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.
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:
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
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.
There is a prodrome of rhinorrhoea or nasal obstruction for several days followed by a cough and increasing respiratory distress.
There may be apnoeic episodes, particularly in neonates, young infants, and ex-preterm infants.
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 no improve
Consider ICU review/admission or transfer if
· Severity does not improve
· Persistent desaturations
· Significant or recurrent apnoeas associated with desaturations
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
In most infants presenting to hospital and/or hospitalised with bronchiolitis, no investigations are required
This is not routinely indicated and may lead to unnecessary treatment with antibiotics with subsequent risk of adverse events
Bloods (including FBE, Blood cultures)
Have no role in management
Nasopharyngeal Aspirate (NPA)
Has no role in management of individual patients
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
Asthma (greater than 12 months old)
Bronchial foreign body
Children with a fever > 39°C should have a careful evaluation to exclude other diagnoses such as bacterial infections.
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.
Oxygen therapy should be instituted when oxygen saturations are persistently less than 92%
It is appreciated that infants with bronchiolitis will have brief episodes of mild/moderate desaturations to levels less than 92%. These brief desaturations are not a reason to commence therapy
Oxygen should be 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. Its use in infants without hypoxia should be limited to the randomised control trial (RCT) setting only
Observations as per local hospital guidelines and Early Warning Tools (EWTs)
Continuous oximetry should not be routinely used to dictate medical management unless the disease is severe
When non-oral hydration is required either intravenous (IV) or nasogastric (NG) hydration are appropriate
If IV fluid is used it should be isotonic (0.9% Sodium Chloride with Glucose or similar)
The ideal volume of IV or NG fluids required to maintain normal hydration remains unknown; between 60% to 100% of maintenance fluid is an appropriate volume to initiate
Beta 2 agonists – Do not administer beta 2 agonists (including those older infants with a personal or family history of atopy)
Corticosteroids – Do not administer systematic or local glucocorticoids (nebulised, oral, intramuscular (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 in bronchiolitis
Antivirals – Are not indicated
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
Is not indicated
HFNC or Nasal CPAP therapy may be considered in the appropriate ward setting
Discharge planning and community-based management
Infants can be discharged when oxygen saturations are greater than or equal to 92% and feeding is adequate
Infants younger than 8 weeks of age are at an increased risk of representation
Discharge on home oxygen can be considered after a period of observation in selected infants as per local policies, if appropriate community short term oxygen therapy is available
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
Use simple infection control practices such as hand washing
Cohorting of infants (based on virological testing) has not been shown to improve outcomes
Fitzgerald D, Kilham H (2004) Bronchiolitis: assessment and evidence ‐ based management. Medical Journal of Australia, 180 (8), p399‐404.
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. Published online 21/12/2012. Accessed at: http://dx.doi.org/10.1016/S2213‐2600(12)70053‐X
NSW Department of Health (2012) Infants and Children: Acute Management of Bronchiolitis, Clinical Practice Guidelines, 2nd edition. Accessed at www.health.nsw.gov.au.
Scottish Intercollegiate Guidelines Network (2006) Bronchiolitis in children, a national clinical guideline.