Source: Bronchiolitis presentation.pptx (9 slides) Author: Lauren Murphy (B6PT) Date: January 2023 Learning Level: Primarily Foundation/Intermediate
Key Learning Points
- What is bronchiolitis
- The physiotherapy role in bronchiolitis
- NICE guidelines
1. Definition and Pathophysiology
What Is Bronchiolitis?
| Aspect | Detail |
|---|---|
| Definition | An acute lower respiratory tract infection (LRTI) affecting those in early childhood (<2 years old) |
| Presentation | Coryzal symptoms with poor feeding |
| Pathology | Inflammation of the bronchioles — acute inflammatory response to infection leading to small airway obstruction |
| Transmission | Spread easily through droplets in coughs or sneezes |
Learning Level: Foundation
Pathophysiology
Inflammation and oedema from the infection cause obstruction of the bronchioles. This causes:
- Hyperinflation
- Increased airway resistance
- Atelectasis
- V/Q mismatching
Learning Level: Foundation
CXR Findings
- Hyperinflation with air-trapping
- Patchy changes / areas of collapse and consolidation
Learning Level: Foundation
2. Epidemiology and Aetiology
| Statistic | Detail |
|---|---|
| Incidence | Approximately 20—33% of all children will experience at least one episode of bronchiolitis during their first year of life |
| Hospitalisation rate | 2—3% of those affected will be hospitalised |
| ICU admission | 10% of hospitalised children will require intensive care |
| Seasonality | Most commonly seen during the Winter/Autumn months (October to March) |
| Causative organism | Respiratory Syncytial Virus (RSV) is the most common causative organism |
Learning Level: Foundation
3. Why Infants Are Mainly Affected
Infants are particularly vulnerable because they have:
- Smaller airways — more easily obstructed by inflammation and oedema
- Higher closing volumes — airways close at higher lung volumes
- Insufficient collateral ventilation — less ability to ventilate past obstructed airways
Learning Level: Foundation
4. Recovery
- Recovery begins with regeneration of bronchiolar epithelium after 3—4 days
- Cilia do not appear for as long as 2 weeks
- Mucus plugs are thus predominantly removed by macrophages (not by mucociliary clearance)
Updated (2026): The “3-4 days for epithelium / 2 weeks for cilia” figures are a clinical teaching simplification. The primary source (Wong JY, Rutman A, O’Callaghan C. Thorax. 2005;60(7):582-587. DOI: 10.1136/thx.2004.024638) shows that full ultrastructural recovery is much more protracted: epithelial integrity score normalises at approximately 13 weeks, and ciliary loss/epithelial abnormalities persist on average for 13—17 weeks. The clinical implication of impaired mucociliary clearance for the first few weeks of recovery still stands.
Learning Level: Intermediate
5. Medical Management and NICE Guidelines
Key Clinical Point: There is a limited physiotherapy role in uncomplicated bronchiolitis.
NICE Guideline Recommendations
| Intervention | Recommendation |
|---|---|
| Physiotherapy | No physio unless significant co-morbidities or intubated |
| Respiratory support | Use oxygen therapy, CPAP and IV fluids |
| Suction | No indication for regular suction (unless respiratory distress) |
| Nebulisers | No indication for nebulisers |
| Vaccination | May be offered Palivizumab vaccination against RSV |
Updated (2026): Palivizumab is more accurately described as passive immunisation with a monoclonal antibody rather than a “vaccination”. Since 2025, NHS England has begun rolling out nirsevimab to replace monthly palivizumab injections. Nirsevimab is a single-dose, longer-acting monoclonal antibody offering >80% protection against severe RSV disease (versus ~55% for palivizumab). The maternal RSV vaccine Abrysvo has also been introduced. See JCVI statement, 11 September 2023 (https://www.gov.uk/government/publications/rsv-immunisation-programme-jcvi-advice-7-june-2023).
Learning Level: Foundation
6. Physiotherapy Assessment and Interventions
When Physiotherapy Is Indicated
Physiotherapy input is warranted when the child has:
- Significant co-morbidities (e.g. congenital heart disease, chronic lung disease, neuromuscular conditions)
- Intubation and mechanical ventilation (PICU setting)
Physiotherapy Role (When Indicated)
- Respiratory assessment and monitoring
- Airway clearance techniques (in the context of intubated patients)
- Suctioning only where clinically indicated by respiratory distress
- Positioning to optimise ventilation
Learning Level: Intermediate
7. Complications and Red Flags
- Progression requiring escalation from oxygen therapy to CPAP to intubation
- Persistent atelectasis
- Secondary bacterial infection
- Apnoea (particularly in premature infants)
- Respiratory failure requiring PICU admission
Learning Level: Intermediate
8. References
- Bronchiolitis with pneumomediastinum | Radiology Case | Radiopaedia.org
- Cochrane Library: Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. DOI: 10.1002/14651858.CD004873.pub6
- Bronchiolitis — ScienceDirect: https://www.sciencedirect.com/science/article/pii/S0929693X18301404
- NICE Guidelines on Bronchiolitis (referenced in presentation)
- Updated (2026): Full reference: NICE. Bronchiolitis in children: diagnosis and management. NICE guideline [NG9]. Published 1 June 2015; last updated 9 August 2021. https://www.nice.org.uk/guidance/ng9. The August 2021 update revised oxygen saturation thresholds (referral/admission threshold now persistent SpO2 <90%, previously 92%, in otherwise healthy babies). Recommendations against routine physiotherapy, suction, and nebulisers remain unchanged from 2015.