Bronchiolitis in Infants and Children - Clinical Features and Diagnosis - UpToDate

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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
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2021. | This topic last updated: Mar 09, 2020.
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 in
infants and children".)
● (See "Acute respiratory distress in children: Emergency evaluation and initial stabilization".)
DEFINITION
Bronchiolitis is broadly defined as a clinical syndrome of respiratory distress that occurs in

children <2 years of age and is characterized by upper respiratory symptoms (eg, rhinorrhea)
followed by lower respiratory infection with inflammation, which results in wheezing and/or
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crackles (rales). Bronchiolitis typically occurs with primary infection or reinfection with a viral
pathogen [1-3]. In young children, the clinical diagnosis of bronchiolitis may overlap with
recurrent virus-induced wheezing and acute viral-triggered asthma. (See "Role of viruses in
wheezing and asthma: An overview".)
For clinical research, bronchiolitis is typically defined as the first episode of wheezing in a child
younger than 12 to 24 months who has physical findings of a viral lower respiratory infection
and no other explanation for the wheezing [4,5].
PATHOGENESIS
Bronchiolitis occurs when viruses infect the terminal bronchiolar epithelial cells, causing direct
damage and inflammation in the small bronchi and bronchioles. Edema, excessive mucus, and
sloughed epithelial cells lead to obstruction of small airways and atelectasis. Based upon biopsy
or autopsy samples in severe cases and animal studies, pathologic changes begin 18 to 24
hours after infection and include bronchiolar cell necrosis, ciliary disruption, and
peribronchiolar lymphocytic infiltration [6-8].
MICROBIOLOGY
Bronchiolitis typically is caused by a viral infection. Although the proportion of disease caused
by specific viruses varies depending upon the season and the year, respiratory syncytial virus
(RSV) is the most common cause, followed by rhinovirus [9-12]. Less common causes include
parainfluenza virus, human metapneumovirus, influenza virus, adenovirus, coronavirus, and
human bocavirus [9,13-15]. With molecular diagnostics, a viral etiology can be identified in >95
percent of cases; two or more viruses are detected in approximately one-third of young children
hospitalized with bronchiolitis [16-19]. In addition, lower respiratory tract infection and
wheezing episodes in infants infrequently are associated with Mycoplasma pneumoniae and
Bordetella pertussis. (See "Mycoplasma pneumoniae infection in children", section on 'Clinical
manifestations' and "Pertussis infection in infants and children: Clinical features and diagnosis",
section on 'Clinical features'.)
● RSV – RSV is the most common cause of bronchiolitis and the virus most often detected as
the sole pathogen. RSV is ubiquitous throughout the world and causes seasonal outbreaks.
In temperate climates, late fall and winter epidemics of bronchiolitis usually are linked to
RSV. In tropical and semitropical climates, the seasonal outbreaks usually are associated

with the rainy season. (See "Respiratory syncytial virus infection: Clinical features and
diagnosis".)
● Rhinovirus – Human rhinoviruses are the main cause of the common cold. There are more
than 170 serotypes. Rhinovirus is associated with lower respiratory tract infection in young
children and in individuals with chronic pulmonary disease [20]. Dual viral infections are
often detected. Rhinovirus is often associated with bronchiolitis in the spring and fall
[12,21]. (See "Epidemiology, clinical manifestations, and pathogenesis of rhinovirus
infections".)
● Parainfluenza virus – Parainfluenza virus type 3, which is associated with epidemics in early
spring and fall, is another cause of bronchiolitis. Parainfluenza virus types 1 and 2 also can
cause bronchiolitis, although croup is the more common presentation [22]. (See
"Parainfluenza viruses in children", section on 'Clinical presentation'.)
● Human metapneumovirus – Human metapneumovirus sometimes occurs in conjunction

with other viral infections and has been identified as an etiology of bronchiolitis and
pneumonia in children [23,24]. In two multicenter cohort studies of infants hospitalized
with bronchiolitis, human metapneumovirus peaked in March and April [12]. (See "Human
metapneumovirus infections".)
● Influenza virus – The lower respiratory tract manifestations of influenza are clinically
indistinguishable from those due to RSV or parainfluenza viral infections. (See "Seasonal
influenza in children: Clinical features and diagnosis", section on 'Clinical features'.)
● Adenovirus – Adenovirus may cause lower respiratory tract infections, including

bronchiolitis, bronchiolitis obliterans, and pneumonia, though it more typically causes
pharyngitis and coryza. Adenovirus can also infect other organs, causing disseminated
disease. (See "Pathogenesis, epidemiology, and clinical manifestations of adenovirus
infection", section on 'Clinical presentation'.)
● Coronavirus – Human coronaviruses are another important cause of the common cold,
which can also cause lower respiratory tract infection, including bronchiolitis throughout
the year [12,25,26]. Severe acute respiratory syndrome and Middle East respiratory
syndrome are also caused by coronaviruses. (See "Coronaviruses".)
● Human bocavirus – Human bocavirus 1 causes upper and lower respiratory infections
during the fall and winter months [13,27-29]. Bronchiolitis and pertussis-like illness can
occur. Human bocavirus 2 through 4 are primarily enteric viruses [30].

EPIDEMIOLOGY
Bronchiolitis typically affects infants and children younger than two years, principally during the
fall and winter [31,32]. Bronchiolitis hospitalization has a peak incidence between two and six
months of age and remains a significant cause of respiratory disease during the first five years
of life [33,34]. It is a leading cause of hospitalization in infants and young children [32,33,35].
The epidemiology of bronchiolitis is similar to that of respiratory syncytial virus (RSV) infection
because most cases of bronchiolitis are caused by RSV. (See "Respiratory syncytial virus
infection: Clinical features and diagnosis", section on 'Epidemiology'.)
RISK FACTORS FOR SEVERE DISEASE
Risk factors for severe or complicated bronchiolitis include [36-43]:
● Prematurity (gestational age ≤36 weeks)

