Stay informed with the latest updates on coronavirus (COVID-19). Find out more >>

Bronchiolitis

  • PIC logo
  • See also

    Asthma   
    Intravenous Fluids   
    High Flow Nasal Cannula therapy
    Oxygen delivery

    Key Points

    1. Bronchiolitis is a clinical diagnosis
    2. No investigations should be routinely performed
    3. Management includes supporting feeding and oxygenation as required
    4. 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 the following: 

    • 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 greater than 92% (in room air)  

    Oxygen saturations 90 - 92% (in room air)

    Oxygen saturations less than 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 - e.g. 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, full blood count (FBC), blood cultures) have no 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) 

    One to two 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 (less than 50% over 12 hours), administer NG hydration

    If not feeding adequately
    (less than 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 greater than
    or equal to 90%
      
    Once improving and not requiring oxygen for 2 hours discontinue oxygen saturation monitoring

    Administer oxygen to maintain
    saturations greater than
    or equal to 90%

    Respiratory
    support
      

      

    Begin with nasal prong oxygen
      
    High flow nasal cannula (HFNC) to be used only if nasal prong oxygen has failed

    Consider HFNC 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 less than 90%
    • Infants with bronchiolitis will have brief episodes of mild/moderate desaturations to levels less than 90%. These brief desaturations are not a reason to commence oxygen therapy
    • Oxygen should be discontinued when oxygen saturations are persistently greater than or equal to 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
    Is not indicated 

    Consider consultation with local paediatric team when:

    • Discharged prior to day 3 of illness with other risk factors (Risk factors for more serious illness)
    • 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
    • Children requiring care above the level of comfort of the local hospital
    • Children whose oxygen requirement is >50%  

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

    Consider discharge when:

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

    • 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

  • Reference List

    1. O’Brien S, Craig S, Babl F et al. Rational use of high-flow therapy in infants with bronchiolitis. What do the latest trials tell us? Journal of Paediatrics and Child Health. 55 (7), 746 – 752. [Available from https://onlinelibrary.wiley.com/doi/full/10.1111/jpc.14496]
    2. Predict. Australiasian Bronchiolitis Guideline. Retrieved from http://www.predict.org.au/download/Australasian-bronchiolitis-guideline.pdf