Clinical Practice Guidelines

Bronchiolitis


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network


  • RCH: Consider 

    Criteria Led Discharge

    See also:


    Background to condition:

    Bronchiolitis is a viral lower respiratory tract infection, generally affecting children under 12 months of age. After 12 months of age consider overlap with asthma.

    Assessment:

    History:

    Time course.
    Is the child improving, stable, or likely to deteriorate over the next few days? Peak severity is usually at around day 2-3 of the illness with resolution over 7-10 days. The cough may persist for weeks.

    Risk factors for severe bronchiolitis

    Young, especially < 6weeks
    Ex-premature infants
    Congenital Heart disease
    Neurological conditions
    Chronic respiratory illness
    Pulmonary hypertension

    Examination:

    Features of bronchiolitis:

    - increased  work of breathing (link)
    - widespread wheeze and crepitations
    - +/- fever
    - May have reduced oxygen saturation
    - Look for signs of dehydration (link)Assessment of Severity

     

     MILD 

     MODERATE

     SEVERE

     Behaviour

    Normal

     Some/intermittent irritability  

    Increasing irritability and/or lethargy
    Fatigue

    Respiratory Rate

    Normal

    Increased Resp rate
    Tracheal Tug
    Nasal Flaring

    Marked increase or decrease
    Tracheal Tug
    Nasal Flaring

    Accessory Muscle Use

     None or minimal 

     Moderate chest wall retraction 

     Marked chest wall retraction

     Feeding

    Normal

     May have difficulty with feeding or reduced feeding 

     Reluctant or unable to feed

     Oxygen

    No oxygen requirement (Sa02  > 93%)

     Mild hypoxemia corrected by oxygen**
    (Sa02 90 - 93%)

     Hypoxemia, may not be corrected by oxygen**
    (Sa02 < 90%)

    Apnoeic episodes

    None

     May have brief apnoeas 

     May have increasingly frequent or prolonged apnoeas

    ** A child who has congenital cardiac disease may have low baseline Sa02 eg <90% Note: Correlation between Sa02 and Bronchiolitis severity may vary significantly. Do not use Sa02 as a primary determinant of severity



    Features on investigation

    In most children with bronchiolitis no investigations are required

    • Nasopharyngeal aspirate
      • NOT routinely required for children with typical bronchiolitis

    Chest x-ray

    • NOT routinely required unless diagnostic uncertainty eg localised signs on auscultation, cardiac murmur with signs of congestive cardiac failure.
    • For children with typical clinical picture of bronchiolitis X-ray typically demonstrates hyperinflation, peribronchial thickening, and often patchy areas of consolidation and collapse.

    Blood gas

    • NOT routinely required

    Acute management:

    The main treatment of bronchiolitis is supportive. This involves ensuring oxygenation and fluid intake, as well as minimal handling. Children are often more settled if comfort oral feeds are continued.

    Severity

    Management

    Mild

    Can be managed at home. Advise parents of the expected course of the illness, and when to return if there are problems Give Parent Information Leaflet.

    Smaller, more frequent feeds. Consider further medical review if early in the illness, risk factors are present (see history) or if the child develops signs of increasing severity after discharge.

    Moderate

    Discuss with local paediatric team - for admission.

    Administer O2 to maintain adequate saturation, >92%

    Consider limiting total fluids at 2/3 maintenance (RCH fluid guideline). One to two hourly observations dependent on condition.

    Severe

    Cardiorespiratory monitoring with close nursing supervision. Supplemental O2 and fluids. Notify local paediatric team early.

    Consider transfer to tertiary centre with HDU/ICU capabilities, as child may need CPAP or ventilation.

    Consider consultation with local paediatric team when:

    - Discharged prior to day 3 of illness with other risk factors (see history).
    - Abnormal oxygen saturations
    - Less than half normal oral intake or urine output
    - Assessed as moderate or severe bronchiolitis

    Consider transfer when:

    - severe bronchiolitis (see above)
    - co-morbidities such as prematurity
    - apnoeas.
    - Children requiring care above the level of comfort of the local hospital.
    - Children whose O2 requirement is >50%

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Discharge requirements:

    Children can be discharged when they are
    - maintaining adequate oxygenation
    - maintaining adequate oral intake

    Parent information sheet:

    Additional notes

    • Bronchodilators such as salbutamol have not shown to alter the course of acute bronchiolitis
    • There is some evidence for the use of nebulised saline, however this is not currently recommended as standard therapy.
    • Antibiotics are not indicated for uncomplicated bronchiolitis.
    • Although there has been some recent evidence regarding the use of intravenous steroids in combination with nebulised adrenaline in bronchiolitis, this data should be considered exploratory only. Use of steroids should be judicial as their use may have neuro-developmental consequences, especially in younger infants. They may also have a negative impact on lung development.
    • Ribavirin (antiviral) treatment is not supported by evidence of significant benefit.
    • Immunoglobulins have no evidence of benefit. 
     Information Specific to RCH

    Children with bronchiolitis are usually admitted under the General Paediatric Team.

    Consider ICU review in children with severe bronchiolitis. 

     

    Last updated March 2011