Bronchiolitis Guideline
SUMMARY
This guideline has been developed to provide an evidence-based clinical framework for the management of infants (0–12 months) with bronchiolitis treated in Australasian emergency departments (EDs) or general paediatric wards. Application of these guidelines for children over 12 months may be relevant but there is less diagnostic certainty in the 12–24 month age group. (All references to age within this guideline refer to chronological age unless stated otherwise).
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FEATURES
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
Bronchiolitis is usually self-limiting, often requiring no treatment or interventions.
RISK FACTORS FOR MORE SERIOUS ILLNESS
- Gestational age less than 37 weeks
- Chronological age at presentation less than 10 weeks
- Post-natal exposure to cigarette smoke
- Breast fed for less than two months
- Failure to thrive
- Chronic lung disease
- Congenital heart disease
- Chronic neurological conditions
- Indigenous ethnicity
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.
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.
INVESTIGATIONS
In most infants presenting to hospital and/or hospitalised with bronchiolitis, no investigations are required.
Chest X-ray (CXR)
- Is not routinely indicated in infants presenting with bronchiolitis and may lead to unnecessary treatment with antibiotics with subsequent risk of adverse events
Blood tests (including 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
Urine microscopy and culture
- May be considered to identify urinary tract infection if a temperature over 38 degrees in an infant less than two months of age with bronchiolitis
| This table is meant to provide guidance in order to stratify severity. The more symptoms the infant has in the mod-severe categories, the more likely they are to develop severe disease. | |||
|---|---|---|---|
| MILD | MODERATE | SEVERE | |
| Behaviour | Normal | Some/intermittent irritability | Increasing irritability and/or lethargy Fatigue |
| Respiratory rate | Normal – mild tachypnoea | Increased respiratory rate | Marked increase or decrease in respiratory rate |
| Use of accessory muscles | Nil to mild chest wall retraction | Moderate chest wall retractions Tracheal tug Nasal flaring | Marked chest wall retractions Marked tracheal tug Marked nasal flaring |
| Oxygen saturation/ oxygen requirement | O2 saturations greater than 92% (in room air) | O2 saturations 90 – 92% (in room air) | O2 saturations less than 90% (in room air) Hypoxemia, may not be corrected by O2 |
| Apnoeic episodes | None | May have brief apnoea | May have increasingly frequent or prolonged apnoea |
| Feeding | Normal | May have difficulty with feeding or reduced feeding | Reluctant or unable to feed |
| DIAGNOSIS | |
|---|---|
| 1 | Infants can be diagnosed with bronchiolitis if they have an upper respiratory tract infection followed by onset of respiratory distress with fever, and one or more of: cough, tachypnoea, retractions and diffuse crackles or wheeze on auscultation. (NHMRC: C, GRADE: Weak) |
| 2 | Clinicians should consider as risk factors for more serious illness: gestational age less than 37 weeks; chronological age at presentation less than 10 weeks; exposure to cigarette smoke; breast feeding for less than two months; failure to thrive; having chronic lung disease; having chronic heart and/or chronic neurological conditions; being Indigenous ethnicity, and should take these into account when managing infants with bronchiolitis. (NHMRC: C, GRADE: Conditional) |
| 3 | Routine CXR is not recommended as it does not improve management in infants presenting with simple bronchiolitis, and may lead to treatments of no benefit. (NHMRC: D, GRADE: Conditional) |
| 4 | There is no role for blood tests in managing infants presenting to hospital and hospitalised with bronchiolitis. Routine bacteriological testing of blood and urine is not recommended.(NHMRC: D, GRADE: Conditional) In infants less than two months of age presenting to hospital or hospitalised with bronchiolitis with a temperature over 38 degrees, there is a low risk of urinary tract infection (UTI). If clinical uncertainty exists clinicians may consider collecting a urine sample for microscopy, culture and sensitivity looking for the concurrent presence of UTI. |
| 5 | In infants with bronchiolitis, routine use of viral testing is not recommended for any clinically relevant end-points, including cohorting of bronchiolitis patients. (NHMRC: C, GRADE: Conditional) |
Respiratory support
- Oxygen therapy should be instituted when oxygen saturations are persistently less than 92%
- It is appreciated that infants with bronchiolitis will have brief episodes of mild/moderate desaturations to levels less than 92%. 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 92%
