Clinical Practice Guidelines

Bronchiolitis


  • Statewide logo

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

  • See also:

    Key Points

    1.       Bronchiolitis is a clinical diagnosis

    2.       No investigations should be routinely performed

    3.       Management is to support 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
    • Viral bronchiolitis 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.
    • The cough may persist for weeks.

    Assessment

    • Bronchiolitis typically begins with an acute upper respiratory tract infection followed by onset of respiratory distress and fever and one or more of:
      • Cough
      • Tachypnoea
      • Retractions
      • Widespread crackles or wheeze  

    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

    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

     
    O2 saturations greater than 92% (in room air)  

    O2 saturations 90 –92%

    (in room air)

     

    O2 saturations less than 90% (in room air)

     

    Hypoxemia, may not be

    corrected by O2

    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
      • 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

       Investigations should only be undertaken when there is diagnostic uncertainty – eg cardiac murmur with signs of congestive cardiac failure.          

    Treatment:

    Children are often more settled if comfort oral feeds are continued.  

    INITIAL MANAGEMENT

    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 risk factors

     

    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,

    O2 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

    Administer O2 to maintain

    saturations greater than

    or equal to 90%

     

    Once improving and not requiring oxygen for 2 hours discontinue oxygen saturation monitoring

    Administer O2 to maintain

    saturations greater than

    or equal to 90%

    Respiratory

    support

     
     

    Begin with NPO2

     

    HFNC to be used only if NPO2 has failed

    Consider HFNC or 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 Parent information sheet

    Provide advice on the expected course of illness and when to

    return (worsening symptoms and inability to feed adequately)

     

    Provide Parent information sheet

    Provide advice on the expected course of illness

     

    Provide Parent information sheet

     

    Management:

    Respiratory support

    • Oxygen therapy should be instituted when oxygen saturations are persistently less than 90%
    • It is appreciated that 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%.
    • Heated humidified high flow oxygen/air via nasal cannulae (HFNC) should only be considered in the presence of hypoxia (oxygen saturation less than 90%) and a lack of response to nasal prong oxygen, or where severe disease is present.

    If oxygen has been required: Once improving and 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

    • 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  

    Medication

    Medications are not indicated in the treatment of bronchiolitis

    Do not administer

    • Beta 2 agonists - (including in 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 (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)
    • Risk factors for more severe illness
    • Apnoea
    • 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.

    Consider discharge when:

    Children can be discharged when they are

    • maintaining adequate oxygenation
    • maintaining adequate oral intake

    Infants younger than 8 weeks of age are at an increased risk of representation    

    Parent information sheet

    Not available 

    Additional notes

    Additional helpful information      

    Last revised March, 2017