SUMMARY

Bronchiolitis is one of the most common reasons for hospital admission in Australian and Aotearoa New Zealand infants. The Australasian Bronchiolitis Guideline aims to provide evidence-based clinical guidance on the management of infants (<12 months) presenting or admitted to hospital with bronchiolitis. The recommendations are applicable to emergency departments (EDs), general paediatric wards, and intensive care units (ICUs) in Australasian hospitals. The guidance has been developed for clinicians working within these settings.

The Guideline recommendations are presented in the table below and can also be downloaded in three documents as above; (1) a detailed Full Guideline summarising the evidence underlying each recommendation, (2) Annexes to the Full Guideline, and (3) a Bedside Summary. Charts for determining initial illness severity, and for decision support regarding use of respiratory support and safe discharge in infants with bronchiolitis, can be downloaded above.

Summary of recommendations

Legend

  • × Strong against
  • Conditional/weak (for or against)
  • Strong for
  • Consensus based

 

Refer to the methodology page or the full guideline report for further information on how the strength of the recommendations were defined and determined.

Topic Recommendation Recommendation strength
DIAGNOSIS
Physical examination and history (R1) 1. Consider a diagnosis of bronchiolitis in an infant if they have an upper respiratory tract infection (rhinorrhoea/ nasal congestion, and/or cough), followed by the onset of a lower respiratory tract infection with one or more of respiratory distress (tachypnoea and/or retractions), or presence of diffuse crackles and/or wheeze, with or without the presence of fever. Additional signs and symptoms can include feeding difficulties, vomiting, dehydration, hypoxaemia, lethargy, uncommonly (<5%) diarrhoea, and rarely (<2%) apnoea. 1. Weak

Risk factors (R2)

2. Clinicians should take into account the following risk factors for more serious illness when assessing and managing infants with bronchiolitis:

  • Gestational age <37 weeks;*
  • Younger chronological age at presentation;*
  • Prenatal and/or postnatal exposure to tobacco smoke;*
  • Reduced breastfeeding exposure;*
  • Faltering growth/ slow weight gain (failure to thrive);
  • Comorbidities including congenital heart disease, chronic lung disease, chronic neurological condition, congenital diaphragmatic hernia, trisomy 21, and other genetic disorders;
  • Being an Indigenous infant†;
  • Being an economically disadvantaged infant;
  • Timing and severity of illness onset at hospital presentation.

*Clinicians should judge these as risk factors on a continuous scale; with higher risk of poor outcomes associated with lower gestational age, lower chronological age, fewer days of breastfeeding exposure, and greater tobacco smoke exposure.

†Indigenous status in itself is unlikely to confer risk but there remains a correlation in Australia and Aotearoa New Zealand with ethnicity and severe bronchiolitis outcomes, independent of socioeconomic status, potentially reflecting the ongoing impacts of colonisation, remote geographical isolation, and the institutional racism in our health systems.

2. Strong

CXR (R3a-c) 3.a. Do not routinely use CXR in infants presenting or admitted to hospital with bronchiolitis. 3.a. Conditional

3.b. Consider CXR in infants with an unexpected deterioration* and/or a clinical course not consistent with bronchiolitis, including concerns regarding the presence of sepsis, pneumonic consolidation, pneumothorax, empyema, immunodeficiency, pleural effusion, or significant cardiac abnormalities.

*Unexpected deterioration refers to an unexpected requirement for an escalation of care.

3.b. Consensus-based

3.c. Consider CXR in infants presenting with bronchiolitis in high dependency/ intensive care settings, where there is clinician diagnostic concern regarding possible sepsis, pneumonic consolidation, pneumothorax, empyema, immunodeficiency, pleural effusion or significant complication of other diseases (e.g., heart failure with congenital heart disease), in order to guide treatment options. 3.c. Consensus-based

Laboratory tests (R4a-c) 4.a.i. Do not routinely use laboratory tests for infants presenting to hospital or hospitalised with bronchiolitis, including bacteriological testing of urine or blood. 4.a.i. Conditional

ii. Consider glucose and/or sodium levels during assessment in infants with bronchiolitis and poor feeding, evidence of dehydration or altered mental state. ii. Consensus-based

