Bronchiolitis Pathway PDF

Bronchiolitis v.9.
1 Criteria and Respiratory Score

Approval & Citation Summary of Version Changes Explanation of Evidence Ratings
PHASE I (Criteria & Respiratory Score)

Epidemiology,
Pathophysiology
& Natural History
Inclusion Criteria
Age <2 years
Prematurity and/or age < 12 weeks may be
included, but expect a more severe course of
illness
Viral upper respiratory symptoms & lower
respiratory symptoms that may include:
increased work of breathing, cough, feeding
difficulty, tachypnea, wheeze, fever
Exclusion Criteria
Cardiac disease requiring baseline medication
Anatomic airway defects
Neuromuscular disease
Immunodeficiency
Chronic lung disease
RESPIRATORY SCORE (RS)
Variable 0 points 1 points 2 points 3 points
RR
2 mo 60 61-69 70
2-12 mo 50 51-59 60
1-2 yr 40 41-44 45
Retractions None Subcostal or intercostal 2 of the following: subcostal, 3 of the following: subcostal,
intercostal, substernal, OR intercostal, substernal,
nasal flaring (infant) suprasternal, supraclavicular
OR nasal flaring / head
bobbing (infant)
Dyspnea
0-2 years Normal feeding, 1 of the following: difficulty 2 of the following: difficulty Stops feeding, no vocalization
vocalizations and feeding, decreased feeding, decreased vocalization or drowsy and confused
activity vocalization or agitated or agitated
Auscultation Normal breathing, no End-expiratory wheeze only Expiratory wheeze only Inspiratory and expiratory
wheezing present (greater than end-expiratory wheeze OR diminished breath
wheeze) sounds OR both
For questions concerning this pathway, Last Updated: February 2017

contact: bronchiolitis@seattlechildrens.org Next Expected Revision: November 2020
2017 Seattle Childrens Hospital, all rights reserved, Medical Disclaimer
Bronchiolitis v.9.1: ED Management
Approval & Citation PHASE II (ED) Explanation of Evidence Ratings
Summary of Version Changes

Inclusion Criteria
Age <2 years
Prematurity and/or age < 12 weeks may be
Urgent Care Transfer included, but expect a more severe course
Criteria of illness Therapies NOT routinely
Viral upper respiratory symptoms & lower recommended
Score >8 or severe
respiratory symptoms that may include:
respiratory distress Albuterol
Albuterol
increased work of breathing, cough, feeding
after suction and Racemic Epinepherine
Racemic Epinepherine
difficulty, tachypnea, wheeze, fever
reevaluation
Exclusion Criteria Corticosteroids
Corticosteroids
Inadequate oral
Cardiac disease requiring baseline Chest
ChestPhysiotherapy
Physiotherapy
hydration
medication
Hypoxemia Montelukast
Montelukast
Apnea Antibiotics
Neuromuscular disease Antibiotics
Signs of clinical
Immunodeficiency Hypertonic Saline
Hypertonic Saline
deterioration
Chronic lung disease
*Transport via ALS
!
Initial assessment
Place in viral isolation Routine testing !
for viral pathogens Chest X-rays
Respiratory score and suction (SCORE, SUCTION,
NOT recommended NOT routinely
SCORE). Start with nasal suction if score <9; follow recommended
unless for cohorting
with NP suction if needed
Provide supplemental O2 to keep saturation >90%
(>88% asleep). Start at L and titrate as needed. Considerations for severely ill patients
May consider ONE-TIME albuterol MDI trial if:
Rehydration Severe respiratory distress OR
Give supplemental NG or IV fluids if moderately to Increased risk for asthma (>12 months old, wheeze, and
severely dehydrated, secretions thick and difficult to one of the following: personal history of atopy or recurrent
mobilize, or severe respiratory distress wheezing OR strong family history of atopy or asthma)
If safe for PO feeds and mildly to moderately
dehydrated, attempt oral feeding If patient responds to albuterol (score decreases by 2 or more)
and is felt to clinically have asthma, change to asthma
pathway. If patient responds to albuterol but is still felt
clinically to have bronchiolitis as a primary pathology, albuterol
Family teaching should be continued on a prn basis only.
Viral illness, treated by hydration and suction
Signs of respiratory distress
How to suction Consider HFNC for significant hypoxia OR severe respiratory
When to suction distress not improving with rigorous supportive care (suction,
Frequent feeds and watch hydration status hydration, antipyretics) (Go to HFNC Phase).
Cough may last 2-4 weeks, do not use OTC cough
and cold medications, avoid tobacco smoke
Suction and reevaluation

Respiratory score (SCORE, SUCTION, SCORE) Discharge
Decision to
Q 1 hour + prn if mild to moderate distress Able to Recommend
Admit /
Respiratory score and suction q30 minutes + prn discharge follow up in
Discharge 24-48 hours
if severe respiratory distress
For patients with prolonged ED stays, may space
suctioning per MD discretion
ICU Admit Criteria

(any of the following)
Medical Unit Admit Criteria
(any of the following) Clinical worsening despite floor max HFNC support
Respiratory score >8 and not meeting ICU criteria Desaturations below 90% despite 50% FiO2
Sustained hypoxemia (SpO2 < 90% awake, 88% asleep) Other late findings of respiratory failure:
Apnea Inappropriately low respiratory rate with
Dehydration/impaired oral hydration requiring ongoing worsening obstruction
IV or NG fluids Lethargy despite noxious stimuli
HFNC trial initiated, clinically improved or unchanged Poor perfusion
Apnea > 20 seconds with associated bradycardia/
desaturation requiring intervention

Bronchiolitis v.9.1: Inpatient Management
PHASE III (Inpatient)