● Low birth weight
● Age less than 12 weeks
● Chronic pulmonary disease, particularly bronchopulmonary dysplasia (also known as
chronic lung disease)
● Anatomic defects of the airways
● Hemodynamically significant congenital heart disease
● Immunodeficiency
● Neurologic disease
Environmental and other risk factors, such as passive smoking, crowded household, daycare
attendance, being born approximately two months before or after the start of the epidemic,
concurrent birth siblings, older siblings, and high altitude (>2500 meters), can also contribute to
more severe disease [41,44-47].
CLINICAL FEATURES
Clinical presentation — Bronchiolitis is a clinical syndrome of respiratory distress that occurs

primarily in children younger than two years of age and generally presents with fever (usually
≤38.3°C [101°F]), cough, and respiratory distress (eg, increased respiratory rate, retractions,
wheezing, crackles). It often is preceded by a one- to three-day history of upper respiratory tract
symptoms (eg, nasal congestion and/or discharge) [48]. Respiratory distress, increased work of

breathing, respiratory rate, and oxygenation all can change rapidly with crying, coughing, and
agitation. Oxyhemoglobin desaturation can occur under all of these circumstances as well as
during sleep when chest wall muscles relax, further narrowing intrathoracic airways.
Clinical course — The duration of the illness due to bronchiolitis depends upon age, severity of
illness, associated high-risk conditions (eg, prematurity, chronic pulmonary disease), and the
causative agent [19]. Bronchiolitis usually is a self-limited disease. Most children who do not
require hospitalization recover by 28 days [49-51].
Typical illness with bronchiolitis begins with upper respiratory tract symptoms, followed by
lower respiratory tract signs and symptoms on days 2 to 3, which peak on days 3 to 5 and then
gradually resolve. In a systematic review of four studies including 590 children with bronchiolitis
who were seen in outpatient settings and not treated with bronchodilators [5,50-52], the mean
time to resolution of cough ranged from 8 to 15 days [53]. Cough resolved in 50 percent of
patients within 13 days and in 90 percent within 21 days. In a cohort of 181 children (not
included in the systematic review), the median duration of caretaker-reported symptoms was 12
days; approximately 20 percent continued to have symptoms for at least three weeks, and 10
percent had symptoms for at least four weeks [49].
Although discharge criteria vary from center to center, in multicenter studies of children
younger than two years hospitalized with bronchiolitis, the median length of stay was two days
[19,54]. Length of stay may be shorter in children with bronchiolitis due to rhinovirus and
longer in children with bronchiolitis due to respiratory syncytial virus (RSV)-rhinovirus co-
infection. The respiratory status typically improves over two to five days [37,55-58]. However,
wheezing persists in some infants for a week or longer.
The course may be prolonged in infants younger than six months (particularly those younger
than 12 weeks) and those with comorbid conditions (eg, bronchopulmonary dysplasia); these
children often are severely affected and may require assisted ventilation [36,59]. (See 'Risk
factors for severe disease' above and 'Respiratory failure' below.)
Complications — In most previously healthy infants, bronchiolitis resolves without

complications. However, severely affected patients, particularly those born prematurely, <12
weeks of age, or who have underlying cardiopulmonary disease or immunodeficiency, are at
increased risk for complications, the most serious of which are apnea and respiratory failure
[60]. Infants who require mechanical ventilation for apnea or respiratory failure may develop air
leak, such as pneumothorax or pneumomediastinum.
Dehydration — Infants with bronchiolitis may have difficulty maintaining adequate

hydration because of increased fluid needs (related to fever and tachypnea), decreased oral
intake (related to tachypnea and respiratory distress), and/or vomiting [61]. They should be
monitored for dehydration (eg, increased heart rate, dry mucosa, sunken fontanelle, decreased
urine output ( table 1)). Parenteral or nasogastric fluid administration may be necessary. (See
"Clinical assessment and diagnosis of hypovolemia (dehydration) in children", section on
'Clinical assessment' and "Bronchiolitis in infants and children: Treatment, outcome, and
prevention", section on 'Fluid management'.)
Aspiration pneumonia — Bronchiolitis may be complicated by aspiration pneumonia. The

risk of aspiration increases during active bronchiolitis and resolves weeks later as tachypnea
and the work of breathing subside.
Apnea — Bronchiolitis may be complicated by apnea, particularly in infants born

prematurely and those younger than two months (ie, those with postmenstrual age <48 weeks)
[60,62-68]. The risk of apnea is not specific to a particular pathogen [66,69]. Presenting with
apnea is a risk factor for respiratory failure and the need for mechanical ventilation. (See
'Respiratory failure' below.)
In a three-year multicenter prospective study (2007 to 2010) that included 2156 children <2
years hospitalized with bronchiolitis, apnea was documented in 5 percent [66]. The study
focused on sicker patients by aiming to enroll 20 percent of patients from the intensive care
unit. Independent risk factors for apnea included age <8 weeks (age was corrected for
gestational age if born preterm), caretaker report of previous apnea during the illness, high or
low respiratory rate at presentation (ie, respiratory rate <30 or >70 breaths/minute), and room
air oxygen saturation <90 percent at presentation. Similar risk factors for apnea were identified
in large prospective and retrospective cohorts [65,68]. The risk of apnea was not increased with
RSV compared with other viral pathogens [66].
These findings suggest that low respiratory (ie, <30 breaths/minute) rate in children with
bronchiolitis is not necessarily reassuring and that results of virologic studies are not helpful in
determining the risk for apnea among hospitalized infants.
Respiratory failure — Respiratory failure is another serious complication of bronchiolitis. In

a multicenter study, 14 percent of 684 infants younger than 12 months who were hospitalized
for management of bronchiolitis required mechanical ventilation for respiratory failure or
apnea [60]. In another multicenter study, 16 percent of infants and children younger than two
years hospitalized with RSV required intensive care support (with or without mechanical
ventilation) [37]. However, the need for intensive care varied depending on the presence and
type of risk factors for serious disease:
● No known risk factors – 7 percent

● Congenital heart disease, bronchopulmonary dysplasia, or immunosuppression – 19 to 37

percent
● Age <6 weeks – 29 percent
Hypoxemia, associated with mucus plugging and atelectasis, is common in children with
bronchiolitis. It may respond to supplemental oxygen alone, although sometimes it requires
additional respiratory support. Hypercapnic respiratory failure, associated with fatigue, usually
requires additional respiratory support (eg, intubation and mechanical ventilation).
Between 2000 and 2009, approximately 2 percent of children younger than two years
hospitalized with bronchiolitis in the Kids Inpatient Database required mechanical ventilation
[32]. Requirement for mechanical ventilation was increased in infants younger than 12 months
and high-risk medical conditions.
Secondary bacterial infection — With the exception of otitis media, secondary bacterial

infection is uncommon among infants and young children with bronchiolitis or RSV infection. In
a nine-year prospective study of 565 children (<3 years) hospitalized with documented RSV
infection, subsequent bacterial infection developed in only 1.2 percent and subsequent
bacterial pneumonia in 0.9 percent [70]. The risk of secondary bacterial pneumonia is increased
among children who require admission to the intensive care unit, particularly those who require
intubation [71,72].
RADIOGRAPHIC FEATURES
Chest radiographs are not necessary in the routine evaluation of bronchiolitis [2,3]. They should
be obtained only if there are clinical findings suggestive of other potential diagnoses [1,73].
(See 'Differential diagnosis' below.)
Radiographic features of bronchiolitis, which are variable and nonspecific, include