- Heated humidified high flow oxygen/air via nasal cannulae (HFNC) can be considered in the presence of hypoxia (oxygen saturation less than 92%) and moderate to severe recessions. Its use in infants without hypoxia should be limited to the randomised controlled trial (RCT) setting only
Monitoring
- Observations as per local hospital guidelines and Early Warning Tools (EWTs)
- Continuous oximetry should not be routinely used to dictate medical management unless disease is severe
Hydration/nutrition
- When non-oral hydration is required either intravenous (IV) or nasogastric (NG) hydration are appropriate
- If IV fluid is used it should be isotonic (0.9% Sodium Chloride with Glucose or similar)
- The ideal volume of IV or NG fluids required to maintain hydration remains unknown; between 60% to 100% of maintenance fluid is an appropriate volume to initiate
Medication
- Beta 2 agonists — Do not administer beta 2 agonists (including those with a personal or family history of atopy)
- Corticosteroids — Do not administer systemic or local glucocorticoids (nebulised, oral, intramuscular (IM) or IV)
- Adrenaline — Do not administer adrenaline (nebulised, IM or IV) except in peri-arrest or arrest situation
- Hypertonic Saline — Do not administer nebulised hypertonic saline
- Antibiotics — Including Azithromycin are not indicated in bronchiolitis
- Antivirals — Are not indicated
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
ONGOING MANAGEMENT
- HFNC or Nasal CPAP therapy may be considered in the appropriate ward setting
| The main treatment of bronchiolitis is supportive. This involves ensuring appropriate oxygenation and fluid intake. | |||
|---|---|---|---|
| MILD | MODERATE | SEVERE | |
| Likelihood of admission | Suitable for discharge Consider risk factors | Likely admission, may be able to be discharged after a period of observation Management should be discussed with a local senior physician | Requires admission and consider need for transfer to an appropriate children’s facility/PICU Threshold for referral is determined by local escalation policies but should be early |
| Observations Vital signs (respiratory rate, heart rate, O2 saturation, temperature) | Adequate assessment in ED prior to discharge (minimum of two recorded measurements or every four hours as per local hospital guidelines and EWT) | Hourly – dependent on condition (as per local hospital guidelines and EWT) | Hourly with continuous cardiorespiratory (including oximetry) monitoring and close nursing observation – dependent on condition (as per local hospital guidelines and EWT) |
| Hydration/nutrition | Small frequent feeds | If not feeding adequately (less than 50% over 12 hours), administer NG or IV hydration | If not feeding adequately (less than 50% over 12 hours), or unable to feed, administer NG or IV hydration |
| Oxygen saturation/oxygen requirement | Nil requirement | Administer O2 to maintain saturations greater than or equal to 92% | Administer O2 to maintain saturations greater than or equal to 92% |
| Respiratory support | Consider HFNC if a trial of NPO2 is ineffective | Consider HFNC or CPAP | |
| Disposition/ escalation | Consider further medical review if early in the illness and any risk factors are present or if child develops increasing severity after discharge | Decision to admit should be supported by clinical assessment, social and geographical factors and phase of illness | Consider escalation if severity does not improve Consider ICU review/ admission or transfer to local centre with paediatric HDU/ICU capacity if: |
| Parental education | Provide advice on the expected course of illness and when to return (worsening symptoms and inability to feed adequately) | Provide advice on the expected course of illness and when to return (worsening symptoms and inability to feed adequately) | Provide advice on the expected course of illness |
| Provide Parent Information sheet | Provide Parent Information sheet | Provide Parent Information sheet | |
| MANAGEMENT | |
|---|---|
| 6 | For infants presenting to hospital or hospitalised with bronchiolitis, there is insufficient evidence to recommend the use of a scoring system to predict need for admission or hospital length of stay. (NHMRC: D, GRADE: Weak) |
| 7 | Oxygen saturations, adequacy of feeding, age (infants younger than eight weeks), and lack of social support should be considered at the time of discharge as a risk for representation. There is insufficient evidence to recommend absolute discharge criteria for infants attending the ED, or hospitalised with bronchiolitis (NHMRC: Practice Point, GRADE: Weak) |
| 8a | Do not administer beta 2 agonists to infants, less than or equal to 12 months of age, presenting to hospital or hospitalised with bronchiolitis. (NHMRC: A, GRADE: Strong) |
