Bronchiolitis (< 2 years)

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Bronchiolitis (< 2 years)

Meets discharge criteria?

Meets ICU level criteria?

Factors increasing the likelihood of asthma

  • > 12 months old
  • Active wheezing
  • History of atopy
  • History of recurrent wheezing
  • Strong family history of asthma or atopy

1 or more sign of poor hydration:

  • No oral intake
  • Minimal urine output
  • Clinical signs of severe dehydration
  • Severe tachypnea

Discharge and follow up within 24 hours

Inhaled bronchodilator (albuterol) trial

  • No evidence that a bronchodilator trial is useful in bronchiolitis

Stage #3: Suction & WARM Score every 2 hours

Stage #4: Suction & WARM Score every 5 hours

Meets discharge criteria?

W.A.R.M Score


0 points

1 point

2 points



End expiratory

Entire expiratory / any inspiratory

Air Exchange (assess all 4 chest areas: left/right front and left/right back)


One area decreased

More than one area decreased

Respiratory Rate

  • ≤ 2 mo

≤ 60

> 60

  • 2 - 12 mo

≤ 50

> 50

  • 1 - 2 years

≤ 40

> 40

Muscle Use/Retractions


Subcostal or intercostal

2 of the following: subcostal, intercostal, substernal OR nasal flaring, trachial tugging or abdominal breathing

During stage 3 & 4:

  • Discontinue pulse oximitry if not on supplemental O2
  • Change to oral feeds if no longer requiring IVF
  • Blub suctioning done by caregiver
  • Begin discharge education

Bronchiolitis and reactive airway disease / asthma are clinical diagnoses that should be differentiated prior to the decision to start therapy.

Symptoms of bronchiolitis = Viral symptoms AND:

  • Persistent cough
  • Feeding difficulty
  • Shallow respirations
  • Wheezing
  • Increased work of breathing
  • Fever

Consider pediatric or pulmonary consult

Stage #2: Suction & WARM Score every 1 hour



Inclusion Criteria
  • Clinical symptoms consistent with bronchiolitis
Exclusion Criteria
  • Toxic appearance
  • Chronic lung disease
  • History of airway anatomical or functional abnormality
  • Complex cardiac disease
  • Complex neurologic disease, hypotonia or neuromuscular disorder
  • Immunodeficiency


NS Bolus
NS infusion

Persistent O2 saturation < 90% awake OR 88% asleep?

Begin supplemental O2 at 1/2 L and titrate as needed

30 min obs

Suction and repeat WARM score


If any signs of clinical deterioration:

  • No clinical response despite optimal therapy
  • Altered mental status
  • Drowsiness/Confusion
  • Greater than 2 hours in stage #2
  • New oxygen requirement
  • Then: Physician reevaluation, consider rapid response team (RRT) or code team depending on patient status

Systemic Glucocorticoids

  • No evidence that steroids improves the treatment of bronchiolitis

Chest X-rays

  • No evidence that x-rays improve the treatment of bronchiolitis.

High Flow Nasal Cannula

  • May be useful for patients with severe symptoms of bronchiolitis.


  • Patients at high risk for apnea should be admitted to an ICU.


  • Not routinely indicated for bronchiolitis patients.

Consider for ICU admission

  • History of apnea
  • Altered mental status
  • Eminent or current respiratory failure or sepsis
  • Severe respiratory distress
  • Hypoxia despite FiO2 > 50%
  • Positive pressure ventilation

Complete WARM Score, nasal suctioning (upper pharynx)

Respiratory isolation, deep nasal suctioning (lower pharynx), continuous pulse oximetry ONLY when on supplemental O2 or acutely ill

PO challenge if tolerable level of respiratory distress

Consider high flow nasal cannula, off pathway

Admit to ICU

Admit to Floor

Discharge criteria

ED/Clinic specific

  • WARM Score < 3 for at least one hour
  • May consider admission if corrected gestational age < 48 weeks
  • No signs or history of apnea

Inpatient specific

  • WARM Score < 3 for at least 12 hours
  • No suctioning needs for at least 4 hours
  • Off oxygen therapy for at least 12 hours
  • No history of apnea in the previous 48 hours

Any environment

  • Respiratory rate < 70
  • Reassuring vital signs
  • No O2 requirement to maintain SpO2 > 90% awake OR 88% asleep
  • Tolerating PO
  • Well-appearing
  • No social/family concerns
  • Reliable follow up in 24 hours
  • Parents comfortable and understand discharge plan
  • Provider comfortable with outpatient therapy

Racemic Epinephrine

  • No evidence that epinephrine improves the treatment of bronchiolitis

Nebulized Hypertonic Saline

  • No evidence that hypertonic saline improves the treatment of bronchiolitis in the emergency setting, but may be used in the inpatient setting.

Leukotriene-receptor antagonists (i.e Montelukast)

  • No conclusive evidence of benefit in bronchiolitis

Chest Physiotherapy (CPT)

  • No evidence that CPT improves the treatment of bronchiolitis.


  • No evidence for improvement in the routine treatment of bronchiolitis.

Virologic studies

  • Not routinely indicated for bronchiolitis patients.

Discharge and follow up within 24 hours

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