hyperinflation and peribronchial thickening ( image 1) [74,75]. Patchy atelectasis with volume
loss may result from airway narrowing and mucus plugging. Segmental consolidation and
alveolar infiltrates are more characteristic of bacterial pneumonia than bronchiolitis, but
radiographic findings are poor indicators of the etiologic diagnosis and must be used in
conjunction with other clinical features in making decisions about diagnosis and treatment.
(See 'Differential diagnosis' below and "Community-acquired pneumonia in children: Clinical
features and diagnosis", section on 'Etiologic clues'.)
In infants and young children with mild disease, radiographs are unlikely to alter treatment and
may lead to inappropriate use of antibiotics [2,74,76]. However, in infants and young children
with moderate or severe respiratory distress (eg, nasal flaring, retractions, grunting, respiratory
rate >70 breaths/minute, dyspnea, or cyanosis), radiographs may be warranted, particularly if
there are focal findings on examination, the infant has a cardiac murmur, or it is necessary to
exclude alternate diagnoses [2]. Radiographs also may be indicated to exclude alternate
diagnoses in children who fail to improve at the expected rate [3]. (See 'Severity assessment'
below and 'Differential diagnosis' below and 'Clinical course' above.)
EVALUATION
The evaluation of infants and young children with suspected bronchiolitis generally requires
only history and physical examination, including pulse oximetry. Laboratory studies and
radiographs usually are not necessary for diagnosis but may be warranted to evaluate
complications, comorbid infections, or other conditions in the differential diagnosis. The
evaluation outlined below is largely consistent with that suggested in clinical practice guidelines
from the American Academy of Pediatrics, the National Institute for Care Excellence, and other
professional groups [3,77-80]. (See 'Society guideline links' below.)
History — Infants with moderate to severe bronchiolitis typically present for medical attention
three to six days after illness onset. Bronchiolitis often is preceded by a one- to three-day
history of upper respiratory tract symptoms, such as nasal congestion and/or discharge and
mild cough [48]. It typically presents with fever (usually ≤38.3°C [101°F), cough, and respiratory
distress (eg, increased respiratory rate, retractions).
Compared with other viruses that cause bronchiolitis, fever tends to be lower with respiratory
syncytial virus (RSV) and higher with adenovirus [81]. (See "Respiratory syncytial virus infection:
Clinical features and diagnosis", section on 'Clinical manifestations' and "Pathogenesis,
epidemiology, and clinical manifestations of adenovirus infection", section on 'Clinical
presentation'.)
Aspects of the history of present illness that help in determining the severity of illness and/or
need for hospitalization include (see 'Severity assessment' below and "Bronchiolitis in infants
and children: Treatment, outcome, and prevention", section on 'Indications for hospitalization')
[3,82]:
● Assessment of hydration status (eg, fluid intake, urine output)

● Symptoms of respiratory distress (tachypnea, nasal flaring, retractions, grunting)
● Cyanosis

● Episodes of restlessness or lethargy (may indicate hypoxemia and/or impending respiratory

failure)
● A history of apnea with or without cyanosis or bradycardia
Aspects of the past medical history associated with severe disease include prematurity, chronic
pulmonary disease, anatomic abnormalities of the airways, hemodynamically significant
congenital heart disease, immunodeficiency, and neurologic disease. (See 'Risk factors for
severe disease' above.)
Examination — Characteristic examination findings of bronchiolitis include tachypnea,

intercostal and subcostal retractions, expiratory wheezing, and cough. Additional auscultatory
findings may include prolonged expiratory phase and coarse or fine crackles (rales). The chest
may appear hyperexpanded with increased anteroposterior diameter and may be
hyperresonant to percussion. Hypoxemia (oxygen saturation <95 percent) commonly is
detected by pulse oximetry. Other findings may include conjunctivitis, pharyngitis, and acute
otitis media [83-85].
Severely affected patients have increased work of breathing (subcostal, intercostal, and
supraclavicular retractions; nasal flaring; and expiratory grunting). They may appear cyanotic
and have poor peripheral perfusion. Wheezing may not be audible if the airways are profoundly
narrowed or when increased work of breathing results in exhaustion.
Laboratory tests or imaging for select patients — Laboratory tests are not routinely
indicated in the evaluation of infants and young children with bronchiolitis. However, laboratory
and/or radiographic evaluation may be necessary to evaluate the possibility of:
● Comorbid or secondary bacterial infection in:
• Neonates ≤28 days of age with fever – Infants ≤28 days old with fever (temperature
≥38°C [100.4°F]) and symptoms and signs of bronchiolitis have the same risk for
serious bacterial infection (SBI) as young febrile infants without bronchiolitis and
should be assessed accordingly [86]. (See "Febrile infant (younger than 90 days of age):
Outpatient evaluation".)
• Infants ≥29 to 90 days of age with fever – Extensive laboratory testing is not routinely
warranted for infants ≥29 to 90 days of age with fever (temperature ≥38°C [100.4°F])
and symptoms and signs of bronchiolitis, particularly if they have tested positive for a
respiratory virus.

For infants ≥29 to 90 days of age who have bronchiolitis and are ill appearing, or are
not age-appropriately immunized against Streptococcus pneumoniae or Haemophilus
inﬂuenzae type b, have symptoms of urinary tract infection (UTI), or have other risk
factors for SBI, complete blood count (CBC), blood culture, chest radiograph, and/or
urinalysis and urine culture may be warranted to exclude comorbid or secondary
bacterial infection. The evaluation for SBI in febrile infants is discussed separately. (See
"Febrile infant (younger than 90 days of age): Outpatient evaluation", section on 'Risk
factors'.)
The yield of the evaluation for SBI in infants with bronchiolitis who are without risk
factors for SBI is likely to be low. Although the CBC is often used to screen for SBI in
infants without bronchiolitis, in systematic reviews and a large retrospective study,
abnormal white blood cell count was not predictive of SBI in infants and young children
who were hospitalized with RSV [1,87,88]. (See "Febrile infant (younger than 90 days of
age): Outpatient evaluation", section on 'Evaluation'.)
Serious comorbid bacterial infection is uncommon in children with bronchiolitis. In

