Bronchiolitis

Initial management

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

Investigations

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)

• There is no role for blood testing in infants presenting to hospital or hospitalised with bronchiolitis. Routine bacteriological testing of blood and urine is not recommended.
• Baseline electrolytes (Urea Electrolytes and Creatinine) should only be checked if commencing IV fluids.

Flocked nasopharyngeal Swab (NPS)

• Well patients who are discharged from ED do NOT need a swab unless pertussis or COVID-19 is suspected.
• An NPS does not affect length of stay or management.
• Consider NPS in admitted patients who are clinically unwell (e.g. requiring respiratory escalation/support) or with possible COVID-19, influenza or pertussis (to aid treatment decision).

Urine microscopy and culture

May be considered to identify urinary tract infection if a temperature >38 degrees Celsius in an infant < two months of age with bronchiolitis.

Management

• Most patients can be managed at home.
• Management consists of supportive care only (oxygen and fluids) in hospital.
• The decision to admit to hospital is made on the basis of the history and physical examination. Investigations are not required to make that decision. The need for admission is based on the above assessment of severity, taking into account the age of the infant, co-morbidity, length of illness and social factors.
• Antibiotics are not indicated.

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 < 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 (HHFNC) can be considered in the presence of hypoxia (oxygen saturations < 92%) and moderate to severe recessions⁷. Use of HFNC in infants without hypoxia is not indicated.

Monitoring

• Observations as per local guidelines and Observation and Response Tool.
• 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 to 3 hourly with decreased volumes may be helpful. 
• When non-oral hydration is required either intravenous (IV) or nasogastric (NG) hydration are appropriate, although NG hydration is preferred in the first instance if able.
  • 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.³
• 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 (Sodium Chloride 0.9% with glucose or similar; glucose concentration will depend on the age of the infant).²
• 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. ⁴
• Check electrolytes prior to commencing IV fluids and then at least daily according to the results and clinical situation. 

Medication²

• 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 (epinephrine) – Do not administer adrenaline (nebulised, IM or IV) except in the peri-arrest or arrest situation.
• Hypertonic sodium chloride – Do not administer nebulised hypertonic saline.
• Antibiotics – (including azithromycin) Are not indicated. ⁵
• Antivirals – Are not indicated. 

Nasal suction²

• 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.²

Ongoing management

•  ⁴Humidified High Flow Nasal Cannula (HHFNC)or Nasal CPAP therapy may be considered in a ward setting that is equipped and skilled nursing staff available.

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 (oxygen saturations 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. 
  • Early warning scores on the Observation and Response Tool trigger an escalation.
• 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. 

Infection Control

Patients with bronchiolitis should be managed with standard, contact and droplet precautions as per hospital infection control policy.

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.
  • Inpatients being discharged home on oxygen must meet the inclusion criteria outlined in the Hospital in the Home policy Home Oxygen Therapy for Children with Acute Bronchiolitis and other Lower Respiratory Tract Infections (internal WA Health only). 
• 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.

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). See reference 2.

References