Inclusion Criteria
Age <2 years Patient admitted
Prematurity and/or age < 12 weeks may
be included, but expect a more severe
course of illness
Viral upper respiratory symptoms & lower
respiratory symptoms that may include: Begin family teaching !
increased work of breathing, cough, Signs of
feeding difficulty, tachypnea, wheeze, Signs of respiratory distress clinical
fever How to suction deterioration:
Exclusion Criteria When to suction
Lethargy despite noxious stimuli,
Cardiac disease requiring baseline
inappropriately low respiratory rate
medication with worsening obstruction, apnea,
Anatomic airway defects poor perfusion
Neuromuscular disease
Immunodeficiency
Place CR monitors and notify MD
Chronic lung disease Assess patient and calculate
Call Rapid Response Team
respiratory score
Pre-suction score is LOW (1-4) Pre-suction score is MODERATE (5-8) Pre-suction score is HIGH (9-12)
Score, Suction, Score prior to feeding or Score, Suction, Score prior to feeds or if Score, Suction, Score in 1 hour
if more distressed, minimum q 4 hours more distressed, minimum q 2 hours Nasal suction
Nasal suction Nasal suction NP suction if clinically indicated after nasal
No continuous pulse oximetry NP suction if clinically indicated after nasal suctioning
If on IV/NG fluids, discontinue fluids and suctioning Continuous pulse oximetry
restart oral feeds No continuous pulse oximetry unless on NG/IV fluids and evaluate safety of oral
supplemental O2 feeds
May consider albuterol trial and HFNC trial
as outlined in escalation box below
Rescore at interval specified above (either 1, 2, or 4

hours) and recategorize based on pre-suction
score
Ready for discharge? Escalation for worsening patients
May consider ONE-TIME albuterol trial (only

Therapies NOT routinely if not previously trialed) if:
recommended Severe respiratory distress OR
Discharge Criteria Increased risk for asthma (>12
Albuterol
months old, wheeze, and one of the
Racemic Epinepherine Patients should be meet ALL of the
following criteria: following: personal history of atopy
Corticosteroids or recurrent wheezing OR strong
Respiratory score <5 for at least 8
Chest Physiotherapy hours family history of atopy or asthma)
Antibiotics No need for NP suctioning for 4 hours
Off supplemental O2 for 12 hours Continue albuterol PRN ONLY if respiratory
Montelukast If apnea occurred, no further apnea score improves by at least 2 points with trial;
for 48 hours otherwise discontinue it.
Hypertonic Saline
Feeding adequately Consider HFNC for significant hypoxia
Family teaching re: respiratory distress
OR severe respiratory distress not
and suction completed, teach-back
done
improving with rigorous supportive
Follow up established care (suction, hydration, antipyretics)
Go to HFNC phase.

Bronchiolitis v.9.1: HFNC Management
PHASE IV (HFNC)
Pre-HFNC care HFNC Inclusion Criteria
Optimize NP suctioning. Recommend at least Children on bronchiolitis pathway
three rounds of suction. Age 44 weeks PMA to < 2 years
Fluid bolus completed ONE of the following:
Antipyretic administered, if febrile 1) Severe respiratory distress (deep retractions
May consider albuterol trial ONCE in multiple areas, grunting, head bobbing), or
2) Significant hypoxia (need for > 1 lpm NCO2 if
Call medical hospitalist (7-6058)
30-90 days, >1.5 lpm for 91 days 6 months, >2
Floor initiations: Also call RRT; resident to lpm for 6 months 2 years)
notify attending MD. HFNC Exclusion Criteria
Concern for impending respiratory failure
(lethargy, poor perfusion, apnea)
Concurrent treatment of pneumonia, asthma, or
croup with antibiotics/steroids
Born prematurely < 34 weeks (if <6 mo)
Initiate HFNC at floor max flow, FiO2 21% History of intubation for respiratory failure
Cardiac disease requiring baseline medication
Titrate FiO2 to maintain SpO2 > 90% awake,
88% asleep; max floor FiO2 is 50% Neuromuscular disease
Score, suction, score + VS q 30 min x 3 Immunodeficiency
Ensure NPO Chronic lung disease
HFNC floor HFNC floor

Age maximum minimum
Huddle 60 minutes (L/min) (L/min)
post HFNC initiation
ED: include ED (RN, RT, resident,
and fellow/attending), hospitalist, and accepting 44wk PMA - 90 days* 4 3
floor resident
91 days - 6 months* 6 4
Floor: include PICU (RISK RN, APP/fellow/

>6 months - 1 year 8 5
attending), hospitalist, and
resident >1 year - <2 years 10 5
*Correct for gestational age Trial HFNC at floor max flow
Clinically worsening Clinically unchanged Improving

In ED:
Transfer to floor
Off In ED: Suction/vitals q1h until transfer
Call PICU (if in ED) Pathway Consult PICU
Call RRT (if on floor) PICU may recommend transfer to floor or ICU On floor:
Transfer patient to ICU Suction + vitals q1h while awaiting transfer Wean flow rates and FiO2 as tolerated
May escalate respiratory support with Suction at least q2 hours until off HFNC
ICU guidance while waiting for transfer On floor: VS q2 hours x 12 hours, then q4 hours
Suction and vitals q30 minutes while Suction at least q2 hours until off HFNC Place NG if anticipated NPO > 2 days
waiting for transfer VS q2 hours x 12 hours, then q4 hours May orally feed once patient has weaned to floor
Patient should be assessed every q4 hours for minimum flow and team feels respiratory status is
improvement and readiness to wean safe for feeding.
First feed should be observed by RN or MD
Use extra caution in neonates < 90 days old
Sign of clinical improvement:

Weaning HFNC on the medical unit:
Improving respiratory score

Lower respiratory rate with improved aeration
Rapidity: Flow and FiO2 should be weaned quickly in improving
patients, including at night.
Lower heart rate
Frequency of weaning trials:
Weans should be trialed at least once a day, unless team
Criteria for transfer to the ICU:
holds wean due to anticipated trajectory or ongoing
Clinical worsening despite floor max HFNC respiratory distress.
support Improving patients should be assessed by RT or RN for
Desaturations below 90% despite 50% FiO2 readiness to wean q4 hours.
Other late findings of respiratory failure: Step-wise approach: Flow should be weaned from floor max
Inappropriately low respiratory rate with flow, to floor min flow, to off (remove cannula).
worsening obstruction Avoid gradual weans using other flows.
Lethargy despite noxious stimuli Weaning from max flow directly to off is also possible, as
Poor perfusion patient condition allows.
Apnea > 20 seconds with associated
bradycardia/desaturation requiring Team guidance: physicians should order flow rate after
intervention assessing patient, observe patient for 10 minutes after flow
turned down, and reasses within 2 hours to ensure sustained
Criteria for transfer from the ICU to floor: successful wean.
Meets pathway criteria and stable on flow
Definition of failed wean: increased work of breathing that the
rate at or below the floor maximum for >12 team judges difficult to sustain for next 12-24 hours, which
hours resolves when flow wean is reversed.
If does not meet bronchiolitis HFNC pathway
criteria, see HFNC policy RRT considerations: May restart HFNC without RRT, if within
24 hours of failed trial off, and if severity does not warrant RRT.

