See also

Asthma   
Dehydration
High flow nasal prong therapy
Oxygen delivery

Key points

1. Bronchiolitis is a clinical diagnosis. Investigations are not indicated
2. The goal of management is to maintain hydration and oxygenation. Medication beyond simple analgesia is not indicated
3. Infants with a history of prematurity or cardiopulmonary disease are at higher risk of deterioration and are more likely to require admission
4. Use nasal prong oxygen for persistent SpO₂ <90%. High flow nasal prong (HFNP) therapy should be reserved for failure of nasal prong supplemental oxygen 

Background

• Bronchiolitis is a viral lower respiratory tract infection, generally affecting children <12 months of age
• It is a clinical diagnosis, based on typical history and examination findings
• Peak severity is usually at around day 2-3 from the onset of increased work of breathing, with resolution over 7-10 days, but disease course may vary
• It is self-limiting, usually requiring no treatment or intervention 
• A cough may persist for weeks

Assessment

History

Bronchiolitis typically begins with a coryzal prodrome followed by onset of one or more of: 

• Cough  
• Fever
• Difficulty feeding
• Apnoeic episodes
• Unsettledness/irritability
  

Risk factors for more serious illness

Consider hospital admission for these children, even if presenting early in illness with mild symptoms

• Chronic lung disease
• Congenital heart disease
• Chronic neurological conditions
• Gestational age <37 weeks, or chronological age at presentation <10 weeks
• Growth restriction
• Indigenous ethnicity
• Immunodeficiency
• Exposure to cigarette smoke
• Trisomy 21

Examination

• Tachypnoea
• Use of accessory muscles
• Bilateral wheeze and/or fine crepitations
• Hypoxia
• See assessment of severity of respiratory conditions

Management

Investigations

In most children with bronchiolitis, no investigations are required or recommended
Investigations should only be undertaken when there is deterioration or diagnostic uncertainty (eg cardiac murmur with signs of congestive cardiac failure)

• Chest X-ray (CXR) is not indicated and may lead to unnecessary treatment with antibiotics. CXRs cannot discriminate between viral and bacterial infections and are poorly reproducible in this age group
• Blood tests are not indicated (including blood gas, FBE, blood cultures) 
• Virological testing (nasopharyngeal swab or aspirate) is not indicated in the management of individual children and should not be used to guide treatment

Treatment

The main treatment of bronchiolitis is supportive. This involves ensuring appropriate oxygenation and fluid intake, and minimal handling  
Some young infants with risk factors (see above) or apnoeas (absence of breathing for >15 seconds, often associated with bradycardia and/or oxygen desaturation) may benefit from a period of hospital observation, even if they do not require fluid or supplemental oxygen therapy.

Bronchiolitis management approach

Supplemental Oxygen 

• Target SpO₂ is 90%, unless the child has an underlying cardiopulmonary disease with specific SpO₂ targets
• Infants with bronchiolitis will have brief episodes of mild/moderate desaturations <90%. These brief desaturations are not a reason to commence supplemental oxygen
• Nasal prong oxygen should only be instituted when oxygen saturations are persistently <90%. If oxygen saturations remain persistently <90% and there is no improvement in respiratory state despite 2 hours of low flow oxygen, consider HFNP
• HFNP is not recommended in children with SpO₂ consistently ≥90%
• Titrate oxygen down to achieve target SpO₂ ≥90%. Aim to use minimum supplemental oxygen. It is unnecessary to aim for SpO2 in mid-high 90’s
• Trial off supplemental oxygen (nasal prong or HFNP) every 6 hours. Recommence nasal prong oxygen if SpO₂ remains <90%
• Once no longer requiring supplemental oxygen for 2 hours, discontinue oxygen saturation monitoring. Continue observations 2-4 hourly and reinstate intermittent oxygen monitoring if clinically deteriorating

Hydration/nutrition

• Children are often more settled if comfort oral feeds are continued
• When non-oral hydration is required, nasogastric (NG) hydration is the route of choice and can be safely used in children on respiratory support
• NG bolus feeding is safe and should be commenced at two-thirds maintenance rate because of potential for increased ADH secretion
• IV hydration should be reserved for children in whom NG feeding is not possible. If IV fluid is used it should be isotonic with added glucose. See IV fluids

Medication

• Beyond simple analgesia, medications are not routinely indicated
• Chloral hydrate may be used to reduce agitation in children with worsening respiratory distress, regardless of need for respiratory support. It is most effective in children <2years and <15kg  
  
  • Dose 0-2 years: 10mg/kg initial dose, every 4-6 hours  
    May increase to 15mg/kg and then up to 20mg/kg every 4-6 hourly if required, but recommend increased monitoring and senior clinician involvement is required outside of critical care areas  
  • Adverse effects: excess sedation, respiratory depression, hypotension, paradoxical agitation
  • Caution in patients with renal or hepatic impairment   
• There is insufficient evidence for the use of caffeine in prevention of bronchiolitis-associated apnoea  
  

Do not administer

• Beta-2 agonists, including in infants with a personal or family history of atopy
• Corticosteroids (nebulised, oral, intramuscular or intravenous)
• Adrenaline (nebulised, intramuscular or intravenous) except in peri-arrest or arrest situation
• Nebulised hypertonic saline 
• Antibiotics, including azithromycin
• Antivirals 
• Caffeine

Nasal suction

• Deep nasal suction beyond the nasopharynx is not 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

Consider consultation with local paediatric team when

• Child has specific risk factors (detailed in assessment section)  
• Requiring supplemental oxygen 
• Less than half normal oral intake and clinically dehydrated
• Respiratory status assessed as moderate or severe

Consider transfer when

• Severe bronchiolitis (see above)
• Risk factors for more severe illness
• Child requiring care above the level of comfort of the local hospital
• Child has oxygen requirement on HFNP with FiO₂ >50%

   For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Considerations for discharge

• Infants can be discharged when SpO₂ ≥90% and feeding is adequate
• Infants <8 weeks of age are at increased risk of representation
• Transfer to Hospital in the Home (HITH) on home oxygen can be considered after a period of observation in selected infants as per local policies
• Parents should be educated about the illness, the expected progression and when and where to seek further advice

Parent information

RCH Kids Info Bronchiolitis

Last updated November 2023