4.b. Consider use of biomarkers (e.g., FBC, CRP, PCT), urine testing, and blood cultures for the diagnosis of serious bacterial co-infection for infants with unexpected deterioration during hospitalisation with bronchiolitis. 4.b. Consensus-based

4.c. Consider use of biomarkers (e.g., FBC, CRP, PCT) and blood cultures for diagnosis of serious bacterial co-infection for infants being admitted to ICU with bronchiolitis. 4.c. Weak

Virological investigations (R5) 5. Do not routinely use viral testing in infants presenting to hospital or hospitalised with bronchiolitis, including testing undertaken solely for cohorting of patients.

5. Conditional

MANAGEMENT
Bronchiolitis scoring systems (R6) 6. Do not routinely use a formal bronchiolitis severity scoring system to predict need for admission or hospital length of stay in infants presenting or admitted to hospital with bronchiolitis. 6. Weak

Criteria for safe discharge (R7)

7. Safe discharge from hospital (either from the ED or ward) for infants with bronchiolitis should take into account risk factors (R2), the distance of the family’s residence from the hospital and their ability to return, parental health literacy, and the timing of the hospital presentation relative to the natural history of bronchiolitis (R1). Consider patients suitable for safe discharge from hospital when the following criteria are met:

1. Infant is clinically stable (defined as with mild to moderate stable respiratory effort).

2. For an infant who has not received oxygen/respiratory support and/or with SpO2≥95%, there is no need to continue to observe for maintenance of oxygen saturations. The infant may be considered for discharge based on criteria below.

For an infant who has received oxygen/respiratory support and/or with SpO2≤94%, they should be observed for maintenance of oxygen saturations in air at the following levels for 3-4 hours, including a period of sleep:
i. for infants aged ≥6 weeks with no underlying health conditions, for maintenance of SpO2≥90%;
ii. for infants aged <6 weeks, or infants aged <12 months with an underlying health condition, for maintenance of SpO2≥92%.

3. All Infants irrespective of presentation to ED or on inpatient ward should be maintaining adequate oral intake of fluids and feeds of at least 1/2 of usual volume with adequate output (>1/2 of usual wet nappies).

4. Parents and/or caregivers should feel confident to manage the infant with bronchiolitis at home.

5. Parents and/or caregivers are educated and provided with written information on possible deterioration and when to return for healthcare review.

6. Social situation allows discharge to home. The following factors should be considered: social factors, the time of day and suitable transport availability.

7. Arrange local follow-up where appropriate.

7. Weak

Beta2 agonists (R8a-b) 8.a. Do not use beta2 agonists in infants (<12 months of age) presenting to hospital or hospitalised with bronchiolitis. 8.a. Strong

×
8.b. Do not use beta2 agonists in infants (<12 months of age) presenting to hospital or hospitalised with bronchiolitis, with a personal or family history of atopy outside of a RCT. 8.b. Strong

×
Adrenaline/ epinephrine (R9) 9. Do not use adrenaline/ epinephrine in infants presenting to hospital or hospitalised with bronchiolitis. 9. Strong

×
Hypertonic saline (R10) 10. Do not routinely use nebulised hypertonic saline in infants presenting to hospital or hospitalised with bronchiolitis outside of a RCT. 10. Weak

Glucocorticoids (R11a-c) 11.a. Do not use systemic or local glucocorticoids in infants with bronchiolitis*.
*For guidance on the use of glucocorticoids when SARS-CoV-2 infection is present, refer to R22b ‘SARS-CoV-2 treatment.’