prospective studies, the risk for bacteremia or meningitis among febrile infants and
young children with bronchiolitis is typically less than 1 to 2 percent [86,89-92]. The risk
of UTI in children with bronchiolitis is also less than 1 to 2 percent. In a meta-analysis of
seven observational studies (five of which required fever for inclusion), the prevalence
of UTI in children with bronchiolitis was 0.8 percent (95% CI 0.3-1.4 percent) when UTI
was defined by the combination of positive urine culture and either pyuria or positive
nitrites, in accordance with the AAP clinical practice guideline for UTI evaluation [93,94].
In the three studies that included low-risk infants <90 days (two of which required fever
for inclusion), the prevalence of UTI was 0.5 percent. (95% CI 0.1 to 1.2 percent).
These findings support our practice of not routinely evaluating children with
bronchiolitis and fever for SBI unless there is another indication (eg, ill-appearance).
However, most of the studies that evaluated the risk of SBI in infants with viral
respiratory infections used viral culture or antigen detection methods rather than
molecular methods with enhanced sensitivity, and may have underestimated the rates
of coinfection [95].
● Complications or other diagnostic considerations in:
• Children of any age with unusual or severe course – CBC and chest radiograph may
be warranted to evaluate secondary bacterial infection and other conditions in the
differential diagnosis in infants and young children with an unusual or prolonged or
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severe course (eg, failure to improve after two to five days, wheezing that persists for
more than one week) [1]. (See 'Clinical course' above and 'Differential diagnosis' below.)
• Children of any age with severe disease – In infants and young children with severe
disease, arterial or capillary blood gas measurements may be necessary to evaluate
respiratory failure. (See 'Respiratory failure' above.)
DIAGNOSIS
Clinical diagnosis — Bronchiolitis is diagnosed clinically. Characteristic features include a viral

upper respiratory prodrome followed by increased respiratory effort (eg, tachypnea, nasal
flaring, chest retractions) and wheezing and/or crackles in children younger than two years of
age [1-3]. (See 'History' above and 'Examination' above.)
Chest radiographs and laboratory studies are not necessary to make the diagnosis of
bronchiolitis and should not be routinely performed [3]. However, they may be necessary to
evaluate the possibility of secondary or comorbid bacterial infection, complications, or other
conditions in the differential diagnosis, particularly in children who have pre-existing
cardiopulmonary disease [1,3,87]. (See 'Complications' above and 'Differential diagnosis' below
and 'Laboratory tests or imaging for select patients' above.)
Virology
Indications — We do not routinely suggest testing for specific viral agents in children with
bronchiolitis unless the results of such testing will alter management of the patient or patient's
contacts (eg, discontinuation of palivizumab prophylaxis, initiation or
continuation/discontinuation of antibiotic therapy, anti-influenza therapy, or isolation or
cohorting of hospitalized patients or caregivers) [1,96]. (See "Seasonal influenza in children:
Prevention and treatment with antiviral drugs", section on 'Antiviral therapy'.)
There is debate about whether testing for specific viral agents alters clinical management or
outcome, particularly in the outpatient setting [1,87,96-102]. However, the identification of a
viral etiologic agent during emergency department evaluation or in hospitalized patients has
been associated with a decreased utilization of antibiotic treatment in some studies [98,103-
107].
Identification of the responsible virus in hospitalized patients may help to avoid health care-
associated transmission by permitting cohorting of patients and/or caregivers. However, direct
evidence that this strategy prevents transmission of respiratory viruses in children is lacking,

and it may be more logical to isolate all infants with bronchiolitis [1,78,101,102,108]. Cohorting
has the potential to increase the risk of infection with other respiratory viruses leading to
prolonged hospitalization [19]. (See "Respiratory syncytial virus infection: Prevention in infants
and children", section on 'Infection control in the health care setting'.)
Approach to testing — When an etiologic diagnosis is necessary (eg, for isolating or

cohorting hospitalized patients or caregivers, if the results will affect other management
decisions such as whether to initiate or continue antibiotic therapy), it can be confirmed with
molecular assays (eg, single or multiplex polymerase chain reaction), antigen detection,
immunofluorescence, or culture.
● For hospitalized patients, molecular assays are preferred to antigen detection or

immunofluorescence given the increased sensitivity and ability to assess a broader panel of
respiratory viruses. Results of multiplex panels must be interpreted with caution because
they do not differentiate asymptomatic from symptomatic infection [109-111]. In a meta-
analysis of case-control studies in children, respiratory syncytial virus (RSV), influenza virus,
parainfluenza virus, and human metapneumovirus were associated with lower respiratory
tract infection (LRTI) symptoms; rhinovirus was only weakly associated with LRTI symptoms;
and adenovirus, bocavirus, and coronaviruses were not associated with LRTI symptoms
[109].
● Rapid antigen tests are available for RSV, parainfluenza, adenovirus, and influenza viruses.
The sensitivity of most rapid antigen tests ranges from 80 to 90 percent [112].
● Direct or indirect immunofluorescence tests also are available for RSV, parainfluenza,
adenovirus, influenza virus, and other viruses that cause bronchiolitis.
● Culture is another method that can be used for viral identification, but results may not be
available in time for clinical decision-making.
The laboratory diagnosis depends upon the quality and proper handling of the specimen.
Virologic testing should be performed on respiratory specimens obtained by nasal wash or
nasal aspirate; midturbinate nasal swab is also acceptable [113-115] .
Nasal wash specimens are obtained by holding the infant or child upright at a 45° angle. A bulb
syringe or a soft plastic catheter attached to suction is used to aspirate nasal secretions after a
small amount of normal saline (1 to 3 mL) is instilled in each nostril.
Severity assessment — Severe bronchiolitis is indicated by persistently increased respiratory

effort (tachypnea; nasal flaring; intercostal, subcostal, or suprasternal retractions; accessory

muscle use; grunting), hypoxemia, apnea, or acute respiratory failure [79]. Repeated
observations are necessary to adequately assess disease severity because examination findings
may vary substantially over time [3]. Infants and young children with severe disease usually
require hospitalization for frequent observation as well as respiratory and/or fluid support. (See
"Bronchiolitis in infants and children: Treatment, outcome, and prevention", section on
'Indications for hospitalization'.)
Other factors that have been associated with increased illness severity include toxic or ill
appearance, oxygen saturation <90 percent by pulse oximetry while breathing room air,
respiratory rate ≥70 breaths/minute, and atelectasis on chest radiograph [36,37,116]. However,
there is limited and/or conflicting evidence relating these clinical findings to clinical outcomes
[3,36,37,55,75,117,118].
Several scoring instruments have been developed to assess the clinical severity of bronchiolitis
in research settings [119-123]. The use of these measures in clinical practice is limited by lack of
sufficient validation [124].
DIFFERENTIAL DIAGNOSIS
Bronchiolitis must be distinguished from a variety of acute and chronic conditions that affect
the respiratory tract, including recurrent viral-triggered wheezing or asthma, bacterial
pneumonia, pertussis, chronic pulmonary disease, foreign body aspiration, aspiration
pneumonia, congenital heart disease, heart failure, and vascular ring [85,125]. Severe
bronchiolitis also can unmask underlying airway obstruction that existed before the infection
(eg, vascular ring). Clinical features (eg, lack of preceding upper respiratory tract symptoms,
witnessed episode of choking, differential aeration, poor growth) may help to distinguish some
of these conditions from bronchiolitis; for others, radiographic or laboratory studies may be
necessary.
● Recurrent viral-triggered wheezing – Recurrent viral-triggered wheezing/recurrent

wheezing is a major consideration in the differential diagnosis of bronchiolitis in older
infants and toddlers. A history of recurrent wheezing episodes and a family or personal
history of asthma, eczema, and atopy help to support a diagnosis of asthma. However,
during the first episode of wheezing, it is difficult to distinguish bronchiolitis from asthma
[126]. (See "Role of viruses in wheezing and asthma: An overview" and "Wheezing
phenotypes and prediction of asthma in young children" and "Evaluation of wheezing in
infants and children".)

