Bronchiolitis

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

 See also:
 Asthma
 Intravenous Fluids
 High Flow Nasal Prong (HFNP) therapy - Nursing Guideline
 Oxygen delivery - Nursing Guideline

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 mo
categories, the more likely they are to develop severe disease.

MILD MODERATE SEVERE

Behaviour Normal Some / intermittent Increasing irritability

irritability Fatigue

Respiratory rate Normal – mild tachypnoea Increased respiratory rate Marked increase or de
respiratory rate

Use of accessory Nil to mild chest wall retraction Moderate chest wall Marked chest wall ret
muscles Retractions
Marked suprasternal r
suprasternal retraction
Marked nasal flaring
Nasal flaring

Oxygen O2 saturations greater than 92% (in O2 saturations 90 –92% O2 saturations less tha
saturation/ room air) air)
(in room air)
oxygen
requirement Hypoxemia, may not
corrected by O2

Apnoeic episodes None May have brief apnoea May have increasingl
prolonged apnoea

Feeding Normal May have difficulty with Reluctant or unable to

feeding or reduced
feeding
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 Suitable for discharge Likely admission, may be able to be Requires

discharged after a period of consider
of admission
observation an appro
Consider risk factors
facility/P
Management should be discussed
with a local senior physician
Threshol
determin
capacity

Observations Adequate assessment in ED prior to One to two Hourly (not continuous) Hourly w
discharge (minimum of two recorded
Vital signs cardiores
measurements or every four hours)
Once improving and not requiring oximetry
(respiratory rate,
oxygen for 2 hours discontinue close
heart rate, oxygen saturation monitoring
nursing o
O2 saturations,
temperature)
Hydration/nutrition Small frequent feeds If not feeding adequately (less If not fee
than 50% over 12 hours), (less than
hours),or
administer NG hydration
administ

Oxygen Nil requirement Administer O2 to maintain Adminis

saturation/oxygen saturations greater than saturatio
requirement or equal to 90% or equal

Once improving and not requiring

oxygen for 2 hours discontinue
oxygen saturation monitoring

Respiratory Begin with NPO2 Consider

support
HFNC to be used only if NPO2 has
failed

Disposition/ Consider further medical review if Decision to admit should be Consider

early in the illness and any risk supported by clinical assessment severity
escalation
factors are present or if child (including risk factors), social and
develops increasing severity after geographical factors, and phase of
Consider
discharge illness
admissio
local cen
paediatri
capacity
• Severit
• Persiste
• Signific
apnoea a
desaturat

 H

Parental Provide advice on the expected Provide advice on the expected Provide a
education course of illness and when to course of illness and when to expected
return (worsening symptoms and return (worsening symptoms and
 inability to feed adequately) inability to feed adequately) Provide P
sheet
Provide Parent information sheet 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