11.a. Strong

×
11.b. Do not use glucocorticoids for the routine treatment of infants with bronchiolitis with a positive response to beta2 agonists or other markers of a latter asthmatic phenotype outside of a RCT. Beta2 agonists should not be used in infants aged <12 months (see R8a,b). 11.b. Strong

×
11.c.i. Do not routinely use a combination of systemic or local corticosteroids and adrenaline/ epinephrine in infants presenting to or hospitalised with moderate bronchiolitis outside of the ICU setting. 11.c.i. Conditional

ii. Consider using a combination of systemic or local corticosteroids and adrenaline/epinephrine in infants with severe bronchiolitis requiring ICU level care. ii. Conditional

Supplemental oxygen and saturation targets (R12a-b)

12.a. Consider the use of supplemental oxygen in the treatment of hypoxaemic* infants with bronchiolitis.

*For definitions of hypoxaemic and target oxygen saturation levels, see R12b (‘Oxygen saturation targets’).

12.a. Conditional

12.b. Consider the use of supplemental oxygen in infants with bronchiolitis if their oxygen saturation is:

  • Persistently <90%, for infants aged ≥6 weeks;
  • Persistently <92%, for infants aged <6 weeks, or infants aged <12 months with an underlying health condition.
12.b. Weak

Continuous pulse oximetry (R13) 13. Do not routinely use continuous pulse oximetry for medical management of non-hypoxaemic infants (SpO2 ≥90% for infants ≥6 weeks age, or SpO2 ≥92% for infants <6 weeks age, or infants aged <12 months an underlying health condition), with bronchiolitis not receiving oxygen, or stable infants receiving low-flow oxygen, who are not at risk of apnoea. 13. Conditional

HF therapy (R14) 14.i. Do not routinely use HF therapy in infants with mild or moderate bronchiolitis who are not hypoxaemic.* 14.i. Conditional

ii. Do not routinely use HF therapy as a first-line therapy in infants with moderate bronchiolitis who are hypoxaemic.* ii. Conditional

iii. Consider HF therapy in infants with bronchiolitis who are hypoxaemic,* and who have failed low flow oxygen. iii. Conditional

iv. Consider HF therapy in infants with bronchiolitis with severe disease prior to CPAP.

* For otherwise healthy infants aged ≥6 weeks: SpO2 persistently <90%. For infants aged <6 weeks, or infants aged <12 months with an underlying health condition: SpO2 persistently <92%.

iv. Conditional

Chest physiotherapy (R15) 15. Do not routinely use chest physiotherapy in infants with bronchiolitis. 15. Conditional

Suctioning (R16a-b) 16.a.i. Do not routinely use nasal suction in the management of infants with bronchiolitis. 16.a.i. Conditional

ii. Consider using superficial suctioning in infants who have respiratory distress or feeding difficulties due to upper airway secretions. ii. Conditional

16.b. Do not routinely use deep nasal suctioning for the management of infants with bronchiolitis. 16.b. Weak

Nasal saline (R17) 17.i. Do not routinely use nasal saline drops in the management of infants with bronchiolitis. 17.i. Conditional

ii. Consider a trial of intermittent nasal saline drops at time of feeding in infants with reduced feeding. ii. Conditional

CPAP (R18) 18. Consider using CPAP therapy in infants with bronchiolitis and impending or severe respiratory failure, and/or with severe illness. 18. Conditional

Antibiotic medication (R19a-c) 19.a. Do not routinely use antibiotics for the treatment of infants with bronchiolitis. 19.a. Conditional

19.b. Do not routinely use azithromycin for treatment of bronchiolitis in infants admitted to hospital. 19.b. Weak

19.c. Do not routinely use antibiotics for the treatment of bronchiolitis in infants who are at risk of developing bronchiectasis (due to known risk factors such as virus type (e.g., Adenovirus), Indigenous ethnicity, socioeconomic disadvantage). 19.c. Weak

Non-oral hydration (R20a-e) 20.a. Use supplemental hydration for infants with bronchiolitis who cannot maintain hydration orally. 20.a. Strong

20.b.i. Use either NG or IV routes for non-oral hydration in infants admitted to hospital with bronchiolitis requiring supplemental hydration. 20.b.i. Strong

ii. Consider NG as the preferred first method of non-oral hydration in infants with moderate bronchiolitis requiring supplemental hydration. ii. Weak

iii. Consider either continuous or bolus methods of NG non-oral hydration with oral rehydration solution, breast milk, or formula in infants admitted to hospital with bronchiolitis requiring an NG. iii. Conditional

