Guidelines for the Management of Bronchiolitis in the Emergency Department at The Children’s Hospital
Definition: Previously well child with no history of reactive airways disease, less than two years of age, with acute, often febrile, lower respiratory tract infection, typified by tachypne retractions or grunting and diffuse wheezing or crackles. Diagnosis is clinical, and viral etiology is not necessary to confirm the diagnosis.
Differential Dx: Foreign body, bacterial pneumonia, airway anomaly, pertussis, reactive airways disease, congestive heart failure (myocarditis or congenital heart disease).
Management and Evaluation
I. Ancillary studies
A. Oximetry. Yes!
• Excellent for documentation.
• Difficult for even experienced physicians to accurately predict the oxygen saturation of infants and children.
• Oxygen saturation may be the single best predictor of severe disease.
B. Chest X-ray usually not necessary. Consider chest X-ray if:
• temperature is >39.5° C;
• history of choking episode consistent with possible foreign body aspiration;
• markedly and consistently asymmetric chest exam;
• illness not following the expected course of resolution over five to seven days;
• concern for cardiac abnormality.
Note: It is not necessary to obtain a chest X-ray for every hospitalized patient or every patient with an oxygen requirement, persistent wheezing, or crackles.
C. Nasal wash usually NOT necessary:
• Overwhelming majority of cases are caused by respiratory syncytial virus (RSV).
• Nasal washes are not necessary for cohorting purposes.
• Nasal washes are not necessary for all hospitalized patients.
Consider nasal wash if:
• patient has clinical symptoms suggestive of pertussis;
• patient is less than 3 months of age and chlamydia is suspected by history or clinically;
• patient has a history of prematurity, bronchopul- monary dysplasia (BPD), cardiac disease, immunosupression, or other chronic lung disease, and ribavirin therapy would be considered;
• impending respiratory failure;
• hospitalized infants less than 4 to 6 weeks of age for whom a sepsis workup is being considered and may be omitted if documentation of RSV would help make the caretakers more comfortable that this is the source for the fever;
• infants with apnea. RSV is an etiology for apnea and this diagnosis alleviates the need for pursuing an aggressive apnea workup.
Additional comments:
Diagnosis of bronchiolitis may be made clinically, and complete blood counts are not routinely indicated, nor are they helpful.
An infant with bronchiolitis does not fall into the category of fever without a source. Babies with fever without a source, under 4 to 6 weeks of age, will most likely be managed with a full sepsis workup. However, if the diagnosis of bronchiolitis has been made, the full sepsis workup is not necessarily indicated.
II. Treatment. Guidelines for treatment of bronchiolitis include:
A. Nebulized albuterol
A trial of albuterol by nebulization is indicated for the patient with bronchiolitis who is showing any signs of associated respiratory distress. Approximately 30% may improve, and 30% may worsen.
An adequate trial consists of one to two nebulizer treatments of 0.5 ml of albuterol. This dosage may be used for infants of any age weight as the younger infants actually receive less of the medication being delivered by the nebulizer.
An albuturol nebulizer treatment is not necessary for every baby with bronchiolitis. A baby who is self-hydrating, alert, interacting without hypoxia, and without significant associated respiratory distress may be treated symptomatically.
Patients with respiratory distress to whom an albuterol nebulizer treatment is given do not need to have continued treatments unless they show a clear and documented response and decrease in their level of distress following the treatment. If the patient does not respond to a trial of nebulized albuterol, there is no benefit in continuing repeat treatments.
Arrange for a home nebulizer for patients who require and respond to treatments and meet discharge criteria (listed on next page).
B. Albuterol syrup
Not an effective therapy. May increase side effects, such as tachycardia, without benefit to the patient.
If an ill patient responds to nebulized albuterol, arrange for home nebulizer therapy.
C. Intravenous fluids
Only indicated for clinically dehydrated patients who are unable to maintain hydration even after treatments, deep nasal suctioning, and/or oxygen therapy (if indicated).
Intravenous access is indicated for patients with severe distress apnea.
Intravenous access is not necessary for all hospitalized patients.
D. Oxygen
In Denver’s altitude, the oxygen requirement has been defined, based on experience, as a room air saturation consistently less than 88%, following nebulizer trial and deep nasal suctioning.
E. Deep nasal suctioning
This is clinically very helpful in many outpatient and hospitalized cases.
F. Steroids
These are of no benefit in the routine treatment of infants with bronchiolitis.
G. Antibiotic therapy
This is not routinely indicated unless there is documentation of a concurrent bacterial process.
III. Indications for hospitalization after treatment and observation:
A. Oxygen requirement as defined above. (Home oxygen is currently being evaluated.)
B. Respiratory distress, defined as severe retractions or respiratory rate consistently in the 70s or higher
C. Altered level of consciousness/poorly responsive
D. Inability to self-hydrate
E. Apnea
F. Consider hospitalization for the high-risk patient:
• history of prematurity, BPD, cardiac disease;
• very young (less than 4 weeks of age);
• patient with borderline saturation who lives at high altitude;
• patient with poor social situation.
IV. Patients with bronchiolitis may be managed as an outpatient if:
1. They are feeding and are well-hydrated.
2. They are alert.
3. They are not significantly distressed.
4. Room air saturation greater than 88%.
Note: Encourage the use of home nebulizers for patients who respond to their trial of albuterol nebulizer treatments in the ED.
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