Introduction
Aim
Definition of Terms
Assessment
Management
Special Considerations
Companion Documents
Evidence Table
Introduction
Bronchiolitis is an acute viral infection of the lower respiratory tract (LRTI). It generally affects children less than 12 months of age, and it is the most frequent cause of hospitalisation in infants under 6 months of age. There is a higher risk of severe bronchiolitis if the child is less than 6 weeks of age. Viruses that enter and infect the respiratory tract cause viral bronchiolitis. Most cases of viral bronchiolitis are due to respiratory syncytial virus (RSV) however other causal agents include Rhinovirus/Adenovirus, Human metapneumovirus (hMPV), Influenza and Parainfluenza. Viral outbreaks occur seasonally.
Symptoms align with an upper respiratory tract infection (URTI) and are characterised by cough, tachypnoea, poor feeding, wheeze, crackles, apnoea, mucous production and inflammation causing obstruction at the level of the bronchioles. The illness typically reaches peak severity around days 2-3 with a resolution of the wheeze and respiratory distress over 7 – 10 days. The cough may continue for up to 4 weeks.
Bronchiolitis is usually a self-limiting condition, however, can be life threatening in infants who have been premature and/or have underlying respiratory, cardiac, neuromuscular or immunological conditions.
Aim
To outline hospital management of infants with bronchiolitis admitted to the ward. Children who require additional support may be managed in the Paediatric Intensive Care Unit (PICU) or Neonatal Intensive Care Unit (NICU).
Initial Assessment
Refer to Clinical Guidelines (Nursing) : Nursing assessment
History
Primary Assessment
Primary assessments should be completed at the start of every shift and then as clinically indicated or if the patient's condition changes. This assessment is documented in flowsheets, further assessments, or changes to be documented in the progress notes. Clinical judgment should be used to decide on the extent of assessment required. Refer to Nursing Guideline: Nursing Assessment
| | Assessment Conditions |
| Airway | Patent, partially obstructed or obstructed Secretions, cough |
| Breathing | Respiratory Rate, Regularity Breathing Effort Respiratory Effort (Nil, Mild, Moderate or Severe) Breath Sounds (Clear, absent, decreased, crackles, wheeze, bilateral air entry and movement) |
| Circulation | Skin Temperature (warm, cool, cold, hot, diaphoretic) Skin Colour (normal, pink, pale, dusky, mottled, cyanotic) Central Capillary Refill (Quick Return, slow return, tenting) Pulses Palpated |
| Disability | Level Of Consciousness (AVPU score) Level of Sedation Score (UMSS) |
Infection Control
Investigations
In most presentations, investigations are not required. Guidance for the use of Chest X-ray and Laboratory including virology – refer to Bronchiolitis CPG
Acute Management
Nursing care for infants with bronchiolitis is largely supportive and includes airway clearance, maintenance of oxygenation and hydration.
Minimal handling and clustering of cares is recommended to avoid exhaustion as infants with bronchiolitis are generally intolerant of interventions. Refer to Nursing guidelines : Ward management of a neonate
| Mild
| Moderate
| Severe
|
|---|
Behaviour | Normal
| Irritability Reduced Activity
| Increased Irritability Lethargy |
Colour | Normal | Pallor | Cyanosis |
Respiratory Rate | Normal | Increased | Increased |
Increased work of Breathing * | Normal Mild | Moderate | Severe |
Heart Rate | Normal Slightly increased | Mildly Increased | Significant Increased or Bradycardia |
Apnoeic | None | Brief Apnoea | Increasing frequent or prolonged apnoea |
Blood Pressure | Normal | Increased | Increased Hypotensive
|
Feeding | Normal | Difficulty feeding reduced feeding | Unable to feed |
Signs of increased work of breathing include:
- Use of accessory muscles and/or retractions e.g. subcostal, intercostal, suprasternal, costal margins
- Nasal flaring, head bobbing, forward posturing
- Grunting
Auscultate chest for breath sounds and air entry once a shift and document findings in Focused Assessment
If any staff member or parent is concerned about the patient deteriorating, escalate to the medical team or notify the Medical Emergency Team (MET) urgently by dialling 22 22 (state MET, building, level, ward, room and specialty).
RCH Policy and Procedure: Medical Emergency Response Procedure
Monitoring
Regular measurements and documentation of primary assessment and physiological observations are requirements for patient monitoring and the recognition of deteriorations. Each set of observations must be recorded in the EMR flowsheets and then trends should be viewed on the VICTOR graph.
Perform observations hourly for Moderate and Continuous for Severely unwell.
For further guidance refer to - Nursing guidelines : Observation and continuous monitoring
As per 2025 Australasian Bronchiolitis Guidelines, continuous pulse oximetry monitoring is not usually recommended for non-hypoxic infants.
* These recommendations serve as a general guide and should not be used as a substitute for clinical judgement
Ongoing Management
Low Flow Oxygen Therapy
Titrate and wean oxygen as per CPG - Clinical Practice Guidelines : Bronchiolitis
Please note: For infants with cardiopulmonary disease, commence supplemental oxygen in line with specific SpO2 targets as set by the medical team
Low Flow oxygen therapy failure can be determined by lack of improvement in respiratory rate, heart rate by signs of worsening respiratory distress.
High Flow Oxygen Therapy (HFNP)
Flow Rate for HFNP Therapy
Weight
| Flow
|
≤ 12 kg
| 2L/Kg/minute
|
> 12 kg
| 2 L/kg/minute for the first 12kg + 0.5L/kg/minute for each kg thereafter (maximum flow 50L/min)
|
Refer to HFNP guideline for weaning flow and offering oral feeds Nursing guidelines : High flow nasal prong (HFNP) therapy.
If the infant does not exhibit signs of clinical stabilization within 4 hours of the commencement of HFNP discuss with bed card team the need for PICU involvement.
Humidification
Humidification of oxygen should be considered where possible to prevent mucous obstruction, mucosa dryness, ulceration and bronchospasms. Refer to Nursing guidelines : Oxygen delivery.
Nasal Aspiration
Nutrition/Hydration
Oral Feeding
Breastfeeding Support
Indications for Nasogastric Feeding
If increased coughing, respiratory distress, apnoeic episodes, visible tiring during oral feeds and/or not tolerating oral feeds >50% of normal intake, or hyponatremic contact medical team to discuss NG feeds.
Indications for Intravenous Fluids
Comfort Feeding
Infants may not be capable of tolerating large amounts of oral feeds. ‘Comfort feeds refer to small feeds, often 10-30ml or a breastfeed less than 5 minutes for children whilst the infant is also receiving intravenous (IV) therapy, which can settle their hunger. These feeds should be given with extreme caution and under strict supervision.
Fluids balance monitoring
Family Centred Care
Breastfeeding:
- Nursing guidelines : Breastfeeding support and promotion
- Mothers who experience a temporary drop in milk supply should be referred to a Maternal Child Health Nurse for appropriate lactation support. Consider environmental factors such as lowering lighting and reducing noise level.
Discharge Planning and Criteria Led Discharge (CLD)
Companion Documents
Evidence table
Evidence Table for this guideline can be viewed here.
Please remember to read the disclaimer.
The development of this nursing guideline was coordinated by Natalie Fung, CNS, Sugar Glider and approved by the Nursing Clinical Effectiveness Committee. Updated March 2026.