Bronchiolitis

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

Key Points

Bronchiolitis is a clinical diagnosis
No investigations should be routinely performed
Management is to support 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
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

Kids Health Info Factsheet for Bronchiolitis

Last revised March, 2017

The Royal Children's Hospital Melbourne

Clinical Practice Guidelines