This document provides clinical guidance for all staff involved in the care and management of an infant (age 0-12 months) presenting to an Emergency Department (ED) in Queensland with symptoms suggestive of bronchiolitis.
This guideline has been developed by senior ED clinicians and Paediatricians across Queensland and endorsed for statewide use by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.
Bronchiolitis is a clinical diagnosis, based on history and examination. It typically begins with an acute upper respiratory tract infection followed by onset of respiratory distress and fever. Illness usually resolves without intervention in 7 – 10 days, with peak severity two to three days post onset. The cough may persist for weeks. Bronchiolitis most commonly occurs in the winter months but can be seen throughout the year.
This guideline is based on the Australasian Bronchiolitis Guideline which has been developed by the Paediatric Research in Emergency Department International Collaborative (PREDICT) research network to provide an evidence-based clinical framework for the management of infants (0-12 months) with bronchiolitis. Infants older than 12 months can have similar disease processes but by convention, it is not called bronchiolitis.
A diagnosis of bronchiolitis requires a history of an upper respiratory tract infection followed by onset of respiratory distress with fever and at least one of the following:
History should include specific information on:
| Mild | Moderate | Severe | |
|---|---|---|---|
| Behaviour | Normal | Some/intermittent irritability | Increasing irritability and/or lethargy, fatigue |
| Respiratory rate | Normal – mild tachypnoea | Increased | Marked increase or decrease |
| Use of accessory muscles | Nil to mild chest wall retraction |
Moderate chest wall retractions Tracheal tug Nasal flaring |
Marked chest wall retractions Marked tracheal tug Marked nasal flaring |
| Oxygen saturations in room air | SpO2 >92% | SpO2 90-92% | SpO2 <90% |
| 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 |
Consider seeking senior emergency/paediatric advice as per local practice for infant with moderate bronchiolitis.
Seek senior emergency/paediatric advice as per local practice for a child with severe bronchiolitis.
Whilst bronchiolitis is the most common cause of respiratory distress in infants, less common diagnoses, or dual diagnoses must be considered in all children.
| Less common causes of respiratory distress in infants | |
|---|---|
| Respiratory |
|
| Other |
|
Consider cardiac disease presenting with congestive cardiac failure in infants with no precipitating viral illness, hypoxia out of proportion to severity of respiratory disease and/or presence of abnormal or unequal peripheral pulses, cardiac murmur or hepatomegaly.
Congenital cardiac diseases affect approximately 1% of infants with up to one third diagnosed at over 12 weeks of age. Infants with congestive cardiac failure may present with respiratory distress and decreased feeding. Note that decompensation may be triggered by an intercurrent viral illness.
Investigations are not routinely recommended in the absence of any diagnostic uncertainty. While respiratory viral PCR has no role in the management of individual patients, viral PCR testing may be required for infection control. Cohorting of patients based on PCR results should be in conjunction with current infection control practices at you site1. Chest X-rays (CXR) may lead to unnecessary antibiotic treatment due to misinterpretation of changes expected in bronchiolitis.
Children aged less than three months with respiratory symptoms and fever ≥38⁰C may have a concurrent bacterial infection. Refer to Fever Guideline for guidance on investigations and management.
Refer to flowchart [PDF 589.69 KB] for a summary of the emergency management for a child with bronchiolitis.
The primary treatment of bronchiolitis is supportive. This involves ensuring appropriate oxygenation and maintenance of hydration.
Seek urgent paediatric critical care advice (onsite or via Retrieval Services Queensland (RSQ)) for infants with any of the following:
Administer oxygen for children with saturations persistently below the target oxygen saturations (SpO2) as per local guidelines. Oxygen therapy is not recommended for infants with only brief episodes of mild/moderate desaturation.
There is no definitive evidence to determine the optimal target saturations. The Australasian Bronchiolitis Guideline recommends target oxygen saturation (SpO2) of ≥92% but lower saturations may be tolerated depending on institutional practice. A study on infants aged less than one year with bronchiolitis found that a target SpO2 >90% was as safe and as clinically effective as 94%.2 Therefore targeting saturations > 90% is reasonable.
Consider seeking senior emergency/paediatric advice as per local practice if unsure of oxygen requirement for a child with bronchiolitis.
| Nasal prongs | Hudson mask |
|---|---|
| Maximum flow rate of 2 L/min | Commence at a minimum flow rate of 4 L/min to ensure adequate delivery if oxygen requirement is greater than 2 L/min |
Consider HFNC therapy in infants with bronchiolitis who are hypoxic (SpO2 <90%) with moderate to severe work of breathing if a trial of NPO2 is ineffective. HFNC therapy is not recommend for infants without hypoxia.
The positive airway pressure provided improves oxygenation and relieves work of breathing. HFNC therapy applied early in the hospital admission in infants with bronchiolitis has been shown to be beneficial.2 It may help avoid intubation but can also provide pre-oxygenation whilst preparation for inevitable intubation is underway.
Follow local policies and procedures for nursing ratios and ward location. View CHQ Nasal High Flow Therapy Guideline.
Nasal CPAP therapy for infants with bronchiolitis may also be considered but is rarely used.
Observations should occur in line with local hospital guidelines and Early Warning Tools (EWTs). Continuous pulse oximetry is not routinely recommended for non-hypoxic infants or stable infants receiving oxygen.
Deep suctioning of the nasopharynx is not recommended as may cause oedema and irritation of the upper airway resulting in increased length of illness.
| Includes children with the following (as a guide): |
|---|
|
| Reason for contact | Who to contact |
|---|---|
| For immediate onsite assistance including airway management | The most senior resources available onsite at the time as per local practices. Options may include:
|
| Paediatric critical care advice and assistance | Onsite or via Retrieval Services Queensland (RSQ). If no onsite paediatric critical care service contact RSQ on 1300 799 127:
RSQ (access via QH intranet) Notify early of child potentially requiring transfer. Consider early involvement of local paediatric/critical care service. In the event of retrieval, inform your local paediatric service. |
| May include child with: |
|---|
|
| Reason for contact | Who to contact |
|---|---|
| Advice (including management, disposition or follow-up) | Follow local practices. Options:
|
| Referral | First point of call is the onsite/local paediatric service |
| Do I need a critical transfer? |
|
| Request a non-critical inter-hospital transfer |
|
| Non-critical transfer forms |
|
There is insufficient evidence to recommend absolute discharge criteria for infants attending the ED with bronchiolitis. Consider discharge for the following infants:
Admission for a further period of observation may be considered for infants who meet the above criteria but are early in their illness and have risk factors for more severe disease (refer to Assessment).
On discharge, parent/caregiver should be provided with a Bronchiolitis factsheet and advised to seek medical help prior to next appointment if worsening symptoms and inability to feed adequately.
The decision to admit should be supported by clinical assessment, social and geographical factors and phase of illness.
Admission is required for infants who present with severe disease and likely for those with moderate disease.
Despite meeting the clinical discharge criteria, admission may be considered for infants:
Consider admission to SSU for infants who are responding to treatment but require a brief period of observation or trial of feeding prior to discharge.
Admission to an inpatient paediatric service is recommended for children who are failing to improve (persistent/recurring or worsening symptoms) after 12 hours of care.