See also
Asthma
Intravenous fluids
High flow nasal prong therapy
Oxygen delivery
Key points
- Bronchiolitis is a clinical diagnosis
- No investigations should be routinely performed
- Management includes supporting feeding and oxygenation as required
- No medication should be routinely administered
Background
- Bronchiolitis is a viral lower respiratory tract infection, generally affecting children under 12 months of age
- It is a clinical diagnosis, based on typical history and examination
- Peak severity is usually at around day two to three of the illness with resolution over 7–10 days
- Usually self-limiting, often requiring no treatment or interventions
- The cough may persist for weeks
Assessment
Red flag features in Red
Bronchiolitis typically begins with an acute upper respiratory tract infection followed by onset of one or more of:
- cough
- tachypnoea
- retractions
- widespread crackles or wheeze
- fever
Risk factors for more serious illness
- Chronological age at presentation less than 10 weeks
- Chronic lung disease
- Congenital heart disease
- Chronic neurological conditions
- Indigenous ethnicity
- Immunodeficiency
- Trisomy 21
Infants with any of these risk factors are more likely to deteriorate rapidly and require escalation of care. Consider hospital admission even if presenting early in illness with mild symptoms
Assessment of severity
This table is meant to provide guidance in order to stratify severity. The more symptoms the infant has in the mod-severe categories, the more likely they are to develop severe disease. |
|
MILD |
MODERATE |
SEVERE |
Behaviour |
Normal |
Some / intermittent irritability |
Increasing irritability and / or lethargy Fatigue |
Respiratory rate |
Normal–mild tachypnoea |
Increased respiratory rate |
Marked increase or decrease in respiratory rate |
Use of accessory
muscles |
Nil to mild chest wall retraction |
Moderate chest wall retractions
Suprasternal retraction
Nasal flaring |
Marked chest wall retractions
Marked suprasternal retraction
Marked nasal flaring |
Oxygen saturation/
oxygen requirement |
Oxygen saturations >92% (in room air) |
Oxygen saturations 90–92% (in room air) |
Oxygen saturations <90% (in room air)
Hypoxemia may not be
corrected by oxygen |
Apnoeic episodes |
None |
May have brief apnoea |
May have increasingly frequent or prolonged apnoea |
Feeding |
Normal |
May have difficulty with
feeding or reduced feeding |
Reluctant or unable to feed |
Management
Investigations
In most children with bronchiolitis no investigations are required
Investigations should only be undertaken when there is deterioration or diagnostic uncertainty (eg cardiac murmur with signs of congestive cardiac failure)
- Chest X-ray (CXR) is not routinely indicated and may lead to unnecessary treatment with antibiotics
- Blood tests (including blood gas, FBE, blood cultures) rarely have a role in management
- Virological testing (nasopharyngeal swab or aspirate) has no role in management of individual patients
Treatment
The main treatment of bronchiolitis is supportive. This involves ensuring appropriate oxygenation and fluid intake, and minimal handling
|
MILD |
MODERATE |
SEVERE |
Likelihood
of admission
|
Suitable for discharge
Consider admission if risk factors present
|
Likely admission, may be able to be discharged after a period of observation
Management should be discussed with a local senior physician
|
Requires admission and consider need for transfer to an appropriate children’s
facility/PICU
Threshold for referral is
determined by local capacity but should be early |
Observations
Vital signs
(respiratory rate,
heart rate,
Oxygen saturations,
temperature) |
Adequate assessment in ED prior to discharge (minimum of two recorded measurements or every four hours) |
1-2 Hourly (not continuous)
Once improving and not requiring oxygen for 2 hours discontinue oxygen saturation monitoring |
Hourly with continuous
cardiorespiratory (including oximetry) monitoring and close
nursing observation |
Hydration / nutrition |
Small frequent feeds |
If not feeding adequately (<50% over 12 hours), administer NG hydration |
If not feeding adequately
(<50% over 12 hours), or unable to feed, administer NG hydration |
Oxygen
saturation/oxygen
requirement
|
Nil requirement |
If oxygen saturations fall below 90%, administer oxygen to maintain
saturations ≥90%
Once improving and not requiring oxygen for 2 hours discontinue oxygen saturation monitoring |
Administer oxygen to maintain
saturations ≥90% |
Respiratory
support
|
|
Begin with nasal prong oxygen
High flow nasal prong (HFNP) therapy to be used only if nasal prong oxygen has failed |
Consider HFNP therapy or Continuous positive airway pressure (CPAP) |
Disposition /
escalation
|
Consider further medical review if early in the illness and any risk factors are present or if child develops increasing severity after discharge |
Decision to admit should be supported by clinical assessment (including risk factors), social and geographical factors, and phase of illness |
Consider escalation if severity does not improve
Consider ICU review/ admission or transfer to local centre with
paediatric HDU/ICU capacity if:
- severity does not improve
- persistent desaturations
- significant or recurrent
apnoea associated with
desaturations - has risk factors
|
Parental education |
Provide advice on the expected course of illness and when to
return (worsening symptoms and inability to feed adequately)
|
Provide advice on the expected course of illness and when to
return (worsening symptoms and inability to feed adequately)
|
Provide advice on the expected course of illness
|
Provide Parent information sheet |
Oxygen Therapy
- Oxygen therapy should be instituted when oxygen saturations are persistently <90%
- Infants with bronchiolitis will have brief episodes of mild/moderate desaturations to levels <90%. These brief desaturations are not a reason to commence oxygen therapy
- Oxygen should be discontinued when oxygen saturations are persistently ≥90%
- Once not requiring oxygen for 2 hours, discontinue oxygen saturation monitoring. Continue other observations 2–4 hourly and reinstate intermittent oxygen monitoring if deterioration occurs
Hydration/nutrition
- Children are often more settled if comfort oral feeds are continued
- When non-oral hydration is required nasogastric (NG) hydration is the route of choice
- If IV fluid is used it should be isotonic with added glucose. See IV fluids
- NG or IV fluids should be commenced at two-thirds maintenance because of potential for increased ADH secretion
Medication
- Medications are not indicated in the treatment of bronchiolitis
Do not administer
- Beta 2 agonists, including infants with a personal or family history of atopy
- Corticosteroids (nebulised, oral, intramuscular (IM) or IV)
- Adrenaline (nebulised, IM or IV) except in peri-arrest or arrest situation
- Nebulised Hypertonic Saline
- Antibiotics, including Azithromycin
- Antivirals
Nasal suction
- Nasal suction is not routinely recommended. Superficial nasal suction may be considered in those with moderate disease to assist feeding
- Nasal saline drops may be considered at time of feeding
Chest physiotherapy
Consider consultation with local paediatric team when
- Discharged prior to day 3 of illness with other risk factors (detailed in assessment section)
- 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)
- Risk factors for more severe illness
- Apnoea
- Child requiring care above the level of comfort of the local hospital
- Child has oxygen requirement >50%
For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.
Consider discharge when
Child maintaining adequate oxygenation and maintaining adequate oral intake
Note: Infants younger than 8 weeks of age are at an increased risk of re-presentation
Parent information
Kids Health Info: Bronchiolitis
Last updated May 2020