Bronchiolitis

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Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of bronchiolitis in emergency departments or general paediatric wards.

Definition

Bronchiolitis is a clinical diagnosis referring to a viral lower respiratory tract infection in infants less than 12 months of age. 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.

Background

  • Bronchiolitis is a viral condition beginning with an acute upper respiratory infection followed by onset of respiratory distress and fever and one or more of:
    • Cough
    • Tachypnoea
    • Retractions
    • Widespread crackles or wheeze
  • The natural history of bronchiolitis is that it worsens over the first few days (peak severity at day 2-3) and then improves thereafter over the next 7-10 days.
  • It is a clinical diagnosis, chest X-Rays are generally not indicated.
  • Bronchiolitis is usually self-limiting, often requiring no treatment of interventions. 
  • Most patients can be managed at home but is a leading cause of hospitalisation in infants in Australia.

Risk factors for more serious illness in Bronchiolitis

Children with the following should be discussed with a Senior Doctor:
  • Born at less than 37 weeks gestation 
  • Chronological age at presentation <10 weeks
  • Post-natal exposure to cigarette smoke
  • Breast fed for less than two months
  • Failure to thrive
  • Congenital heart disease
  • Chronic lung disease
  • Chronic neurological conditions
  • Indigenous ethnicity
  • Other factors eg. Immunodeficiency, other chronic medical conditions, social factors – geographical location and access to transport.
These children are at risk of more likely to deteriorate and require escalation of care. Consider hospital admission even if presenting early in illness with mild symptoms.

History

  • There may be apnoeic episodes, particularly in neonates, young infants, and ex-preterm infants
  • Hydration status: reduced feeding and decreased urine output (fewer wet nappies).

Examination

  • Assess the respiratory status of the child including respiratory rate, oxygen saturations and work of breathing (signs of respiratory distress).
    • Signs of increased work of breathing includes nasal flaring, head bobbing, tracheal tug, accessory muscle use and grunting
  • Child may look pale and unwell.
  • Decreased level of consciousness indicates exhaustion and impending risk of respiratory arrest.
  • Cyanosis is a late sign and indicates severe disease.
  • Fever may be present.
  • There may be clinical signs of dehydration such as a sunken fontanelle, slow capillary refill or dry mucous membranes.
  • Chest auscultation reveals bilateral, widespread wheeze and / or crackles. There may be areas of decreased air entry (due to atelectasis from mucous plugging).

Initial assessment 

This table intends 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.

 
Table 1: Initial assessment
   Mild   Moderate  Severe
 Behaviour Normal Some/intermittent irritability Increasing irritability and/or lethargy
Fatigue
 Respiratory rate Normal or mildly increased Increased respiratory rate Marked increase or decrease in respiratory rate
 Use of accessory muscles Nil to mild chest wall retractions Moderate chest wall retraction
Tracheal tug
Nasal flaring
Marked chest wall retraction
Marked tracheal tug
Marked nasal flaring
 Oxygen saturation/oxygen requirements O2 saturations greater than 92% (in room air) O2 saturations 90-92% (in room air) O2 saturation less than 90%
Hypoxaemia, 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

Initial management

The main treatment of bronchiolitis is supportive to ensure appropriate oxygenation and fluid intake.

Table 2: Initial management
   Mild   Moderate  Severe
Likelihood of admission Suitable for discharge
Consider risk factors for more serious illness
Likely admit, may be discharged after period of observations

Management discussed with senior doctor
Requires admission, consider need for transfer for higher level care
Observations:
Vital signs (respiratory rate, heart rate, O2 saturation, temperature)

Adequate assessment in ED prior to discharge (minimum 2 recorded measurements or every 4 hours as per hospital guidelines and EWT)
Hourly – dependent on condition (as per hospital EWT)
Hourly with continuous cardiorespiratory (including oximetry) monitoring and close nursing observation - dependent on condition (as per hospital 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) administer NG or IV hydration
Oxygen saturation/oxygen requirements Nil required
Administer O2 to maintain SpO2 greater than or equal to 92%
Administer O2 to maintain SpO2 greater than or equal to 92%
Respiratory support

Consider HFNC if a trial of NPO2 is ineffective (exercise caution - see HFNC guidelines)
Consider HFNC or CPAP
Oxygen monitoring None Intermittently done with other observations 

Continuous oxygen monitoring, consider apnoea monitor 
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 if:
  • Severity does not improve
  • Persistent desaturations
  • Significant or recurrent apnoeas associated with desaturations 
Parental education 
Provide advice on the expected course of illness and when to return (worsening symptoms and inability to feed adequately). Provide Parent information sheet
Provide advice on the expected course of illness and when to return (worsening symptoms and inability to feed adequately)

Provide parent information sheet
Provide advice on the expected course of illness

Provide parent information sheet

Investigations

As bronchiolitis is a clinical diagnosis and treatment is supportive, investigations are not routinely required.

Chest X-ray

Not routinely indicated in infants presenting with typical bronchiolitis and may lead to unnecessary treatment with antibiotics with subsequent risk of adverse events.

Bloods (including FBE, Blood cultures)

Have no role in management (baseline electrolytes (UEC) should be checked if commencing IV fluids).

Flocked nasopharyngeal Swab (NPS)

  • A NPS does not affect length of stay or management.
  • Well patients who are discharged from ED do NOT need a swab unless pertussis is suspected.
  • Consider NPS in admitted patients who are clinically unwell (e.g. requiring respiratory escalation/support) or with possible influenza or pertussis (to aid treatment decision).

Urine microscopy and culture

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.

Management

  • Bronchiolitis is a viral condition – antibiotics are not indicated
  • Management consists of supportive care only (oxygen and fluids)
  • Most patients can be managed at home.