Scope of the Problem
Bronchiolitis: leading cause of infant hospitalization in the U.S.

Approximately 3% of all children are hospitalized with bronchiolitis at
some point in their lives
Annual mid-winter epidemics of bronchiolitis lead to a 239% increase in
hospitalizations in children <6 months
Costs associated with bronchiolitis admissions:

Charges: $1.7 billion annually and increasing over time
Relative cost: among top 10 costliest pediatric inpatient diagnoses
Hasegawa 2013, Keren 2012, AAP Clinical Practice Guideline 2014
Definition
Bronchiolitis is an acute infectious inflammation of the bronchioles

resulting in obstructive airway disease.
Age <2 years (peak 3-6 months)

Prodromal viral upper respiratory symptoms
Lower respiratory symptoms follow
Small airway edema and epithelial cell
sloughing
mucus production
bronchospasm
hyperinflation
AAP 2014
Image source: http://www.healthuse.com
Return to Criteria & RS Return to ED Return to Inpatient Return to HFNC

Etiology
Respiratory Syncytial Virus (50-80%)

Other viruses
Human Metapneumovirus
Rhinovirus
Coronavirus
Parainfluenza
Influenza
Adenovirus
Coinfection (multiple pathogens) in up to 30%
Zorc 2010, AAP 2014.

Iimage Source: http://globalbiodefense.com/2013/11/08/nih-scientists-develop-
candidate-vaccine-for-rsv
Natural History
Epidemiology
o Peak incidence DecemberMarch
o >90% infected with RSV by 2 years of age
o 40% develop a lower respiratory tract infection with first
infection, and most do not require hospitalization
Transmission
o Direct contact with secretions (including on fomites,
where it can persist for >6 hours)
o Young children typically shed virus for > 2 weeks Source: AAP 2014, Zorc 2010
Image source: Getty Images
o 30-70% of household contacts become ill
Natural history
o Begins with a URI
o Progresses to LRI in 2-6 days
o Variable and dynamic course
o Lasts ~2-4 weeks
Reinfection common

Natural History: Complications
Respiratory complications uncommon

o Apnea (~3%), esp. if premature
o Respiratory failure
Bacterial complications relatively uncommon
o Otitis media most common
o In young infants, most common is UTI
o Pneumonia uncommon
Mortality rare
o Fewer than 400 deaths annually
o Most deaths in those 6 months of age and younger, with
approximately half in patients with comorbidities
AAP 2014, Zorc 2010, Hasegawa 2013

Diagnosis: Symptoms
Upper followed by lower

respiratory tract infection
URI: Rhinorrhea, congestion, cough
LRI: Airway obstruction (tachypnea,
IMAGE SOURCE:
wheezing, respiratory distress)
http://www.amsj.org/archives/3369
May also have:

Fever
Feeding difficulty
Post-tussive emesis
Source: AAP 2014

Diagnosis: Physical Exam
Vital signs
o Tachypnea
o Hypoxemia
Inspection
o Respiratory distress
Grunting, flaring, retractions
o Vigor vs. fatigue
Auscultation
o Prolonged expiratory phase
o Wheezes
o Crackles
NOTE: The exam may change quickly / often due to varying

clearance of obstruction.
AAP 2014, Zorc 2010
Diagnosis: Differential Diagnosis
Consider alternate diagnoses for babies with severe respiratory

distress, lack of viral symptoms, or frequent / recurrent episodes.
Viral-triggered wheeze
Infection
o Pneumonia
o Pertussis
Irritant
o Gastro-esophageal reflux
o Aspiration
Anatomic
o Foreign body aspiration
o Congenital airway anomaly
Congestive heart failure
Zorc 2010, AAP 2014

Diagnosis: Imaging
There is no evidence to support the routine use

of chest X-rays in bronchiolitis (AAP 2014).
The risk of bacterial pneumonia is low.
Chest X-ray findings do not correlate
with disease severity.
Chest X-rays lead to unnecessary
antibiotic use.
Obtaining a chest X-ray could be
considered if the child has >2 days of Image source:
fever, an asymmetric chest exam, does http://www.allposters.com/-sp/Normal-
Chest-X-Ray-3-Year-Old-Child-
not demonstrate improvement, or has an Posters_i4257610_.htm
unusually high O2 need.
Diagnosis: Identification of Pathogen
Identification of a pathogen is not routinely recommended (AAP 2014).
Diagnostic testing m ay be considered if:

o Need for cohorting
o Uncertain clinical diagnosis
o Age <2 m onths
o To assess for influenza
Pathogen identification IS recom m ended: Image Source:

http://www.cdhb.govt.nz/measl
o any patient with hospital-acquired infection es/images/throat-swab.jpg
o High-risk patients (im m une-com prom ised,
chronic lung / heart disease)

Identifying Patients Appropriate for the Bronchiolitis Pathway
Patients who meet criteria should be placed on the bronchiolitis pathway

via bronchiolitis orderset (AAP 2014).
Inclusion Criteria Exclusion Criteria

Chronic lung disease or other significant lung
Age <2 years disease (e.g., cystic fibrosis)
Viral upper respiratory symptoms Cardiac disease requiring daily medications
& lower respiratory symptoms or with baseline symptoms
that may include: increased work
of breathing, cough, feeding Anatomic airway defects
difficulty, tachypnea, wheeze, Neuromuscular disease
fever
Immunodeficiency
NOTE: Ex-premature infants and those <12 weeks of age are not excluded from the
pathway, but providers should be aware that these children may have a more
severe course of illness.
Defining Admission Criteria

Admit to ward if patient meets ANY of the following criteria:
1. Moderate / severe respiratory distress
o Respiratory score 9-12 after suctioning
o Severe distress requiring high flow nasal cannula
2. Hypoxemia (O2 saturation <90% awake, 88% asleep)
3. Apnea
4. Dehydration requiring ongoing IV or NG hydration
5. Consider admission for adherence risk (lack of reliable caregiver, inability to
follow recommended care plan, risk for loss to follow-up)
Admit to ICU for:
o Clinically worsening despite maximum floor HFNC flow
o Desaturations despite maximum floor FiO2 50%
o Late findings of respiratory failure: lethargy despite noxious stimuli, inappropriately low
respiratory rate despite worsening obstruction, poor perfusion
o Apnea with bradycardia and cyanosis

Respiratory Scoring Tool (Slide 1 of 3)
How do I use the respiratory scoring tool?

