Inpatient Bronchiolitis Management (< 2 years)



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Inpatient Bronchiolitis Management (< 2 years)

Is bronchiolitis the primary dx? (v.s. asthma)

SEVERE

Respiratory Score 9-12

  • Score q1h
  • Suction q1h
  • Continuous pulse ox
  • Consider NPO with IVF or NG feeds if RR>60

Respiratory Score 1 - 4

Consider trial of nebulized albuterol and repeat score in 30 minutes

Consider trial of nebulized saline (if not previously tried) and repeat score in 30 minutes

Respiratory Score 5 - 8

Respiratory Score 9 - 12

Tests & Treatments NOT ROUTINELY RECOMMENDED

Tests

  • Viral testing
  • Chest X-ray
  • Labs, like CBC, electrolytes, blood gas

Treatments

  • Nebulized normal saline
  • Albuterol
  • Racemic epinephrine
  • Corticosteroids
  • Antibiotics
  • Anticholinergic medications (e.g. ipratropium)
  • Hypertonic saline

Did R.S. improve >2 points?

Repeat Respiratory Score with frequency according to severity.

Refer to discharge criteria

MILD

Respiratory Score 1-4

  • Score q4h
  • Suction q4h prn
  • Pulse ox check q4h (unless on supplemental O2)

Calculate Respiratory Score

Inclusion Criteria
  • Clinical signs consistent with bronchiolitis: tachypnea, retractions, wheezing, crackles
  • Clinical symptoms consistent with bronchiolitis: cough, nasal congestion, difficulty breathing
  • Age <24 months old
Exclusion Criteria
  • Appearing toxic or critically ill
  • Prior diagnosis of asthma or >2 episodes of wheezing in the last year
  • Immunodeficiency
  • Neuromuscular disease
  • Anatomic airway defects
  • Congenital heart disease AND on medication for CHF, pulmonary hypertension, or cyanotic heart disease
  • Chronic lung disease (BPD, interstitial lung disease)
  • Order nebulized saline prn
  • Continue as above
  • Follow guidance based on score

Weaning Oxygen

  • Attempt to wean supplemental O2 with each Respiratory Score
  • Titrate supplemental O2 to maintain spO2 >90%
  • Once off supplemental O2 for >4h, change to intermittent pulse ox checks

Initial patient assessment

  • Assess spO2 Give supplemental oxygen for spO2 <90% for at least 1 minute. Initiate 0.5L NC for patients <6 months old or 1L NC for >6 months old. Titrate to maintain spO2 >90%.
  • Max 2L NC O2. If higher rate is needed, refer to High Flow Nasal Cannula Pathway.
  • Assess need for PIV/NGT hydration: poor oral intake, poor UOP, RR >60.

  • Continue as above
  • Follow guidance based on score

MODERATE

Respiratory Score 5-8

  • Score q2h
  • Suction q2h prn
  • Pulse ox check q4h (unless on supplemental O2)

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact the Clinical Pathway Oversight Committee at CPOC@montefiore.org.

Disclaimer: Clinical pathways are intended as a resource to guide diagnosis, treatment and management in order to improve quality of care and promote better patient outcomes. They are based on available medical evidence at the time of development; the date on the pathway indicates the most recent update. Pathways are not intended to provide medical advice or consultation regarding the care of any individual patient, and should not replace or supersede a practitioner’s professional opinion or clinical judgment. Because medical knowledge is constantly evolving, and accepting the possibility of error, The Children’s Hospital at Montefiore does not warrant or represent that pathways are complete or accurate. Neither the Hospital nor the individuals involved in the development or publication of the pathways is responsible for results or outcomes related to their use.

Corresponding EPIC Order Set:

  • IP PED Bronchiolitis

Did RS improve >2 points after nebulized albuterol?




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