Acute viral bronchiolitis in South Africa: Intensive care management for severe disease

Abstract

It is estimated that 2 - 3% of children will be hospitalised with viral bronchiolitis during their first year of life, and a small proportion of
them will have a severe course of the disease, requiring intensive care and ventilatory support. In South Africa, 20% of children admitted
to a paediatric intensive care unit (PICU) had positive respiratory viral isolates (especially respiratory syncytial virus), with symptomatic
respiratory disease. Rapid laboratory-based diagnosis using multiplex polymerase chain reaction is recommended to reduce overall
antibiotic use in the PICU and neonatal ICU (NICU) and improve the targeted use of antibiotics (antibiotic stewardship). The mainstay of
bronchiolitis management in the PICU and NICU is supportive, comprising fluid management, oxygen supplementation and/or respiratory
ventilatory support, and antipyretics if needed. Non-invasive nasal continuous positive airway pressure and high-flow nasal cannula oxygen
therapy are increasingly being used in children with severe bronchiolitis, and may reduce the need for intubation. Infants with bronchiolitis
may have a variety of clinical presentations, which may require different ventilatory approaches. Children may present predominantly with
apnoeas, air trapping and wheeze, atelectasis and parenchymal disease (in acute respiratory distress syndrome), or a combination of these.
Lung-protective ventilation, using a low tidal volume pressure-limited approach, is essential to limit ventilator-induced lung injury.