20.c. Consider fluid restriction at 50-75% of recommended maintenance due to the risk of fluid overload from SiADH, and hyponatremia in bronchiolitis. Monitor for signs of overhydration. 20.c. Consensus-based

20.d. Consider using either 0.9% sodium chloride (normal saline) with 5% glucose, or balanced fluid (e.g., Plasma-lyte 148TM or Hartmann’s solution) with 5% glucose, for use as maintenance fluid in infants admitted to hospital with bronchiolitis requiring IV hydration. For younger infants aged up to 4 weeks corrected with bronchiolitis, consider 10% glucose, or monitoring of blood sugar levels if receiving 5% glucose. 20.d. Consensus-based

20.e.i. Consider enteral feeding (NG or oral), if tolerated, in infants receiving high flow. 20.e.i. Weak

ii. Consider continuous NG feeding in infants receiving CPAP who are not judged at imminent risk of intubation. ii. Consensus-based

Infection control practices (R21) 21.i. Use hand hygiene practices for the management of infants with bronchiolitis. 21.i. Strong

ii. Consider multicomponent infection control practices for the management of infants with bronchiolitis. ii. Weak

iii. Consider cohorting of infants admitted to inpatient wards with bronchiolitis. iii. Weak

SARS CoV-2 co-infection and treatment (R22a-b) 22.a. Do not routinely use SARS-CoV-2 status to stratify increased risk for deterioration in infants with bronchiolitis. SARS CoV-2 infection or co-infection does not appear to place infants at increased risk of severe outcome from bronchiolitis. 22.a. Weak

22.b.i. Consider use of dexamethasone in hypoxic patients presenting with bronchiolitis who are also positive for SARS-CoV-2 co-infection. 22.b.i. Consensus-based

ii. Consider use of remdesivir in immunosuppressed infants who are also positive for SARS-CoV-2 infection. ii. Consensus-based

PREVENTION
Infant RSV monoclonal antibody prophylaxis (R23) 23.i. Consider use of monoclonal antibodies (palivizumab or nirsevimab) during RSV season in infants at increased risk of severe complications with bronchiolitis; chronic lung disease, congenital heart disease, and infants born very preterm (<32 wGA). 23.i. Conditional

ii. Consider universal nirsevimab as a population-based approach to reduce morbidity due to RSV bronchiolitis. ii. Conditional

Maternal active RSV immunisation (R24) 24. Consider universal maternal antenatal immunisation with a RSV prefusion F protein-based vaccine as a population-based approach to reduce morbidity due to RSV bronchiolitis. 24. Conditional

Infant active RSV immunisation (R25) 25. Do not routinely use universal infant RSV immunisation. 25. Weak

CPAP = Continuous positive airway pressure; CRP = C-reactive protein; CXR = Chest x-ray; ED = Emergency department; FBC = Full blood count; HF = High flow; ICU = Intensive care unit; IV = Intravenous; NG = Nasogastric; PCT = Procalcitonin; RCT = Randomised controlled trial; RSV = Respiratory syncytial virus; SARS-CoV-2 = Severe acute respiratory syndrome coronavirus 2; SiADH = Syndrome of inappropriate antidiuretic hormone secretion; SpO2 = Peripheral oxygen saturation; UTI = Urinary tract infection, wGA = weeks’ gestational age.

Disclaimer: The PREDICT Australasian Bronchiolitis Guideline aims to provide evidence-based clinical guidance for the management of infants (aged <12 months) with bronchiolitis, who have presented to an ED, or who have been admitted to a general paediatric ward or ICU (requiring treatment up to the point of mechanical ventilation) in an Australasian hospital. The content provided is not intended to replace personal consultation with, diagnosis and treatment by a qualified health care professional. Care should always be based on professional medical advice, appropriate for a patient’s specific circumstances.