4 Respiratory Assessment Elements Score
The respiratory scoring tool consists of 4
1. RESPIRATORY RATE: assessed over 60 (1-3) elements that make up the respiratory
seconds assessment of the patient in distress.
2. RETRACTIONS: work of breathing (0-3) You assess each component distinctly and
add them to make a total between 1-12.
3. DYSPNEA: shortness of breath (0-3)
o A patients RR is 1-3 whereas all other
4. AUSCULTATION: wheezing on lung exam (0-3) categories are scored 0-3.
TOTAL SCORE 1-12
The Seattle Children's respiratory scoring tool was adapted from the Seattle
Childrens asthma pathway. Interrater reliability was validated (see asthma
pathway for references).
Other scoring tools have been validated, but no single tool has been adopted
universally or has clearly superior performance in bronchiolitis.
Respiratory Scoring Tool Table (Part 1 of 2)

Variable 0 points 1 point 2 points 3 points
1. RESPIRATORY RATE: assessed over 60 seconds (1-3)
<2 mo 60 61-69 70
2-12 mo 50 51-59 60
1-2 yr 40 41-44 45
2-3 yr 34 35-39 40
4-5 yr 30 31-35 36
6-12 yr 26 27-30 31
>12 yr 23 24-27 28
NOTE: This is the same respiratory score as used for asthma.

Respiratory Scoring Tool Table (Part 2 of 2)

Variable 0 points 1 point 2 points 3 points
2. RETRACTIONS: work of breathing (0-3)
None Subcostal or intercostal 2 of the following: subcostal, 3 of the following: subcostal,
intercostal, substernal, OR intercostal, substernal,
nasal flaring (infant) suprasternal, supraclavicular
OR nasal flaring / head
bobbing (infant)
3. DYSPNEA: shortness of breath (0-3)
0-2 Normal feeding, 1 of the following: difficulty 2 of the following: difficulty Stops feeding, no
years vocalizations and feeding, decreased feeding, decreased vocalization, drowsy or
activity vocalization or agitated vocalization or agitated confused
2-4 Normal feeding, 1 of the following: decreased 2 of the following: decreased Stops eating or drinking,
years vocalizations and play appetite, increased coughing appetite, increased coughing stops playing, OR drowsy
after play, hyperactivity after play, hyperactivity and confused
>4 Counts to 10 in one Counts to 7-9 in one breath Counts to 4-6 in one breath Counts to 3 in one breath
years breath
4. AUSCULTATION: wheezing on lung exam (0-3)
Normal breathing, no End-expiratory wheeze only Expiratory wheeze only Inspiratory and expiratory
wheezing present (greater than end-expiratory wheeze OR diminished
wheeze) breath sounds OR both
NOTE: This is the same respiratory score as used for asthma.
Defining Discharge Criteria
Patients should be discharged when they meet ALL of the following

criteria:
Respiratory distress only mild / moderate (respiratory score <5 for at
least 8 hours)
No need for nasopharyngeal suctioning x 4 hours
Off supplemental O2 for 12 hours
If apnea occurred, no further apnea x 48 hours
Feeding adequately
Caregiver teaching re: respiratory distress and suction completed with
teach-backs
Follow-up established

Caregiver and Family Teaching
Teaching should start on arrival:

Signs of respiratory distress
When to call PCP, go to ED, call 911
How and when to nasally suction
Using bulb syringe or mouth operated nasal aspirator
Maintaining hydration
Small frequent feeds
Signs of dehydration
Anticipatory guidance:
Cough can last up to 4 weeks
Do not use over-the-counter cough/cold medications
Treatment: Therapies that Work
Best practice is FEWER interventions. Therapy is primarily supportive.

o Suction
o Intravenous or nasogastric fluids if dehydrated
o Supplemental oxygen if hypoxemic
o Escalation therapies only if high risk of respiratory failure

Treatment: Suctioning (Slide 1 of 2)
Suctioning is not widely evaluated in the literature, but is

considered essential to bronchiolitis care.
Used to clear secretions from the nares / airway that
the child is unable to clear himself / herself.
Induces coughing, which allows child to clear lower
airway secretions.
Reduces work of breathing and improves oral intake.
Suction gaps may be associated with longer LOS Bulb suction
Patients admitted with bronchiolitis should receive
suction of the nares at frequent intervals
Mussman 2013, AAP 2014
Olive tip suction
Mouth-operated nasal aspirator Nasopharyngeal (NP)

(To be used by caregiver only) suction catheter
Treatment: Suctioning (Slide 2 of 2)
Suction should be primarily nasal:

Nasal suction (with an olive tip catheter, bulb, or parental mouth-operated nasal
aspirator) should be used routinely, at regular intervals.
Nasopharyngeal suction should be used in patients in severe respiratory distress
and fail to improve with olive tip suction. Nasal edema may result from repeated
nasopharyngeal suction events. Some articles suggest nasopharyngeal suction is
associated with a longer LOS, and using it less often does not make outcomes
worse (Mussman 2013, Mittal 2014).
Suction response should be documented, with a respiratory score

recorded before and after all types of suctioning.
Family should be trained how/when to use nasal suction at home.