● Bacterial pneumonia – It can be difficult to distinguish bacterial pneumonia from

bronchiolitis in young children because the symptoms and signs of both conditions are
nonspecific; children with bacterial pneumonia may be more ill appearing (eg, higher
fever), but clinical features cannot reliably differentiate bacterial from viral lower respiratory
tract infection ( table 2). (See "Community-acquired pneumonia in children: Clinical
features and diagnosis", section on 'Diagnosis'.)
● B. pertussis infection – The clinical presentation of B. pertussis infection in infants may be

similar to that of bronchiolitis. Infants with pertussis may lack the characteristic "whoop"
and may have a nonparoxysmal cough. Microbiologic testing is necessary for diagnosis.
(See "Pertussis infection in infants and children: Clinical features and diagnosis", section on
'Diagnosis'.)
● Chronic pulmonary disease – Chronic underlying pulmonary conditions should be

suspected in children with prolonged or recurrent symptoms, such as recurrent wheezing,
poor weight gain, recurrent aspiration, stridor, or recurrent respiratory infection. (See
"Assessment of stridor in children" and "Approach to the child with recurrent infections"
and "Poor weight gain in children younger than two years in resource-rich countries:
Etiology and evaluation", section on 'Etiology'.)
Children with underlying pulmonary disease may have a superimposed acute episode of
bronchiolitis, and, in some cases, the underlying disorder is unrecognized before the acute
episode. The clinical course of bronchiolitis in children with underlying pulmonary disorders
tends to be severe and may require prolonged hospitalization.
● Foreign body aspiration – Clinical features of foreign body aspiration may include a
history of choking (not always present), focal monophonic wheezing, decreased air entry, or
regional variation in aeration. A high index of suspicion should be maintained for foreign
body aspiration so that definitive treatment can be provided. (See "Airway foreign bodies in
children".)
● Aspiration pneumonia – Aspiration pneumonia may occur secondary to gastroesophageal

reflux disease and/or swallowing dysfunction. It also may occur as a complication of
bronchiolitis; the risk of aspiration increases during active bronchiolitis and resolves weeks
later as tachypnea and the work of breathing subside. Clinical features associated with
aspiration may include coughing with feeds, weak suck reflex, cyanosis during feeding, and
recurrent or chronic stridor. (See "Gastroesophageal reflux in infants" and "Aspiration due
to swallowing dysfunction in children".)

● Congenital heart disease – Associated clinical findings of congenital heart disease may
include poor weight gain, poor peripheral perfusion, and abnormalities on cardiac
examination (eg, pathologic heart murmur, abnormal second heart sound, gallop, rub,
active precordium). (See "Suspected heart disease in infants and children: Criteria for
referral".)
Children with underlying cardiac conditions may have a superimposed acute episode of
bronchiolitis, and, in some cases, the underlying disorder is unrecognized before the acute
episode. The clinical course of bronchiolitis in children with underlying cardiac disorders
tends to be severe and may require prolonged hospitalization.
● Heart failure – Associated clinical findings of heart failure in infants may include easy
fatigue and/or diaphoresis with feeding, poor weight gain, heart murmur or gallop rhythm,
and hepatomegaly. (See "Heart failure in children: Etiology, clinical manifestations, and
diagnosis", section on 'Clinical manifestations'.)
● Vascular rings – Although stridor is more common, children with vascular rings may also
have wheezing (typically with pulmonary artery slings). Anterior bowing of the trachea in
the lateral chest radiograph may be a clue, but other modalities (barium contrast
esophagogram, bronchoscopy, magnetic resonance angiography) usually are necessary for
definitive diagnosis. (See "Vascular rings and slings", section on 'Clinical manifestations'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Bronchiolitis in infants
and children".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or email these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword[s] of interest.)
● Basics topic (see "Patient education: Bronchiolitis (and RSV) (The Basics)")
● Beyond the Basics topic (see "Patient education: Bronchiolitis (and RSV) in infants and
children (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Bronchiolitis is broadly defined as a clinical syndrome of respiratory distress that occurs in

children <2 years of age and is characterized by upper respiratory symptoms (eg,
rhinorrhea) followed by lower respiratory infection with inflammation, which results in
wheezing and or crackles (rales). (See 'Definition' above and 'Clinical features' above.)
● Bronchiolitis typically is caused by a viral infection. Respiratory syncytial virus is the most
common cause, followed by rhinovirus; less common causes include parainfluenza virus,
human metapneumovirus, influenza virus, adenovirus, coronaviruses, and human
bocavirus. (See 'Microbiology' above and "Respiratory syncytial virus infection: Clinical
features and diagnosis".)
● Bronchiolitis typically affects infants and children younger than two years, principally
during the fall and winter. Risk factors for severe disease and/or complications include
gestational age ≤36 weeks, age <12 weeks, chronic pulmonary disease, congenital and
anatomic defects of the airways, hemodynamically significant congenital heart disease,
immunodeficiency, and neurologic disease. (See 'Epidemiology' above and 'Risk factors for
severe disease' above.)
● The evaluation of infants and young children with suspected bronchiolitis generally
requires only history and physical examination. Chest radiographs and laboratory tests are
not necessary for diagnosis but may be warranted to evaluate complications, comorbid
infections, or other conditions in the differential diagnosis. (See 'Evaluation' above.)
● Bronchiolitis is diagnosed clinically. Characteristic features include a viral upper respiratory

prodrome followed by increased respiratory effort (eg, tachypnea, nasal flaring, chest
retractions) and wheezing and/or crackles in children younger than two years. (See 'Clinical
diagnosis' above and 'History' above and 'Examination' above.)

