Bronchiolitis Clinical Guidelines



100
75% 100% Zoom 125%


Export to PDF
Contribute Edits
Bronchiolitis Clinical Guidelines

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

Inclusion Criteria
  • Age < 2 years
  • Upper and lower respiratory symptoms (increased WOB, cough, difficulty feeding, tachypnea, wheeze, fever)
Exclusion Criteria
  • 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




100
75% 100% Zoom 125%


Export to PDF