Treatment: Supplemental Oxygen
Supplemental oxygen should be provided if SpO2 falls persistently

below 90%. The goal is to provide oxygen to maintain SpO2 at or above
90%. (AAP 2014)
Oxygen is supplied via nasal cannula, using the lowest flow possible.
SpO2 drops to 88% are acceptable during sleep.
<20 sec drops in SpO2 to the 80s in the sleeping child do not require
supplemental oxygen; these may occur in healthy infants. (Hunt 1999)
Deeper self-resolving desaturations may not be clinically meaningful in mild-
to-moderate bronchiolitis patients, who should therefore be taken off
continuous pulse oximetry once off supplemental oxygen. (Principi 2016)
Treatment: IV Fluids (Slide 1 of 2)
Intravenous (IV) or nasogastric (NG) fluid administration should be

considered if the patient cannot maintain hydration orally or is severely
dehydrated (AAP 2014).
NG hydration is as effective as IV hydration in patients with
bronchiolitis, and requires fewer attempts at placement. It is
advisable to involve caregivers in the decision of how to hydrate
their child.
Because respiratory distress may increase the risk of aspiration:
Patients with significant coughing, choking, gagging, or worsening
tachypnea with feeds should be made NPO, and IV/NG feeds started.
Patients with a sustained respiratory rate > 60 should be evaluated for
safety of a feeding trial. If severe distress, do not attempt feeding trial
and make NPO.
Patients on HFNC at floor maximum flow rates should be NPO.

Treatment: IV Fluids (Slide 2 of 2)
Hypotonic IV fluids should not be used in patients with bronchiolitis.

Bronchiolitis patients should be started on D5NS with potassium per
Maintenance IV Fluids Pathway
Hyponatremia can be seen in severe bronchiolitis, as fever, pain, and
inflammation are non-osmotic triggers for ADH release.
o Consider checking a sodium level in patients with severe bronchiolitis on IV fluids.
(AAP 2014)
Treatment: Therapies NOT Routinely Recommended
Numerous randomized controlled trials

do not demonstrate benefit with:
Bronchodilators
Corticosteroids
Chest physiotherapy
Antibiotics
Leukotriene receptor antagonists

Treatment: Bronchodilators (Slide 1 of 2)
There is NO consistent improvement in

duration of illness or length of
hospitalization due to bronchodilators.
As with any medication, bronchodilators
have side effects and costs. Albuterol
should NOT be used routinely in children
with bronchiolitis (AAP 2014, Gadomski
Cochrane 2014).
Treatment: Bronchodilators (Slide 2 of 2)
Because there is a paucity of data on critically-ill infants, albuterol

may be trialed in patients with severe distress or risk factors for
asthma (>12 months old with wheeze, history of recurrent wheeze,
strong family history of atopy or asthma).
Document response (pre /post respiratory score and exam).
Continue PRN only if significant improvement in respiratory score
(2+ point improvement) after albuterol administration.
If no significant response, albuterol should not be trialed again.
If albuterol not effective, higher doses are not better.
MDI is the preferred delivery method.

Treatment: Racemic Epinephrine
Racemic epinephrine has no benefit over albuterol for treatment of

inpatients with bronchiolitis and should not be used routinely (AAP 2014).
Though there is some evidence suggesting benefit in the outpatient

setting, studies conflict. There is no evidence to support its use in
inpatients with bronchiolitis.
The bronchodilator of choice, if a child is to have a trial, should be
albuterol (due to its longer duration of action, low risk for adverse effects,
and common use in other settings).
Treatment: Corticosteroids
Corticosteroids do not improve length of stay in the hospital, length of

illness, or clinical score, and should not be used routinely (AAP 2014,
Fernandes Cochrane 2013).
Even if there is concern for a significant reactive airway component,
steroids may not benefit young viral wheezers (Panickar 2009).
Consider steroids in patients with chronic lung disease who are
EXCLUDED from pathway (+/- in consultation with pulmonary medicine).

Treatment: Chest Physiotherapy
Chest physiotherapy does not improve

respiratory score, length of stay, or O2
requirement, and is not recommended for
routine use in bronchiolitis (AAP 2014).
Image source: www.uwhealth.org
Treatment: Antibiotics
The risk of serious bacterial infection in infants with bronchiolitis is low,

and antibiotics do not improve length of stay in the hospital for patients
with bronchiolitis.
Antibiotics should not be used routinely, and they should only be used
in patients with evidence of specific secondary bacterial infections (AAP
2014).

Treatment: Montelukast
There is no evidence for improvement with montelukast and it is not

recommended for use in bronchiolitis (AAP 2014).

Monitoring: Continuous Pulse Oximetry
Continuous pulse oximetry should be discontinued when patients are

clinically improving and no longer require supplemental oxygen (AAP
2014).
Pulse oximetry can lead to alarm fatigue, caregiver distress, and
overtreatment. In some studies, it is associated with higher admission
rates or longer LOS without evidence of patient benefit.
Pulse oximetry should be used judiciously and discontinued once
patients improve.
(Shuh 2014, Hunt 1999, AAP 2014)
Monitoring: Blood Gas Monitoring
Clinicians may check a CBG if there are signs of clinical deterioration

(apnea, lethargy, poor perfusion, signs of impending respiratory failure).

Monitoring: Apnea
Initiate ABC (apnea / bradycardia / cyanosis) monitoring if patient has an

episode of apnea while inpatient or a significant history of apnea.
Consider ICU consult / transfer for persistent episodes of apnea or for
apnea with bradycardia and/or cyanosis.
NOTE: Pertussis PCR is recommended for infants with apnea.
Escalation Therapies
Cochrane reviews on HFNC and CPAP state that there is

insufficient evidence to recommend routine use in bronchiolitis
There is a paucity of high-quality research in critical illness
Retrospective ICU studies of HFNC in bronchiolitis show
decreased intubation rates and decreased ICU length of stay.
2014 AAP guideline: Although promising, the absence of any

completed randomized trial of the efficacy of high-flow nasal
cannula in bronchiolitis precludes specific recommendations
on its use at this time.