| 8b | Do not administer beta 2 agonists to infants, less than or equal to 12 months of age, presenting to hospital or hospitalised with bronchiolitis, with a personal or family history of atopy. (NHMRC: D, GRADE: Weak) |
| 9 | Do not administer adrenaline/epinephrine to infants presenting to hospital or hospitalised with bronchiolitis. (NHMRC: B, GRADE: Strong) |
| 10 | Do not administer nebulised hypertonic saline in infants presenting to hospital or hospitalised with bronchiolitis. (NHMRC: D, GRADE: Conditional) |
| 11a | Do not administer systemic or local glucocorticoids to infants presenting to hospital or hospitalised with bronchiolitis. (NHMRC: B, GRADE: Strong) |
| 11b | Do not administer systemic or local glucocorticoids to infants presenting to hospital or hospitalised with bronchiolitis, with a positive response to beta 2 agonists. (NHMRC: D, GRADE: Weak) |
| 11c | Do not administer a combination of systemic or local glucocorticoids and adrenaline/epinephrine to infants presenting to hospital or hospitalised with bronchiolitis. (NHMRC: D, GRADE: Weak) |
| 12a | Consider the use of supplemental oxygen in the treatment of hypoxic (oxygen saturations less than 92%) infants with bronchiolitis. (NHMRC: C, GRADE: Conditional) |
| 12b | In uncomplicated bronchiolitis oxygen supplementation should be commenced if the oxygen saturation level is sustained at a level less than 92%. At oxygen saturation levels of 92% or greater, oxygen therapy should be discontinued. (NHMRC: C, GRADE: Conditional) |
| 14 | High Flow Nasal Cannulae Oxygen (HFNC) in bronchiolitis can be considered in the inpatient setting on infants with bronchiolitis with hypoxia (oxygen saturations less than 92%). Its use in children without hypoxia should be limited to the RCT setting only. (NHMRC: C, GRADE: Conditional) |
| 15 | Chest physiotherapy is not recommended for routine use in infants with bronchiolitis. (NHMRC: B, GRADE: Strong) |
| 16a | Nasal suction is not recommended as routine practice in the management of infants with bronchiolitis. Superficial nasal suction may be considered in those with moderate disease to assist feeding. (NHMRC: D, GRADE: Conditional) |
| 16b | Deep nasal suction for the management of bronchiolitis is not recommended. (NHMRC: D, GRADE: Conditional) |
| 17 | Routine nasal saline drops are not recommended. Trial of intermittent saline drops may be considered at time of feeding. (NHMRC: Practice Point, GRADE: Weak) |
| 18 | Nasal CPAP therapy for infants with bronchiolitis may be considered for the management of infants. (NHMRC: C, GRADE: Conditional) |
| 19 | Nasal CPAP therapy for infants with bronchiolitis may be considered for the management of infants. (NHMRC: C, GRADE: Conditional) After a period of observation, infants at low risk for severe bronchiolitis can be considered for discharge on home oxygen as part of an organised ‘Home Oxygen Program’ which has clear ‘Return to Hospital’ advice. (NHMRC: C, GRADE: Conditional) |
| 20a | Do not use antibiotics to treat infants with bronchiolitis. (NHMRC: B, GRADE: Conditional) |
| 20b | Do not use azithromycin for treatment of infants admitted to hospital with bronchiolitis. (NHMRC: B, GRADE: Conditional) |
| 20c | Do not use azithromycin for treatment of infants admitted to hospital with bronchiolitis who are at risk of developing bronchiectasis. (NHMRC: C, GRADE: Conditional) |
| 21a | Supplemental hydration is recommended for infants who cannot maintain hydration orally. (NHMRC: Practice Point, GRADE: Weak) |
| 21b | Both NG and IV routes are acceptable means for non-oral hydration in infants admitted to hospital with bronchiolitis. (NHMRC: B, GRADE: Strong) |
| 21c | There is insufficient evidence to recommend a specific proportion of maintenance fluid. There is a risk of fluid overload therefore judicious and vigilant use of hydration fluid is and regular clinical review is recommended. Isotonic fluid is recommended. (NHMRC: Practice Point, GRADE: Weak) |
| 22 | Hand hygiene is the most effective intervention to reduce hospital acquired infections and is recommended. There is inadequate evidence for benefits in cohorting infants with bronchiolitis. (NHMRC: D, GRADE: Weak) |
- Infants can be discharged when oxygen saturations are greater than or equal to 92% and feeding is adequate
- Infants younger than 8 weeks of age are at an increased risk of representation
- Discharge on home oxygen can be considered after a period of observation in selected infants as per local policies, if appropriate community short term oxygen therapy is available
- Follow-up and review as per local practice
EDUCATION (PARENT/CARE-GIVER)
- A Bronchiolitis Parent Information Sheet should be provided
- Parents should be educated about the illness, the expected progression and when and where to seek further medical care
SAFETY INITIATIVES
- Use simple infection control practices such as hand washing
- Cohorting of infants (based on virological testing) has not been shown to improve outcomes