● Severe bronchiolitis is indicated by persistently increased respiratory effort (tachypnea;

nasal flaring; intercostal, subcostal, or suprasternal retractions; accessory muscle use;
grunting), hypoxemia, apnea, or acute respiratory failure. Children with severe disease
usually require hospitalization for respiratory and fluid support. (See 'Severity assessment'
above and "Bronchiolitis in infants and children: Treatment, outcome, and prevention",
section on 'Severe bronchiolitis'.)
● The differential diagnosis of bronchiolitis includes recurrent viral-triggered wheezing or

recurrent wheezing, pneumonia, foreign body aspiration, chronic pulmonary disease,
aspiration pneumonia, congenital heart disease, heart failure, and vascular ring. Clinical
features (eg, lack of preceding upper respiratory tract symptoms, witnessed episode of
choking, differential aeration, poor growth) may help to distinguish some of these
conditions from bronchiolitis; for others, radiographic or laboratory studies may be
necessary. (See 'Differential diagnosis' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
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. Midulla F, Scagnolari C, Bonci E, et al. Respiratory syncytial virus, human bocavirus and
rhinovirus bronchiolitis in infants. Arch Dis Child 2010; 95:35.
10. Meissner HC. Viral Bronchiolitis in Children. N Engl J Med 2016; 374:62.
11. 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.
12. Hasegawa K, Goto T, Hirayama A, et al. Respiratory Virus Epidemiology Among US Infants
With Severe Bronchiolitis: Analysis of 2 Multicenter, Multiyear Cohort Studies. Pediatr
Infect Dis J 2019; 38:e180.
13. 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.
14. 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.
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. 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.
20. 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.

21. 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.
22. 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.
23. Greensill J, McNamara PS, Dove W, et al. Human metapneumovirus in severe respiratory
syncytial virus bronchiolitis. Emerg Infect Dis 2003; 9:372.
24. Edwards KM, Zhu Y, Griffin MR, et al. Burden of human metapneumovirus infection in
young children. N Engl J Med 2013; 368:633.
25. Kuypers J, Martin ET, Heugel J, et al. Clinical disease in children associated with newly
described coronavirus subtypes. Pediatrics 2007; 119:e70.
26. 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.
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. Hall CB, Weinberg GA, Iwane MK, et al. The burden of respiratory syncytial virus infection
in young children. N Engl J Med 2009; 360:588.
35. Pelletier AJ, Mansbach JM, Camargo CA Jr. Direct medical costs of bronchiolitis
hospitalizations in the United States. Pediatrics 2006; 118:2418.
36. Shaw KN, Bell LM, Sherman NH. Outpatient assessment of infants with bronchiolitis. Am J
Dis Child 1991; 145:151.
37. 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.
38. 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.
39. 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.
40. Meissner HC. Selected populations at increased risk from respiratory syncytial virus
infection. Pediatr Infect Dis J 2003; 22:S40.
41. Mansbach JM, Piedra PA, Stevenson MD, et al. Prospective multicenter study of children
with bronchiolitis requiring mechanical ventilation. Pediatrics 2012; 130:e492.
42. 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.
43. Butler J, Gunnarsson R, Traves A, Marshall H. Severe Respiratory Syncytial Virus Infection in
Hospitalized Children Less Than 3 Years of Age in a Temperate and Tropical Climate.
Pediatr Infect Dis J 2019; 38:6.
44. 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.
45. 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.
46. 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.
47. Choudhuri JA, Ogden LG, Ruttenber AJ, et al. Effect of altitude on hospitalizations for
respiratory syncytial virus infection. Pediatrics 2006; 117:349.
48. Florin TA, Plint AC, Zorc JJ. Viral bronchiolitis. Lancet 2017; 389:211.
49. Swingler GH, Hussey GD, Zwarenstein M. Duration of illness in ambulatory children
diagnosed with bronchiolitis. Arch Pediatr Adolesc Med 2000; 154:997.
50. 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.
51. Petruzella FD, Gorelick MH. Duration of illness in infants with bronchiolitis evaluated in the
emergency department. Pediatrics 2010; 126:285.
52. 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.
53. Thompson M, Vodicka TA, Blair PS, et al. Duration of symptoms of respiratory tract
infections in children: systematic review. BMJ 2013; 347:f7027.
54. 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.
55. 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.
56. 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.
57. Dawson KP, Mogridge N. Acute bronchiolitis: a three year study. N Z Med J 1989; 102:528.
58. Robbins JM, Kotagal UR, Kini NM, et al. At-home recovery following hospitalization for
bronchiolitis. Ambul Pediatr 2006; 6:8.
59. 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.

60. Willson DF, Landrigan CP, Horn SD, Smout RJ. Complications in infants hospitalized for
bronchiolitis or respiratory syncytial virus pneumonia. J Pediatr 2003; 143:S142.
61. Pinnington LL, Smith CM, Ellis RE, Morton RE. Feeding efficiency and respiratory
integration in infants with acute viral bronchiolitis. J Pediatr 2000; 137:523.
62. Kneyber MC, Brandenburg AH, de Groot R, et al. Risk factors for respiratory syncytial virus
associated apnoea. Eur J Pediatr 1998; 157:331.
63. Bruhn FW, Mokrohisky ST, McIntosh K. Apnea associated with respiratory syncytial virus
infection in young infants. J Pediatr 1977; 90:382.
64. Hall CB, Kopelman AE, Douglas RG Jr, et al. Neonatal respiratory syncytial virus infection. N
Engl J Med 1979; 300:393.
65. 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.
66. Schroeder AR, Mansbach JM, Stevenson M, et al. Apnea in children hospitalized with
bronchiolitis. Pediatrics 2013; 132:e1194.
67. 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.
68. 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.
69. Mansbach JM, Geller RJ, Hasegawa K, et al. Association of Serum Albumin With Apnea in
Infants With Bronchiolitis: A Secondary Analysis of Data From the MARC-35 Study. JAMA
Netw Open 2019; 2:e197100.
70. 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.
71. 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.
72. Duttweiler L, Nadal D, Frey B. Pulmonary and systemic bacterial co-infections in severe RSV
bronchiolitis. Arch Dis Child 2004; 89:1155.
73. 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.

74. 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.
75. Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J
Paediatr Child Health 1990; 26:209.
76. Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute
bronchiolitis. J Pediatr 2007; 150:429.
77. National Institute for Health and Care Excellence. Bronchiolitis: diagnosis and managemen
t of bronchiolitis in children. Clinical Guideline NG 9. June 2015. https://www.nice.org.uk/g
uidance/ng9 (Accessed on August 20, 2015).
78. O'Brien S, Borland ML, Cotterell E, et al. Australasian bronchiolitis guideline. J Paediatr
Child Health 2019; 55:42.
79. Scottish Intercollegiate Guidelines Network. Bronchiolitis in children. A national clinical gui
deline. 2006. www.sign.ac.uk/pdf/sign91.pdf (Accessed on August 25, 2015).
80. Tapiainen T, Aittoniemi J, Immonen J, et al. Finnish guidelines for the treatment of
laryngitis, wheezing bronchitis and bronchiolitis in children. Acta Paediatr 2016; 105:44.
81. 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.
82. 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.
83. 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.
84. Andrade MA, Hoberman A, Glustein J, et al. Acute otitis media in children with
bronchiolitis. Pediatrics 1998; 101:617.
85. Welliver RC. Bronchiolitis and infectious asthma. In: Feigin and Cherry’s Textbook of Pediat
ric Infectious Diseases, 8th ed, Cherry JD, Harrison G, Kaplan SL, et al (Eds), Elsevier, Philad
elphia 2018. p.199.

