Emergency Department Bronchiolitis

Care Guideline
At Risk for Severe Disease
 Premature ( <32 weeks)
Inclusion Criteria:  Age < 12 weeks
 Age less than 2 years
 Mild rhinorrhea or nasal congestion for 1-3 days, followed by:
- Persistent cough
- Wheezing with or without rales
- Tachypnea or retractions NOT Indicated:
- Afebrile or T<39C CXR
Exclusion Criteria: RSV/VRP
 Prior wheezing episode, concern for asthma, Asthma, Chronic Lung Disease, Routine Labs (consider only
Anatomical defects of the airways, Hemodynamically significant congenital heart if fever >39C)
disease, Immunodeficiency, Neuromuscular disease, Signs of pneumonia (T >39C with Antibiotics
focal findings on lung exam) Bronchodilators
Steroids
Chest Physiotherapy

Assessment
 Vital Signs with O2 saturation; Respiratory status
Recommendations/
Considerations
Interventions
 The mainstay of Bronchiolitis care is
 Oxygen to keep O2 saturations >/= 92%
supportive with adequate hydration,
 Assure adequate hydration PO or IV
oxygenation and maintaining an
 Frequent Suctioning
open airway by nasal bulb suctioning
PRN.
 High Flow Nasal Cannula (HFNC)
should be considered for patients
presenting with increased respiratory
distress. Refer to protocol for
Suction and Score to Determine
initiation, titration and transfer to ICU
Clinical Severity criteria includes starting at 4-8 LPM
*Refer to HFNC Respiratory Assessment Scoring Tool with Fio2 of 0.4 and titrating
accordingly.
 Cardiorespiratory monitoring during
acute phase for prematurity, chronic
underlying conditions and for infants
< 3 months of age.

Mild Disease Moderate Disease Severe Disease

 No tachypnea  Mild to moderate tachypnea Any of the following:
 No or minimal retractions  Apnea or history of apnea Discharge Criteria
 Mild to moderate retractions
 Clear BS or mild end expiratory  Marked tachypnea (RR >70)  On room air without respiratory
 Diffuse expiratory wheezing
wheezing  Marked retractions, nasal flaring distress
with or without early
 Looks well or grunting  Able to handle secretions (bulb
inspiratory wheeze
 Feeding well and hydrated  May be irritable or ill-  Looks seriously ill or toxic suction only)
 Markedly irritable or decreased  Adequate PO and activity
appearing but not toxic
 Education complete; family able to
 HFNC Respiratory level of consciousness
 O2 sat persistently <90% or demonstrate nasal bulb suctioning,
Assessment Score of > 5
verbalize follow up care, and as
 Continue to evaluate and presence of cyanosis
 HFNC Respiratory Assessment applicable: understand dosing and
suction PRN
purpose of medications, discharge
 Assess hydration Score of >5
medication/equipment in place
 Nasal Suctioning  Parents able to follow-up with PMD
 Pulse Ox within 48 hours or able to return to
 Antipyretic for fever if emergency care if needed
indicated  Notify physician
 Repeat clinical  Provide supplemental oxygen if
assessments over next 1-2 Patient Education
pulse oximetry is <90%  Bronchiolitis – Kids Heath Handout –
hours  Use High Flow Nasal Cannula
 Use High Flow Nasal Parent Version
Cannula  Bulb suction

See page 2
for
Admission
Criteria Page
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Reassess the appropriateness of Care Guidelines as condition changes and 24 hrs after
Approved Evidence Based Medicine
admission. This guideline is a tool to aid clinical decision making. It is not a standard of care.
Committee 10/18/17 © 2017 Children’s Hospital of Orange County
The physician should deviate from the guideline when clinical judgment so indicates.
Emergency Department Bronchiolitis
Care Guideline

Continued
from Page
1

Admission Criteria
 Clinical Indications for Admission to Inpatient Care
 Admission is indicated for 1 or more of the following:
 Hypotension (SBP less than 70mmHG)
 Respiratory fatigue( elevated pCO2)
 Hypoxemia (SPO2 less than 92% on RA)
 Central cyanosis
 Apnea
 Inpatient admission required because of 1 or more of the following:
 Tachypnea, wheeze, or retractions that are severe or persistent after observation care
treatment
 Inability to maintain oral hydration
 Feeding difficulties
 Lethargy
 Other condition, treatment , or monitoring requiring inpatient admission per physician
discretion

 Observation is appropriate for patient with 1 or more of the following:

 Infants with abnormal respiration indicated by 1 or more of the following:
 Tachypnea
 Retractions
 Wheezing
 Ability to feed or maintain hydration unclear
 Child whose situation includes 1 or more of the following:
 Clinical response to outpatient therapy uncertain
 Outpatient supervision by parents or care givers uncertain
 Other observation care needs per physician discretion

PICU Admission if:

 Multiple episodes of apnea
 HFNC Max: > 6L
 FiO2 > 40%

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 References
Emergency Department Bronchiolitis Care Guideline

American Academy of Pediatrics Section on Emergency Medicine Committee on Quality

Transformation Clinical Algorithm for Bronchiolitis in the Emergency Department
Setting. (2016, June). Retrieved from https://www.aap.org/en-us/about-the-aap/
Committees-Councils-Sections/Section-on-Emergency-Medicine/Documents/SOEM-
AAPSOEMCOQTBronchiolitisGuideline.pdf
Bronchiolitis: Clinical guidelines from the Stanford University Emergency Department. (2015,
May).
Children's Hospital of Orange County. (2014, April). Bronchiolitis Care Guideline Inpatient.
Retrieved from https://www.choc.org/wp/wp-content/uploads/2014/12/
BronchiolitisCareGuideline.pdf
Dayton Children's Hospital. (2013, December). Bronchiolitis Clinical Practice Guidelines.
Retrieved from https://www.childrensdayton.org/sites/default/files/Bronchiolitis-CPG-
2017.pdf
Florin, T. A., Plint, A. C., & Zorc, J. J. (2017). Viral bronchiolitis. The Lancet, 389, 211-224.
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Hough, J. L., Pham, T. M., & Schibler, A. (2014). Physiologic effect of high-flow nasal cannula
in infants with bronchiolitis. Pediatric Critical Care Medicine, 15(5), e214-e219.
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Piedra, P. A., & Stark, A. R. (2015, April). Bronchiolitis in infants and children: Treatment,
outcome, and prevention. Retrieved from UpToDate: https://www.uptodate.com/
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Ralston, S. L., Lieberthal, A. S., Meissner, H. C., Alverson, B. K., Baley, J. E., Gadomski, A.
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Schroeder, A. R., & Mansbach, J. M. (2014). Recent evidence on the management of
bronchiolitis. Current Opinion in Pediatrics, 26(3), 328-333. doi:10.1097/
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Seattle Children's Hospital. (2014, February). Bronchiolitis Clinical Pathway. Retrieved from
http://www.seattlechildrens.org/healthcare-professionals/gateway/pathways/
Silver, A. H., Esteban-Cruciani, N., Azzarone, G., Douglas, L. C., Lee, D. S., Liewehr, S., . . .
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