Rational prescribing for acute bronchiolitis.

Acute bronchiolitis is the commonest lower respiratory illness of infancy and early childhood, and it is usually associated with respiratory syncytial virus infection. In the majority of infants, the illness is self-limiting and hence management is directed at maintaining fluid intake, minimal handling and close observation. Children who develop apnoea, fatigue and/or feeding difficulties as well as progressive respiratory distress require hospital admission. Oxygen, intravenous fluids and minimal handling are the pillars of hospital management, and less than 1% of hospitalised infants require additional assisted ventilation. Pharmacological therapy of acute bronchiolitis is contentious. Sympathomimetics are the drugs most frequently used. Inhaled salbutamol (albuterol) has been associated with both positive and negative outcomes. Recent work suggests that nebulised racemic adrenaline (epinephrine) may be helpful in reducing respiratory distress, but further work is needed to confirm this finding. The use of the antiviral drug ribavirin (tribavirin) in acute bronchiolitis remains very contentious. The overwhelming majority of infants do not require the drug and debate remains as to its true effectiveness. The literature tends to support its use in patients with underlying heart or lung disease, but the drug may not be cost effective in this setting. However, the costs of ribavirin therapy could be reduced by the implementation of more rigid treatment guidelines. A reduction in the use of bronchodilators, antibiotics and corticosteroids would help to reduce the overall costs of management. To date, acute bronchiolitis has not lent itself to pharmacological treatment and prescribing should therefore be very strictly audited by clinicians.