86. 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.
87. Viswanthan M, King V, Bordley C, et al. Management of bronchiolitis in infants and childre
n. Evidence Report/Technology Assessment No. 69. ARHQ Publication No. 03-E014, Agency
for Healthcare Research and Quality; US Department for Health and Human Services, Rock
ville, MD 2003.
88. 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.
89. 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.
90. 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.
91. 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.
92. Byington CL, Enriquez FR, Hoff C, et al. Serious bacterial infections in febrile infants 1 to 90
days old with and without viral infections. Pediatrics 2004; 113:1662.
93. McDaniel CE, Ralston S, Lucas B, Schroeder AR. Association of Diagnostic Criteria With
Urinary Tract Infection Prevalence in Bronchiolitis: A Systematic Review and Meta-analysis.
JAMA Pediatr 2019; 173:269.
94. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement

and Management, Roberts KB. Urinary tract infection: clinical practice guideline for the
diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months.
Pediatrics 2011; 128:595.
95. Nicholson EG, Avadhanula V, Ferlic-Stark L, et al. The Risk of Serious Bacterial Infection in
Febrile Infants 0-90 Days of Life With a Respiratory Viral Infection. Pediatr Infect Dis J 2019;
38:355.
96. 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.
97. Antonow JA, Byington CL. Use of respiratory syncytial virus testing could safely eliminate
many sepsis evaluations. Arch Pediatr Adolesc Med 1999; 153:1310.
98. Smyth RL, Openshaw PJ. Bronchiolitis. Lancet 2006; 368:312.
99. Hall CB. Diagnosis and testing in bronchiolitis: a systematic review. J Pediatr 2004; 145:417.
100. 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.
101. Schroeder AR, Ralston SL. Viral Testing for Pediatric Respiratory Infections: Why Precise
Diagnoses Do Not Always Translate to Patient Benefit. JAMA 2017; 318:472.
102. Gill PJ, Richardson SE, Ostrow O, Friedman JN. Testing for Respiratory Viruses in Children:
To Swab or Not to Swab. JAMA Pediatr 2017; 171:798.
103. 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.
104. 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.
105. 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.
106. 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.
107. 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.
108. Bourke T, Shields M. Bronchiolitis. BMJ Clin Evid 2011; 2011.
109. Shi T, McLean K, Campbell H, Nair H. Aetiological role of common respiratory viruses in
acute lower respiratory infections in children under five years: A systematic review and
meta-analysis. J Glob Health 2015; 5:010408.

110. Self WH, Williams DJ, Zhu Y, et al. Respiratory Viral Detection in Children and Adults:
Comparing Asymptomatic Controls and Patients With Community-Acquired Pneumonia. J
Infect Dis 2016; 213:584.
111. Esposito S, Zampiero A, Terranova L, et al. Pneumococcal bacterial load colonization as a

marker of mixed infection in children with alveolar community-acquired pneumonia and
respiratory syncytial virus or rhinovirus infection. Pediatr Infect Dis J 2013; 32:1199.
112. American Academy of Pediatrics. Respiratory syncytial virus. In: Red Book: 2018 Report of t
he Committee on Infectious Diseases, 31st ed, Kimberlin DW, Brady MT, Jackson MA, Long
SS (Eds), American Academy of Pediatrics, 2018. p.682.
113. 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.
114. Blaschke AJ, McKevitt M, Ampofo K, et al. Midturbinate Swabs Are Comparable to
Nasopharyngeal Swabs for Quantitative Detection of Respiratory Syncytial Virus in Infants.
J Pediatric Infect Dis Soc 2019; 8:554.
115. Macfarlane P, Denham J, Assous J, Hughes C. RSV testing in bronchiolitis: which nasal
sampling method is best? Arch Dis Child 2005; 90:634.
116. Mulholland EK, Olinsky A, Shann FA. Clinical findings and severity of acute bronchiolitis.
Lancet 1990; 335:1259.
117. Brooks AM, McBride JT, McConnochie KM, et al. Predicting deterioration in previously
healthy infants hospitalized with respiratory syncytial virus infection. Pediatrics 1999;
104:463.
118. 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.
119. 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.
120. Martinello RA, Chen MD, Weibel C, Kahn JS. Correlation between respiratory syncytial virus
genotype and severity of illness. J Infect Dis 2002; 186:839.

121. Klassen TP, Rowe PC, Sutcliffe T, et al. Randomized trial of salbutamol in acute
bronchiolitis. J Pediatr 1991; 118:807.
122. 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.
123. 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.
124. 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.
125. Coffin SE. Bronchiolitis: in-patient focus. Pediatr Clin North Am 2005; 52:1047.
126. Landau LI. Bronchiolitis and asthma: are they related? Thorax 1994; 49:293.
Topic 6018 Version 45.0

GRAPHICS
Physical findings of volume depletion in infants and children
Mild Moderate Severe

Finding
(3 to 5%) (6 to 9%) (≥10%)
Pulse Full, normal rate Rapid Rapid and weak or absent
Systolic pressure Normal Normal to low Low
Respirations Normal Deep, rate may be increased Deep, tachypnea or

decreased to absent
Buccal mucosa Tacky or slightly dry Dry Parched
Anterior fontanelle Normal Sunken Markedly sunken
Eyes Normal Sunken Markedly sunken
Skin turgor Normal Reduced Tenting
Skin Normal Cool Cool, mottled, acrocyanosis
Urine output Normal or mildly reduced Markedly reduced Anuria
Systemic signs Increased thirst Listlessness, irritability Grunting, lethargy, coma
Graphic 76198 Version 7.0

Bronchiolitis radiographs
The above radiographs demonstrate the following findings that are consistent with bronchiolitis:
1) Patchy atelectasis, in particular of the right middle lobe
2) Bilateral peribronchial infiltrations with air bronchograms
3) Hyper-inflation of the lungs with flattening of the diaphragms

Clinical and radiographic clues to the etiology of pneumonia in children*
Etiology Clinical features Radiographic features
Bacteria Children of all ages Alveolar infiltrates

