PERSONAL PRACTICE Management of acute bronchiolitis

As winter approaches, paediatricians steel themselves for the annual flood of babies with acute bronchiolitis. It is the commonest lower respiratory tract infection in infants. Around 10% of babies develop bronchiolitis in their first year and a fifth of these are admitted to hospital.' In this children's hospital between 200 and 260 infants are admitted with the disease each winter. The epidemic imposes great strains on the hospital: for example, in the first eight weeks of 1993, there were 179 admissions of infants with bronchiolitis, with a mean length of stay of 4-5 days. We ventilate 12-25 babies for bronchiolitis each winter: they occupy a total of 70-190 days a year on the intensive care unit. Many aspects of management remain controversial. For example, what is the most reliable way of assessing the severity of bronchiolitis? What is the role of electronic monitoring, or ribavirin (tribavirin), of physiotherapy? Are bronchodilators helpful? If babies cannot feed, should they be given intravenous or nasogastric fluids? Which babies need intensive care? How can we reduce cross infection? In this paper we examine these and other controversies in the care of the child with bronchiolitis.