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  • See also

    Intravenous fluids   
    High flow nasal prong 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


    • 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


    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.







    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

    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  


    May have brief apnoea

    May have increasingly frequent or prolonged apnoea



    May have difficulty with
    feeding or reduced feeding

    Reluctant or unable to feed



    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  


    The main treatment of bronchiolitis is supportive. This involves ensuring appropriate oxygenation and fluid intake, and minimal handling





    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
    Threshold for referral is
    determined by local capacity but should be early

    Vital signs
    (respiratory rate,
    heart rate,
    Oxygen saturations,

    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


    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%



    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 /

    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
    •  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


    • 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


    • 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 (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

  • 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]
    2. Predict. Australiasian Bronchiolitis Guideline. Retrieved from