(most commonly Streptococcus Abrupt onset Segmental consolidation
pneumoniae) Ill-appearance Lobar consolidation
Chills "Round" pneumonia
Moderate to severe respiratory distress
Focal auscultatory findings Complications:
Localized chest pain Pleural effusion/empyema
WBC count >15,000/microL (if obtained) Lung abscess
Elevated acute phase reactants (if obtained) Necrotizing pneumonia
Pneumatocele
Atypical bacterial Children of all ages (most common in children >5 years) M. pneumoniae:
(Mycoplasma pneumoniae, Abrupt onset with constitutional findings (malaise, myalgia, Lobar or segmental
Chlamydia pneumoniae) headache, rash, conjunctivitis, photophobia, sore throat, consolidation (37%)
headache)
Parahilar or peribronchial
Gradually worsening nonproductive cough infiltrates (27%)
Wheezing Localized reticulonodular
Extrapulmonary manifestations or complications (eg, infiltrates (21%)
Stevens-Johnson syndrome, hemolytic anemia, hepatitis, Patchy infiltrates (15%)
etc)

Viral Usually children <5 years Interstitial infiltrates

Gradual onset
Preceding upper airway symptoms
Nontoxic appearing
Diffuse, bilateral auscultatory findings
Wheezing
May have associated rash (eg, measles, varicella)
Afebrile pneumonia of infancy Usually in infants 2 weeks to 4 months Hyperinflation with interstitial
(most commonly Chlamydia Insidious onset infiltrates
trachomatis) Rhinorrhea
Staccato cough pattern
Peripheral eosinophilia (if CBC obtained)
Fungal Appropriate geographic or environmental exposure Mediastinal or hilar

adenopathy
Mycobacterium tuberculosis Children of any age Mediastinal or hilar

Chronic cough adenopathy
Constitutional symptoms
Exposure history
WBC: white blood cell; CBC: complete blood count.

* The clinical features frequently overlap and cannot reliably distinguish between bacterial, atypical bacterial, and viral etiologies; up to
one-half of community-acquired pneumonias in children may be mixed bacterial/viral infections. Chest radiography generally is not
helpful in determining the potential causative agent of pneumonia. Nonetheless, these features may facilitate decisions regarding
empiric therapy.
Data from:
1. Bartlett JG, Mundy LM. Community-acquired pneumonia. N Engl J Med 1995; 333:1618.
2. Boyer KM. Nonbacterial pneumonia. In: Textbook of Pediatric Infectious Diseases, 6 th ed, Feigin RD, Cherry JD, Demmler-Harrison GJ,
Kaplan SL (Eds), Saunders, Philadelphia 2009. p.289.
3. Broughton RA. Infections due to Mycoplasma pneumoniae in childhood. Pediatr Infect Dis 1986; 5:71.

4. McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.

5. Cho YJ, Han MS, Kim WS, et al. Correlation between chest radiographic ﬁndings and clinical features in hospitalized children with
Mycoplasma pneumoniae pneumonia. PLoS One 2019; 14:e0219463.

Contributor Disclosures
Pedro A Piedra, MD Grant/Research/Clinical Trial Support: Novavax, Gilead, Janssen, Icosavax, and Mapp
[Respiratory syncytial virus]; Shinogi [Influenza]; Sanofi-Pasteur [Viral diagnostics]. Consultant/Advisory
Boards: Novavax and Ablynx [Respiratory syncytial virus]; Roche, Genetech, and Sanofi-Pasteur
[Respiratory syncytial virus and influenza]; Shianogi [Influenza]; Pfizer [DSMB]. Ann R Stark, MD Nothing
to disclose Gregory Redding, MD Nothing to disclose Morven S Edwards, MD Grant/Research/Clinical
Trial Support: Pfizer [Group B Streptococcus]. Mary M Torchia, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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16/2/2021 Bronchiolitis in infants and children: Clinical features and diagnosis - UpToDate

Official reprint from UpToDate®

Bronchiolitis in infants and children: Clinical features and

The microbiology, epidemiology, clinical features, and diagnosis of bronchiolitis will be

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

Bronchiolitis is broadly defined as a clinical syndrome of respiratory distress that occurs in

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● Human metapneumovirus – Human metapneumovirus sometimes occurs in conjunction

● Adenovirus – Adenovirus may cause lower respiratory tract infections, including

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RISK FACTORS FOR SEVERE DISEASE

Risk factors for severe or complicated bronchiolitis include [36-43]:

● Prematurity (gestational age ≤36 weeks)

Clinical presentation — Bronchiolitis is a clinical syndrome of respiratory distress that occurs

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Complications — In most previously healthy infants, bronchiolitis resolves without

Dehydration — Infants with bronchiolitis may have difficulty maintaining adequate

Aspiration pneumonia — Bronchiolitis may be complicated by aspiration pneumonia. The

Apnea — Bronchiolitis may be complicated by apnea, particularly in infants born

Respiratory failure — Respiratory failure is another serious complication of bronchiolitis. In

● No known risk factors – 7 percent

● Congenital heart disease, bronchopulmonary dysplasia, or immunosuppression – 19 to 37

Secondary bacterial infection — With the exception of otitis media, secondary bacterial

Radiographic features of bronchiolitis, which are variable and nonspecific, include

● Assessment of hydration status (eg, fluid intake, urine output)

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● Episodes of restlessness or lethargy (may indicate hypoxemia and/or impending respiratory

Examination — Characteristic examination findings of bronchiolitis include tachypnea,

● Comorbid or secondary bacterial infection in:

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Serious comorbid bacterial infection is uncommon in children with bronchiolitis. In

● Complications or other diagnostic considerations in:

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Clinical diagnosis — Bronchiolitis is diagnosed clinically. Characteristic features include a viral

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Approach to testing — When an etiologic diagnosis is necessary (eg, for isolating or

● For hospitalized patients, molecular assays are preferred to antigen detection or

Severity assessment — Severe bronchiolitis is indicated by persistently increased respiratory

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● Recurrent viral-triggered wheezing – Recurrent viral-triggered wheezing/recurrent

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● Bacterial pneumonia – It can be difficult to distinguish bacterial pneumonia from

● B. pertussis infection – The clinical presentation of B. pertussis infection in infants may be

● Chronic pulmonary disease – Chronic underlying pulmonary conditions should be

● Aspiration pneumonia – Aspiration pneumonia may occur secondary to gastroesophageal

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SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

● Bronchiolitis is broadly defined as a clinical syndrome of respiratory distress that occurs in

● Bronchiolitis is diagnosed clinically. Characteristic features include a viral upper respiratory

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● Severe bronchiolitis is indicated by persistently increased respiratory effort (tachypnea;

● The differential diagnosis of bronchiolitis includes recurrent viral-triggered wheezing or

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2. Fitzgerald DA, Kilham HA. Bronchiolitis: assessment and evidence-based management.

4. Wainwright C, Altamirano L, Cheney M, et al. A multicenter, randomized, double-blind,

6. Colby TV. Bronchiolitis. Pathologic considerations. Am J Clin Pathol 1998; 109:101.