Escalation Therapies: High Flow Nasal Cannula
Terms: Also called high-flow, or high-humidity nasal cannula

Function: HFNC delivers a higher flow of air or oxygen than nasal
cannula. Gas is delivered with a mixer so FiO2 can be adjusted (21-100%),
although actual delivered FiO2 does not reach 100%. By contrast, nasal
cannula oxygen is not humidified and dries airways at higher flow rates.
Proposed mechanisms of HFNC action in bronchiolitis:
1. Provides CO2 washout of respiratory physiologic dead space
2. Provides very low-level positive pressure that aids lung recruitment
Exact amount of PEEP varies based on:
Flows
Nasal cannula fit to nares
Whether mouth is open or closed
3. Warmth and humidity
Keep secretions moist, improving mucociliary clearance
Inhibit bronchoconstriction reflexes triggered by cold and dry air

Escalation Therapies: HFNC Pathway Criteria
Patients eligible for HFNC bronchiolitis pathway:
Children on bronchiolitis pathway
Age 44 weeks PMA to <2 years with clinical bronchiolitis
ONE of the following, despite rigorous supportive care trial:
o Severe respiratory distress
o Significant hypoxia (> 1 L/min NCO2 if 30-90 days, >1.5 L/min for 91 days 6
months, >2 L/min for 6 months 2 years)
Exclusion Criteria
Cardiac disease requiring baseline medication Concern for respiratory failure:
Lethargy
Anatomic airway defects Poor perfusion
Neuromuscular disease Apnea
Immunodeficiency Born prematurely < 34 weeks if < 6 mo

Chronic lung disease History of intubation for respiratory failure
Concurrent treatment of pneumonia, asthma, or croup

Escalation Therapies: HFNC Initiation
Escalation steps
1. Suction and hydrate well prior to HFNC
2. Consider albuterol trial ONCE if appropriate and not already done
3. For inpatients: Call RRT, notify attending MD
For ED: Call respiratory therapist and medical hospitalist (7-6058)
4. Make patient NPO
5. Set up HFNC initially at 21% FiO2 and maximum floor flow for age
6. Continue to suction frequently both pre- and post-HFNC initiation.
NOTE: If patient weaned off HFNC and it is re-initiated >24

hours later, an RRT must be called.
Escalation Therapies: HFNC 60-minute huddle
Studies show that HFNC responders show improvement in respiratory

rate, heart rate, and work of breathing within 60-90 minutes.
Recommendations:
Conduct a huddle, in which key players in the patients care re-evaluate
the patients clinical course 60 minutes after HFNC initiation
Clinically worsening patients are transferred to the PICU
Clinically improving or unchanged patients may stay on the floor
Huddle 60 minutes
post HFNC initiation
ED: include ED (RN, RT, resident,
and fellow/attending), hospitalist, and accepting
floor resident
Floor : include PICU (RISK RN, APP/fellow/

attending), hospitalist, and
resident

Escalation Therapies: HFNC Weaning
HFNC should be weaned quickly in improving

patients.
FiO2 may be weaned by RN/RT
Flow must be weaned by provider order
RN/RT should assess readiness to
wean flow every 4 hours, and prompt IMAGE SOURCE: http://www.qmed.com
team to wean if appropriate

Teams should wean flow at least daily,
unless team holds due to anticipated
trajectory or patient severity
Flow should be weaned stepwise, from
floor max to min to off.
Trials off: Flow can be weaned from max
flow to off if appropriate
Escalation Therapies: HFNC PICUtoFloor Transfers
PICU bronchiolitis patients should meet criteria before transfer:

Be stable on a flow rate at or below the floor maximum for >12 hours
Have no HFNC pathway EXCLUSION criteria (i.e. no neuromuscular
disease, no chronic lung disease, etc.)
For patients who do not meet criteria for HFNC pathway:

Transfer subject to hospital-wide policy
See CHILD: Care of the Patient on High-Flow Nasal Cannula (HFNC))

Escalation Therapies: Feeding Patients on HFNC
No strong evidence exists to guide feeding practices on HFNC.

Recommendations:
Patients who wean to minimum floor flow are eligible to resume oral feeds.
Patients should only attempt oral feeding if clinically improving and if no
known aspiration history
First oral feeding should be supervised by an RN, SLP/OT, or provider
Oral feeding should be stopped if associated with increased coughing,
choking, or worsening respiratory distress.
An NG tube should be placed and enteral feeds initiated for patients NPO for
> 2 days.
Signs of Deterioration in a Patient With Bronchiolitis
Increasing respiratory distress

Inappropriately low respiratory rate despite worsening obstruction
Increasing heart rate
Criteria for transfer to the ICU :
Worsening hypoxia Clinical worsening despite floor max HFNC
support
Apnea requiring intervention Desaturations below 90% despite 50% FiO2
Other late findings of respiratory failure:
Lethargy Inappropriately low respiratory rate with
worsening obstruction
Poor perfusion Lethargy despite noxious stimuli
Poor perfusion
Apnea > 20 seconds with associated
bradycardia/desaturation requiring
intervention
Criteria for transfer from the ICU to floor :

Meets pathway criteria and stable on flow
rate at or below the floor maximum for >12
hours
If does not meet bronchiolitis HFNC pathway
criteria, see HFNC policy

Prevention
RSV can persists on fomites for hours and has been identified in the air
up to 22 feet from the patient's bed.
Viral isolation is standard for inpatients at Seattle Children's:

o Strict handwashing / alcohol-based rubs, gown, gloves, mask
o Wash hands or gel before and after patient contact, after contact with
inanimate objects directly near the patient, and after glove removal
o Limit visits by young children
Family education re: hand hygiene (AAP 2014)
Consider RSV monoclonal antibody (i.e. monthly Synagis) for at-

risk infants (AAP palivizumab policy statement 2014)
Source: AAP 2014, AAP Committee on Infectious Diseases 2014

Bronchiolitis Approval & Citation
Approved by the CSW Bronchiolitis Team for the January 3, 2017 go live.
CSW Bronchiolitis Team:

Pathway Owner, Hospitalist Sarah Zaman, MD
Pathway Owner, Emergency Anne Slater, MD
Clinical Nurse Specialist, Medical Unit Coral Ringer, MN, RN, CPN
Clinical Nurse Specialist, Emergency Elaine Beardsley, MN, RN, CPEN
ICU/RISK Team, Stakeholder Joan Roberts, MD
Pulmonology, Stakeholder Amanda Striegl, MD
Respiratory Therapy, Stakeholder Rob Di Blasi, RRT-NPS, FAARC
Clinical Effectiveness Team:

Consultant: Jeff Foti, MD
Project Manager: Dawn Hoffer, MBA
CE Analyst: Holly Clifton, MPH
CIS Informatician: Carlos Villavicencio, MD
CIS Analyst: Heather Marshall
Librarian: Sue Groshong, MLIS
Project Coordinator: Kristyn Simmons
Executive Approval:
Sr. VP, Chief Medical Officer Mark Del Beccaro, MD
Sr. VP, Chief Nursing Officer Madlyn Murrey, MN, RN
Surgeon-in-Chief Bob Sawin, MD
Retrieval Website: http://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdf
Please cite as:

Seattle Childrens Hospital, Zaman S, Beardsley E, Crotwell D, Di Blasi R, Foti J, Hoffer D, Ringer C,
Roberts J, Slater A, Striegl A, Villavicencio C, 2017. Bronchiolitis Pathway. Available from: http://
www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdf

Evidence Ratings
This pathway was developed through local consensus based on published evidence and expert
opinion as part of Clinical Standard Work at Seattle Childrens. Pathway teams include
representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical
Effectiveness, and other services as appropriate.
When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed
as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the
following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):
Quality ratings are downgraded if studies:

Have serious limitations
Have inconsistent results
If evidence does not directly address clinical questions
If estimates are imprecise OR
If it is felt that there is substantial publication bias
Quality ratings are upgraded if it is felt that:

The effect size is large
If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR
If a dose-response gradient is evident
Guideline Recommendation is from a published guideline that used methodology deemed

acceptable by the team.
Expert Opinion Our expert opinion is based on available evidence that does not meet GRADE
criteria (for example, case-control studies).
To Bibliography

Summary of Version Changes
Version 1.0 (10/10/2011): Go live
Version 1.1 and 1.2 (07/20/2012): Copyrighted photos and diagrams removed
Version 2.0 (10/22/2012): Updated to SpO2 monitoring recommendations
Version 3.0 (12/10/2013): Go live of Bronchiolitis HFNC Pathway
Version 3.1 (12/13/2013): Changes made to add contact hospitalist; correction to oral feeds to
match training slide; wording change in trial of albuterol to match the orders
Version 3.2 (01/15/2014): Changes to inclusion and exclusion criteria; changes to reflect
medical hospitalist at ED 90 minute huddle; admit to medical hospitalist
Version 4.0 (02/5/2014): Pathway document was divided into two documents and posted as
Bronchiolitis Pathway and HFNC Pathway
Version 5.0 (10/01/2014): Added citation page and link; removed HFNC Test Your
Knowledge link; updated training slides L, M, and V. In the HFNC phase only: Removal of daily
CBG while on HFNC; highlighting of ability to recheck PC02 after HFNC started for improved
patients to meet floor admit criteria; PCO2 removed from inclusion criteria; composition of
members of ED huddle; ability to admit to general medicine service; ability to trial patient on RA
or low flow NC O2 after stable on HFNC at 2 lpm for 4 hours
Version 6.0 (01/30/2015): HFNC Phase ONLY: Update to the pathway inclusion criteria to
include severe respiratory distress; added ICU to floor transfer criteria and link to education slide
in transfer criteria box
Version 7.0 (11/04/2015): Periodic Review; updated literature search, recommendations and
pathway tools. Combined bronchiolitis and HFNC pathway documents.
Version 8.0 (3/7/2016): HFNC inclusion/exclusion criteria amended, HFNC huddle participants
amended, changes to HFNC ED management for unchanged patients, HFNC restarting after
weaning clarified
Version 9.0 (1/3/2017): Process Improvement Change; optimization of secretion management,
focusing on high-flow cannula use, and improving high-flow efficacy.
Version 9.1 (2/27/17): Title of first green box on HFNC Phase changed and grammar adjustment
made in Inclusion Criteria.

Medical Disclaimer
Medicine is an ever-changing science. As new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to provide information
that is complete and generally in accord with the standards accepted at the time of publication.
However, in view of the possibility of human error or changes in medical sciences, neither the
authors nor Seattle Childrens Healthcare System nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained herein is in every
respect accurate or complete, and they are not responsible for any errors or omissions or for the
results obtained from the use of such information.
Readers should confirm the information contained herein with other sources and are encouraged to
consult with their health care provider before making any health care decision.

Bibliography, Page 1
Studies were identified by searching electronic databases using search strategies developed and executed by a medical
librarian, Susan Groshong. This periodic review search was completed in April, 2015, and updated searches originally
performed in 2010, 2012 and 2013. The following databases were searched: Cochrane Database of Systematic Reviews
via the Ovid platform, CINAHL, and Cincinnati Childrens Evidence-Based Care Recommendations. Retrieval was limited
to ages 0-18, English, French or German languages, and the period October 1, 2013 to current, reflecting incorporation
of a 2014 American Academy of Pediatrics guideline. For review of Medline and Embase, the team relied upon ongoing
quarterly alert results. Appropriate CINAHL Headings were used, along with text words, and the search strategy was
adapted for other databases using text words. Concepts searched were bronchiolitis, respiratory syncytial viruses and
metapneumovirus. All retrieval was further limited to certain evidence categories, such as relevant publication types,
index terms for study types and other similar limits.
Identification
97 records identified 1 additional records identified

through database searching through other sources
Screening
98 records after duplicates removed
98 records screened 69 records excluded
Eligibility
17 full-text articles excluded,
0 did not answer clinical question
29 records assessed for eligibility
17 did not meet quality threshold
0 outdated relative to other included study
Included
12 studies included in pathway
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535
To Bibliography, Pg 1

