Respiratory support

Respiratory support

Evidence-based approach to the use of respiratory support in infants with bronchiolitis

FiO2 = fractional concentration of inspired oxygen; HF = Humidified high flow; nCPAP = nasal continuous positive airway pressure.
¹For otherwise healthy infants aged ≥6 weeks: SpO₂ persistently <90%. For infants aged <6 weeks, or infants <12 months with an underlying health condition: SpO₂ persistently <92%.
²Response to therapy (low-flow or HF oxygen therapy) is determined by a reduction in respiratory rate, a reduction in heart rate, or a paediatric early warning score within 4-5 hours of commencing therapy.
³If at any time, the infant has severe respiratory distress, escalate care. Respiratory distress is a subjective finding. Severe respiratory distress is a level where a senior clinician determines that escalation in care is required, transferring the patient to the emergency department resuscitation area, paediatric ward resuscitation area, high dependency unit, or intensive care unit. Junior staff should escalate concerns regarding severe respiratory distress to senior colleagues.

Supplemental oxygen

Consider use of supplemental oxygen in the treatment of hypoxaemic infants with bronchiolitis. (Evidence quality: low; recommendation strength: conditional)

Supplementary oxygen should not be used for work of breathing alone.

Oxygen saturation targets

Supplemental oxygen therapy should be considered in infants with bronchiolitis when oxygen saturation levels meet the following criteria:

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

(Evidence quality: low; recommendation strength: weak)

Infants with bronchiolitis may have brief episodes of mild or moderate desaturations to levels below these thresholds, particularly during sleep. These brief desaturations are not a reason to commence oxygen therapy. Interpretation of ’persistently less’ should be considered in light of the stage at which the child is in the disease course and whether the child is awake or asleep.

Oxygen saturation targets are not considered alone for decision-making and are one of many data-points. They should be considered in light of the full disease picture involving other factors such as need for supplemental feeding, day of illness, and underlying risk factors.

When used, supplementary oxygen should be discontinued when oxygen saturations are persistently greater than or equal to the appropriate threshold outlined (90% or 92%) (see Figure 2 for guidance on observation periods).

Oxygen saturations should be tested and monitored every 4 to 6 hours, according to institutional policy.

Humidified high flow (HF) therapy

Do not routinely use HF therapy in infants with mild or moderate bronchiolitis who are not hypoxaemic.* (Evidence quality: low; recommendation strength: conditional)

Infants with moderate work of breathing are suitable to be on the ward with appropriate nursing ratios.

Do not routinely use HF therapy as a first-line therapy in infants with moderate bronchiolitis who are hypoxaemic.* (Evidence quality: low; recommendation strength: conditional)

Consider HF therapy in infants with bronchiolitis who are hypoxaemic,* and who have failed low flow oxygen. (Evidence quality: low; recommendation strength: conditional)

Consider HF therapy in infants with bronchiolitis with severe disease prior to continuous positive airway pressure (CPAP). (Evidence quality: low; recommendation strength: conditional)

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

Low flow oxygen failure is defined as a lack of response to therapy (determined by a lack of reduction in respiratory rate, heart rate, or a paediatric early warning score within 4-5 hours of commencing therapy), and/or the onset of severe respiratory distress.

Continuous positive airway pressure (CPAP)

CPAP therapy can be considered for use in infants with bronchiolitis and impending or severe respiratory failure, and/or with severe illness. (Evidence quality: very low; recommendation strength: conditional)