolitis from 70% in 2007 to 58% in 2010. Bronchodilator doses per patient fell by 45% and inappropriate use of chest physiotherapy also declined from 14% to 4.2% from 2007 to 2010 at the participating hospitals.[134] Researchers at Cincinnati Childrens Hospital found that bronchiolitis admissions were increasing so that patients could receive bronchodilator therapy. In 1997, the hospital instituted evidence-based point-of-care algorithms and rules based on guideline recommendations on the overuse of therapies for bronchiolitis and reviewed them in 2001, 2005, and 2006. The hospitals guidelines discouraged etiologic testing (because the treatment is directed at the syndrome rather than at its cause), reduced the use of chest radiography (because opacities [atelectasis] are unlikely to change for 7-9 days and are not influenced by antibiotics or chest physiotherapy), and discouraged the use of steroids and bronchodilators unless clear and sustained improvement was noted 20 minutes after aerosol administration.[135] After introduction of the guidelines, decreases were seen in admissions (29%), length of stay (17%), nasopharyngeal washings for RSV antigen (52%), chest radiography (20%), all respiratory therapies (30%), beta-agonist administrations (51%), cost of all services (37%), and cost of respiratory therapy services (77%).[136] These changes continued in the 3-year and 4-year follow-up investigations