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Risk of Hospitalization for Respiratory Syncytial Virus Infection. Pediatrics 2014;134:415 -420
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[improvement]. 2012;2(4):202-209. Accessed 5/22/2014 3:37:25 PM.
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severity of bronchiolitis in a population of hospitalized infants. J Asthma [improvement]. 2013;50(10):1056-
1061. Accessed 5/22/2014 3:37:25 PM. 10.3109/02770903.2013.834504 [doi].
Fernandes RM, Bialy LM, Vandermeer B, et al. Glucocorticoids for acute viral bronchiolitis in infants and young
children. Cochrane Database Syst Rev. 2013;6:CD004878.
Gadomski AM, Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2014;6:CD001266.
Hartling L, Bialy LM, Vandermeer B, et al. Epinephrine for bronchiolitis. Cochrane Database Syst Rev.
2011(6):CD003123.
Hasegawa K, Tsugawa Y, Brown DF, Mansbach JM, Camargo CA, Jr. Trends in bronchiolitis hospitalizations in the
United States, 2000-2009. Pediatrics. 2013;132(1):28-36.
Hegde S, Prodhan P. Serious air leak syndrome complicating high-flow nasal cannula therapy: A report of 3 cases.
Pediatrics. 2013;131(3):e939-44.
Hunt CE et al. Collaborative Home Infant Monitoring Evaluation (CHIME) Study Group. Longitudinal assessment of
hemoglobin oxygen saturation in healthy infants during the first 6 months of age. JAMA. 1999;135: 580-586.
Jarvis K, Pirvu D, Barbee K, et al. Change to a standardized airway clearance protocol for children with bronchiolitis
leads to improved care. J Pediatr Nurs [PRS Bronchiolitis]. 2014;29(3):252-257. Accessed 4/15/2015 5:58:59
PM. 10.1016/j.pedn.2013.11.007.
Kelly GS, Simon HK, Sturm JJ. High-flow nasal cannula use in children with respiratory distress in the emergency
department: Predicting the need for subsequent intubation. Pediatr Emerg Care [improvement].
2013;29(8):888-892. Accessed 5/22/2014 3:37:25 PM. 10.1097/PEC.0b013e31829e7f2f [doi].
Keren R et al. Prioritization of Comparative Effectiveness Research Topics in Hospital Pediatrics. JAMA Pediatrics.
2012;166(12):1155-1164
Maffey A, Moviglia T, Mirabello C, et al. Swallowing and respiratory distress in hospitalized patients with
bronchiolitis. Dysphagia. 2013;28(4):582-587. Accessed 20131206; 1/2/2015 7:39:12 PM. http://dx.doi.org/
10.1007/s00455-013-9470-0.
Mayfield S, Bogossian F, O'Malley L, Schibler A. High-flow nasal cannula oxygen therapy for infants with
bronchiolitis: Pilot study. J Paediatr Child Health. 2014;50(5):373-378. Accessed 20140416; 4/14/2015
1:57:30 PM. http://dx.doi.org/10.1111/jpc.12509.

Mayfield S, Hough J, Pham T, Schibler A. High flow nasal prong oxygen reduces the need for mechanical ventilation
in bronchiolitic infants. Pediatr Crit Care Med. 2011;12(3):A118.
McCallum GB, Morris PS, Wilson CC, et al. Severity scoring systems: Are they internally valid, reliable and
predictive of oxygen use in children with acute bronchiolitis? Pediatr Pulmonol [improvement]. 2013;48(8):797-
803. Accessed 5/22/2014 3:37:25 PM. 10.1002/ppul.22627 [doi].
McKiernan C, Chua LC, Visintainer PF, Allen H. High flow nasal cannulae therapy in infants with bronchiolitis. J
Pediatr. 2010;156(4):634-638.
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A physiologic study. Intensive Care Med. 2013;39(6):1088-1094.
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pp. 342 -349

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Bronchiolitis v.9.

1 Criteria and Respiratory Score

PHASE I (Criteria & Respiratory Score)

RESPIRATORY SCORE (RS)

Variable 0 points 1 points 2 points 3 points

For questions concerning this pathway, Last Updated: February 2017

Summary of Version Changes

Suction and reevaluation

ICU Admit Criteria

For questions concerning this pathway, Last Updated: February 2017

PHASE III (Inpatient)

Rescore at interval specified above (either 1, 2, or 4

Ready for discharge? Escalation for worsening patients

May consider ONE-TIME albuterol trial (only

For questions concerning this pathway, Last Updated: February 2017

HFNC floor HFNC floor

Floor: include PICU (RISK RN, APP/fellow/

*Correct for gestational age Trial HFNC at floor max flow

Clinically worsening Clinically unchanged Improving

Sign of clinical improvement:

For questions concerning this pathway, Last Updated: February 2017

Bronchiolitis: leading cause of infant hospitalization in the U.S.

Costs associated with bronchiolitis admissions:

Hasegawa 2013, Keren 2012, AAP Clinical Practice Guideline 2014

Bronchiolitis is an acute infectious inflammation of the bronchioles

Age <2 years (peak 3-6 months)

Return to Criteria & RS Return to ED Return to Inpatient Return to HFNC

Respiratory Syncytial Virus (50-80%)

Zorc 2010, AAP 2014.

Return to Criteria & RS Return to ED Return to Inpatient Return to HFNC

Respiratory complications uncommon

AAP 2014, Zorc 2010, Hasegawa 2013

Return to Criteria & RS Return to ED Return to Inpatient Return to HFNC

Upper followed by lower

May also have:

Source: AAP 2014

Return to Criteria & RS Return to ED Return to Inpatient Return to HFNC

NOTE: The exam may change quickly / often due to varying

AAP 2014, Zorc 2010

Diagnosis: Differential Diagnosis

Consider alternate diagnoses for babies with severe respiratory

Zorc 2010, AAP 2014

Return to Criteria & RS Return to ED Return to Inpatient Return to HFNC

There is no evidence to support the routine use

Diagnosis: Identification of Pathogen

Identification of a pathogen is not routinely recommended (AAP 2014).

Diagnostic testing m ay be considered if:

Pathogen identification IS recom m ended: Image Source:

Return to Criteria & RS Return to ED Return to Inpatient Return to HFNC

Patients who meet criteria should be placed on the bronchiolitis pathway

Inclusion Criteria Exclusion Criteria

Defining Admission Criteria

Return to Criteria & RS Return to ED Return to Inpatient Return to HFNC

How do I use the respiratory scoring tool?

TOTAL SCORE 1-12

Respiratory Scoring Tool (Slide 2 of 3)

Respiratory Scoring Tool Table (Part 1 of 2)

NOTE: This is the same respiratory score as used for asthma.

Return to Criteria & RS Return to ED Return to Inpatient Return to HFNC

Respiratory Scoring Tool Table (Part 2 of 2)

NOTE: This is the same respiratory score as used for asthma.

Defining Discharge Criteria

Patients should be discharged when they meet ALL of the following