Uncertainty in the management of viral lower respiratory tract disease.

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Approximately 3% of children in the United States will be hospitalized in the first year of life because of a viral infection of the lower respiratory tract.1,,2Viruses that account for the vast majority of hospitalizations resulting from pneumonia and bronchiolitis include respiratory syncytial virus (RSV), parainfluenza viruses (particularly type 3), influenza viruses, and adenoviruses. A recent report from the Centers for Disease Control and Prevention provides important information on the epidemiology of pediatric viral lower respiratory tract disease in the United States, estimating that 123 000 hospitalizations resulting from bronchiolitis occur each year in children in the first year of life.1 During the 17 years covered in this report from 1980 to 1996, hospitalization rates for children <12 months with viral infection of the lower respiratory tract increased more than twofold. RSV alone accounts for 50% to 90% of bronchiolitis hospitalizations and 20% to 50% of pediatric hospitalizations for pneumonia. Approximately 500 RSV-associated deaths occur each year in the United States.3 This mortality figure is lower than an estimate made in 1985 by the National Institute of Medicine, at least partly because of improvements in the management of hospitalized infants.4 The annual cost of RSV hospitalization for infants in the United States is estimated to be in excess of $300 million to $400 million.5 Despite the fact that about 16% of hospital admissions for children in the first year of life are because of viral lower respiratory tract illness, there remains a remarkable lack of consensus on the optimal management of patients.1,,6 Viral infection of the lower airway is generally a self-limited condition. Nonetheless, bronchiolitis is notorious for variation in disease expression based on a number of factors, including the presence of underlying heart or lung disease, gestational age, chronological …