0 points | 1 point | 2 points | 3 points | |
RR | ||||
< 2 mo | < 60 | 61-69 | > 70 | |
2-12 mo | < 50 | 51-59 | > 60 | |
12-24 mo | < 40 | 41-44 | > 45 | |
Retractions | None | Subcostal or intercostal | 2 of the following: subcostal, intercostal, substernal OR nasal flaring (infant) | 3 of the following: subcostal, intercostal, substernal, suprasternal, supraclavicular OR nasal flaring/head bobbing (infant) |
Dyspnea | Normal feeding, vocalizations and activity | 1 of the following: difficulty feeding, decreased vocalization, agitation | 2 of the following: difficulty feeding, decreased vocalization, agitation | Stops feeding, no vocalization, drowsy and confused |
Auscultation | Normal breathing, no wheezing | End-expiratory wheezes only | Expiratory wheeze only | Inspiratory and expiratory wheeze AND/OR diminished breath sounds |
- Age < 2 years
- Upper and lower respiratory symptoms (increased WOB, cough, difficulty feeding, tachypnea, wheeze, fever)
- Cardiac disease, chronic lung disease, neuromuscular disease, abnormal airway anatomy
Respiratory Score?
RS 5-8:
- Score, suction, score Q2 hours at minimum (before feeds, if distressed)
- No continuous pulse ox unless on supplemental O2
- Consider one-time Albuterol trial
RS 1-4:
- Score, suction, score Q4 hours at minimum (before feeds, if distressed)
- If on IV fluid, consider DC and start PO feeds
NOT ROUTINELY RECOMMENDED:
- Racemic Epi
- Hypertonic saline
- Corticosteroids
- Chest PT
- Albuterol
- Antibiotics
- CXR
Criteria for initiation of HHFNC (heated high-flow nasal cannula):
- Persistently increased work of breathing despite frequent suctioning and repositioning
- Persistent hypoxemia SpO2 <90% despite maximal support on conventional nasal cannula (2LPM if <2yo, 4LPM if >2yo)
See HHFNC Initiation Pathway.
References:
1) John Muir Medical Center Bronchiolitis Clinical Practice Guideline. Internal document.
2) Seattle Children’s Bronchiolitis Pathway v8.0: http://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdf.
3) Clinical Practice Guidelein: The Diagnosis, Management, and Prevention of Bronchiolitis. American Academy of Pediatrics, 2014. http://pediatrics.aappublications.org/content/pediatrics/early/2014/10/21/peds.2014-2742.full.pdf.
'At risk for asthma' if:
- > 12 months old with wheeze and history of wheeze/atopy
- Previous wheeze with treatment with bronchodilators
- History preterm birth
- Strong family history of atopy or asthma
Discharge criteria:
- RS < 5 for 12 hours
- No suction needed for 4 hours
- No supplemental oxygen for 12 hours (preferably during period of sleep)
- No apnea for 48 hours
- Parent teaching completed
- Follow up established
Admit to ICU:
- Apnea with bradycardia/cyanosis
- Lethargy
- Poor perfusion
- Respiratory failure
In Emergency Department
- Viral isolation
- Respiratory score (score, suction, repeat score)
- Supplemental O2 to keep O2 sats > 90% (88% while asleep). Start at 0.5L.
- RS Q1 hour and PRN
- IV fluid if needed (poor UOP, poor oral intake, RR > 60)
- Consider one-time Albuterol use (if RS 9-12 after suction or at risk for asthma)
- CXR not routinely indicated
Admit to Inpatient floor:
- Definitely admit if RS 9-12
- Consider admission if RS 5-8 and other risk factors
- Hypoxemia (< 90% while awake, < 88% while asleep)
- Apnea
- Dehydration
RS 9-12:
- Score, suction, score Q1 hour
- Continuous pulse ox
- Consider IV fluid
- Consider one-time Albuterol if not previously trialed