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Child Health Guideline Identifier

Bronchiolitis

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This guideline is based on the PREDICT Australasian bronchiolitis clinical guideline with additional information specific to Starship.  This is intended for infants aged 0-12 months with bronchiolitis.  The guideline may be relevant for 12-24 months old but there is less diagnostic certainty in this age group.

Diagnosis

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.  Bronchiolitis most commonly occurs in the winter months, but can be seen all year round. Bronchilitis is usually self-limiting, often requiring no treatment or interventions.

Bronchiolitis typically begins with an acute upper respiratory tract infection followed by onset of respiratory distress and fever, and one or more of:

  • cough
  • tachypneoa
  • retractions
  • widespread crackles or wheeze

Investigations

Chest X-ray Not routinely indicated.  Consider if complications are suspected e.g. pleural effusion or extraneous air, in severe cases, or where the diagnosis uncertain.
Blood tests Not routinely indicated
Virological testing (NPA or swab)  Not routinely indicated
Urine microscopy and culture Consider if temp>38 deg in infant < 2 months old
Severely unwell infant Consider alternative diagnoses, including investigations for sepsis if bronchiolitis diagnosis not clear.
Refer to the Fever - investigations & management guideline for further advice.

Initial assessment

Initial Assessment

Table reproduced with permission from Murdoch Childrens Research Institute https://www.mcri.edu.au/

Admission

Mild Moderate Severe
• Suitable for discharge
• Consider risk factors
• Likely admission, may be able to be discharged after a period of
  observation
• Discuss with senior paediatric staff
• Requires admission
• Consider need for escalation of care (PICU)

Risk factors for more serious illness

  • Gestational age <37 weeks
  • Chronological age <10 weeks
  • Post-natal smoke exposure
  • Breastfed <2 months
  • Failure to thrive/faltering growth
  • Chronic lung disease
  • Congenital heart disease
  • Chronic neurological conditions

Infants with 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.

Management

HFNC (heated humidified high flow oxygen/air via nasal cannulae) Consider use if saturation < 92% and moderate-severe recessions
See High Flow oxygen therapy below
Monitoring As per Starship monitoring guideline
Do not use continuous saturation monitoring to determine medical management unless disease severe
Hydration/nutrition If non-oral hydration required, either nasogastric or intravenus hydration is appropriate
If IV fluids required follow Starship IV Fluids guideline
Medication • Do not administer beta-agonists
• Do not administer corticosteroids (systemic or nebulised)
• Do not administer adrenaline (except in peri-arrest/arrest)
• Do not administer hypertonic saline
• Antibiotics and antivirals are not indicated in bronchiolitis
Nasal suction/saline Nasal suction is not routinely recommended.  Consider use to assist with feeding in those with moderate disease.
Nasal saline drops can be considered at time of feeding
Chest physiotherapy Not indicated
Caffeine Sometimes used in CED and PICU for very young infants with apnoea. Caffeine should be stopped as soon as an infant is transferred to ward as it has a long half-life. This can make decisions regarding safety of discharge more difficult. See  Newborn drug protocols - Caffeine citrate.
 Respiratory support Oxygen therapy if saturations persistently < 92%
Brief, self-correcting mild/moderate desaturations of < 92% do not require oxygen therapy
Discontinue oxygen therapy when saturations persistently >92%

Oxygen therapy

  • Administer oxygen to maintain adequate saturation (>92%).
  • Administer via nasal cannula using flow rate up to 4 L/min (for infants and newborns a maximum flow of 2 L/min is suggested)
  • Weaning oxygen - use clinical judgement and the following guide to reduce oxygen when clinically stable or improving (consistently maintaining Sa02 >  92%)
    • Wean down by increments of 0.5 L 02  on a high flow meter (2 L/min 1.5 Lmin 1 L/min)
    • When on 1 L/min then switch to low flow meter
    • When on low flow meter then decrease from 1 L/min→0.5 L/min →0.25 L/min → room air
    • Assess the following ½ hour after each reduction: Sa02, pulse and respiration rate and respiratory effort
    • If not consistently maintaining Sp02 >92%, do not wean further.
    • Attempt to wean oxygen every 4hrs day or night

High flow therapy (HFNC)

Consider if:

  • O2 saturations less than 92%
  • Patients not responding to use of traditional low flow nasal oxygen

See Bronchiolitis - High Flow Nasal Cannula Treatment for further information

Fluids and Feeding

  • Small frequent oral feeds if tolerated
  • In moderate and severe cases nasogastric feeds may be needed either as small frequent bolus feeds or as continuous feeds.
  • In severe respiratory distress consider IV fluids.
  • For infants with signs of shock (severe tachycardia, poor peripheral perfusion, anuria) consider an initial bolus of normal saline.
  • For infants on IV fluids, follow IV fluid guideline

Discharge Planning

Criteria for discharge:

  • Child clinically stable and improving
  • Sa02 ≥ 92% on air ( should be off oxygen for at least 4 hours )
  • Feeding adequately ( at least 2/3 of normal feeds )
  • Family feel confident to manage at home
  • Family have ability to return or seek assistance if deterioration occurs (phone and access to transport)
  • Social situation allows ongoing care at home
  • Consider home care nursing or other follow up in the community
  • Provide written information regarding care at home and expected course of illness

Follow up

Most children fully recover from acute viral bronchiolitis, and many will not require any follow up other than clear advice.  Some however can have long lasting sequlae such as bronchiectasis.  Risk factors for sequelae include severe disease (prolonged stay, ICU admission, ventilation, evidence of hypercarbia, x-ray appearances) and specific infections (especially adenovirus).  Recurrent bronchiolitis or persistent respiratory symptoms can also be an indication of underlying issues.

When developing a discharge plan, consider these risk factors and possible underlying conditions.  Where there are clinical concerns, on discussion with the admitting consultant, the discharge plan may include:

  • Planned GP follow up
  • Additional screening investigations depending on the specific clinical circumstances (for example, these may include IgG/IgA/IgM levels, full blood count, sweat test, chest xray when well, swallow assessment)
  • Other follow up as discussed with the admitting consultant

The discharge summary should clearly document the follow up recommendations.

Information for Families

Kidshealth factsheet on Bronchiolitis

References

Australasian Bronchiolitis Guideline (2017), PREDICT

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Document Control

  • Date last published: 20 October 2017
  • Document type: Clinical Guideline
  • Services responsible: General Paediatrics
  • Author(s): Greg Williams, Stuart Dalziel
  • Owner: Greg Williams
  • Editor: Greg Williams
  • Review frequency: 2 years

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