Respiratory support

  • Oxygen therapy should be instituted when oxygen saturations are persistently less than 92%. 
  • Oxygen therapy should not be instituted or escalated for work of breathing alone.
  • It is appreciated that infants with bronchiolitis will have brief episodes of mild / moderate desaturation to levels less than 92%. These brief desaturations are not a reason to commence oxygen therapy.
  • Oxygen therapy should be considered a medical prescription. Medical staff should be notified when oxygen therapy is initiated or escalated.
  • Oxygen should be weaned and 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 saturations less than 92%) and moderate to severe recessions. 
    • Use of HFNC in infants without hypoxia should be limited to the randomised control trial (RCT) setting only.

Monitoring

  • Observations as per local guidelines and Early Warning Tools (EWT’s).
  • Continuous oximetry should not be routinely used to dictate medical management unless the disease is severe. See Table 2.

Hydration/nutrition

  • Oral feeds can be continued if the child is able to take greater than 50% of usual feeds without significantly increased work of breathing. Feeding 2-3 hourly with decreased volumes may be helpful. 
  • When non-oral hydration is required either intravenous (IV) or nasogastric (NG) hydration are appropriate. 
    • In children with moderate illness there is no evidence to suggest that the use of the intravenous route has any advantage over the nasogastric route.
  • If child develops worsening respiratory distress and cannot tolerate oral / NG fluids, then commence intravenous fluids and give nil by mouth.
  • If IV fluid is used it should be isotonic (0.9% Sodium Chloride with glucose or similar; glucose concentration will depend on the age of the infant).
  • The ideal volume of IV or NG fluids required to maintain normal hydration remains unknown; between 60 and 100% of maintenance fluid is an appropriate volume to initiate. Clinicians should be aware of the potential risk of ‘Syndrome of Inappropriate Antidiuretic Hormone Secretion’ (SIADH) / fluid retention. 
  • Check electrolytes prior to commencing IV fluids and then at least daily according to the results and clinical situation. 

Medication

  • Beta 2 agonists – should not be administered to infant’s ≤ 12 months of age presenting with bronchiolitis, including infants with a personal or family history of atopy.
  • Corticosteroids – Do not administer systemic or local glucocorticoids (nebulised, oral, IM or IV).
  • Adrenaline – Do not administer adrenaline (nebulised, IM or IV) except in the peri-arrest or arrest situation.
  • Hypertonic Saline – Do not administer nebulised hypertonic saline.
  • Antibiotics – (including azithromycin) Are not indicated.
  • 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 the time of feeding.

Chest physiotherapy

  • Is not indicated.

Ongoing management

Paediatric Critical Care (PCC) Referral 

  • Children require review by PCC doctor / team if: 
    • Developing features of severe respiratory distress. 
    • Frequent or prolonged apnoeic episodes with oxygen desaturation (SpO2 less than 90%). 
    • Requiring greater than 50% oxygen to maintain oxygen saturations greater than 92%. 
    • Showing fatigue, poor respiratory effort, maximal accessory muscle use / exhaustion or altered conscious state. 
    • Developing circulatory compromise. 
    • EWT scores trigger an escalation (refer to EDOES / CEWT charts).
  • Blood gas measurements may be taken at this stage depending on the clinical circumstance; however a capillary blood gas measurement is not a criterion for either PCC review or admission. PCC admission can only be decided by clinical examination by an experienced clinician. 
  • The decision to admit a patient to PCC needs to be discussed with the patient’s consultant or the on call consultant if the former is unavailable. 

Discharge planning

  • Infants can be discharged when oxygen saturations are greater than or equal to 92% in air for at least 4 hours and feeding is adequate. In very young infants it is advisable to have a period of observation in air whilst the infant is asleep prior to discharge.
  • Consider initiating Criteria Led Discharge if infant likely to go home in the next 24 hours.
  • Infants younger than 8 weeks of age are at an increased risk of representation and may influence discharge decision making in the ED.
  • Discharge on home oxygen can be considered after a period of observation in selected infants, if appropriate community short-term oxygen therapy is available.
  • Most children with bronchiolitis do not require outpatient follow up after discharge.

Education (parent/caregiver)

  • A bronchiolitis parent information sheet should be provided
  • Parents should be educated about the illness, the expected prognosis and when and where to seek further medical care
  • Parents should be informed that their child may continue to have some symptoms of bronchiolitis (mainly cough) for up to 4 weeks from diagnosis.

Safety initiatives

  • Use simple infection control practices such as hand washing.

Acknowledgement

This guideline has been adapted with permission from the 2016 Australasian Bronchiolitis Guideline  developed by the Paediatric Research in Emergency Departments International Collaborative (PREDICT).

Bibliography

  1. Fitzgerald D, Kilham H (2004) Bronchiolitis: assessment and evidence ‐ based management. Medical Journal of Australia, 180 (8), p399‐404.
  2. Oakley E, Babl FE, Acworth J, Borland M, Kreiser D, Neutze J, Theophilos T, Donath S, South M, Davidson A. (2012) Nasogastric hydration versus intravenous hydration for infants with bronchiolitis: a randomised trial. 
  3. NSW Department of Health (2012) Infants and Children: Acute Management of Bronchiolitis, Clinical Practice Guidelines, 2nd edition
  4. Scottish Intercollegiate Guidelines Network (2006) Bronchiolitis in children, a national clinical guideline.
  5. The Australasian Bronchiolitis Guideline (Dec 2016) Paediatric Research in Emergency Departments International Collaborative (PREDICT) NHMRC grant GNT 1058560  

Endorsed by:  Director, Medical Services  Date: Mar 2020


 Review date:  Mar 2022


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