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.
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