We thank Dr. Sharma for her interest in our article . We
provided an evidence-based update on management of
bronchiolitis. Unfortunately, there are gray areas where
there is inadequate evidence to guide the management.
We do appreciate that there may be
difficulty in clinically differentiating between
bronchiolitis or viral bronchopneumonia or wheezing due to
asthma. There may be certain indicators for asthma like
multiple previous similar episodes or family history of
The definition mentioned in the AAP
guidelines is of little clinical relevance as it describes
the pathophysiologic process in bronchiolitis . It is
further complicated by other phenotypes of wheezing,
including transient wheezing during infancy, episodic and
multi-trigger wheezing . We mentioned that some authors
have used the definition ‘the first episode of wheezing in a
child younger than 12 to 24 months who has physical findings
of a viral respiratory infection and has no other
explanation for the wheezing, such as pneumonia or atopy’;
it is important to note the later part of the definition
highlighting that there is no other explanation for the
wheezing. A child with repeated episodes of wheezing may
have bronchiolitis but other conditions like
wheeze-associated lower respiratory infection, multi-trigger
wheeze/ asthma are more likely.
As mentioned by the author, there is
little evidence to support use of steroids or
bronchodilators. Some of the children clinically diagnosed
as bronchiolitis may have asthma which responds to
bronchodilators; this is the rationale for a trial of
bronchodilators. It will not be advisable to use therapies
that have not demonstrated any benefits in clinical trials.
There are various clinical scores which
include measures of respiratory rate, respiratory effort,
severity of wheezing, and oxygenation. The most widely used
score is Respiratory Distress Assessment Instrument .
However, none of the clinical evaluation scores have been
found to be predictive of outcomes, or validated for use to
titrate therapy .
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2. American Academy of Pediatrics
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3. Brand PL, Baraldi E, Bisgaard H, Boner
AL, Castro-Rodriguez JA, Custovic A, et al.
Definition, assessment and treatment of wheezing disorders
in preschool children: an evidence-based approach. Eur
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4. Lowell DI, Lister G, Von Koss H, McCarthy P. Wheezing
in infants: the response to epinephrine. Pediatrics.