Summary of guideline
Clinical Contents:
- Diagnosis
- Initial illness severity assessment
- Risk factors for severe illness
- Investigations
- SARS-CoV-2 co-infection
- Monitoring
- Respiratory support
- Medication
- Nasal suction and clearance techniques
- Hydration and nutrition
- Discharge planning
- Prevention of RSV bronchiolitis
- Infection control
- Education modules
Technical Contents:
Initial Illness severity assessment
Severity of bronchiolitis based on the initial assessment
| Severity | Mild | Moderate | Severe | ||
| Behaviour | Normal | Some/intermittent irritability | Increasing irritability and/or lethargy fatigue | ||
| Respiratory rate (/min) |
<50 | 50-59 | 60-69 | ≥70 | |
| Use of accessory muscles | Nil to mild chest wall retraction | Moderate chest wall retractions Moderate tracheal tug Moderate nasal flaring |
Marked chest wall retractions Marked tracheal tug Marked nasal flaring |
||
| Oxygen saturations for those <6/52 or ≥6/52 with underlying chronic disease |
Persistent SpO2 ≥95% |
Persistent SpO2 92-94% |
Initial SpO2 87-91% and hypoxaemia corrected by low flow O2 |
Hypoxaemia not corrected by low flow O2 or initial SpO2 <87% |
|
| Oxygen saturations for those ≥6/52 and no underlying chronic disease |
Persistent SpO2≥95% | Persistent SpO2 90-94% | Initial SpO2 85-89% and hypoxaemia corrected by O2 |
Initial SpO2 <85% or hypoxaemia not corrected by low flow O2 |
|
| Apnoea | None | Brief apnoea not requiring stimulus to resolve |
Increasingly frequent or prolonged apnoea |
||
| Heart rate (/min) |
<160 | 160-169 | 170-179 | ≥180 | |
| Feeding | Maintaining adequate oral intake of fluids and feeds. At least 1/2 of usual volume with adequate output (>1/2 of usual wet nappies) |
Not maintaining adequate oral intake of fluids and feeds <1/2 of usual volume with inadequate output (<1/2 of usual wet nappies) and/or |
Infant not able to feed >20% of normal volume and/or >5% dehydrated |
||
| ≤5% dehydrated | |||||
| Early warning score zone1 |
White | Yellow/Orange | Red/Purple |
1Note, early warning scores have been developed and validated for use in inpatient settings and not in EDs. SpO2= Peripheral oxygen saturation. This table is meant to provide guidance in order to stratify. The more symptoms the infant has in the moderate to severe categories, the more likely they are to have moderate or severe disease.
Click here to download table as a PDF
Throughout the guideline, the terms mild, moderate, and severe are used with regards to the clinical condition of the infant with bronchiolitis. Within the research literature, the definition of these subgroups varies. Further, the definition of these terms varies between individual clinicians and healthcare settings. The evidence for bronchiolitis diagnosis and management is largely based on observational studies or RCTs which have occurred in the ED, inpatient paediatric wards, or in the ICU.
To define mild, moderate, and severe disease, a pragmatic definition has been developed that is consistent with the inclusion and exclusion criteria from the majority of the evidence. This table is intended to serve as a reference point to help define and guide assessments of illness severity. It may also be used to clarify definitions of mild, moderate, and severe bronchiolitis used in the guideline recommendations.
What level of care is required for infants with bronchiolitis?
Within Australia and Aotearoa New Zealand, management of bronchiolitis is such, that while tertiary children’s hospitals may see patients who move through the various levels of care from ED to inpatient ward to ICU based on the settings that the studies have occurred in, this may not be reflective of care in metropolitan, regional, and rural hospitals, where most infants with bronchiolitis are seen. In these hospitals, bronchiolitis patients with severe disease may be managed for some time in an ED or inpatient paediatric ward prior to transfer to a tertiary children’s hospital ICU or managed in an adult ICU without transfer. Transfer should occur safely according to local protocols.
The appropriate setting for delivery of care should reflect resources and skills that are available, rather than a specific physical location or label.
- Standard nursing ratios in the ED and ward environment are suitable for infants with mild or moderate bronchiolitis.
- For mild disease, no hydration or respiratory support is required, and these infants are usually managed in ED and as an outpatient.
- For moderate disease, hydration support and/or oxygen therapy (low flow or HF oxygen) can be safely delivered in an ED or ward environment with standard nursing ratios.
- Standard nursing ratios in the ED and ward environment have been shown to be safe for stable infants on HF therapy.
Severe bronchiolitis requires either a 1:1 or 1:2 nursing ratio. This will usually require HDU/ICU care, or escalation to a higher level of care depending on the health facility, and may involve transport to an HDU/ICU or higher-level facility. Post stabilisation of severe bronchiolitis with improvement in condition, nursing ratios can be revised.