This document provides clinical guidance for all staff involved in the care and management of an infant (age 0-12 months) presenting to an Emergency Department (ED) in Queensland with symptoms suggestive of bronchiolitis.
This guideline has been developed by senior ED clinicians and Paediatricians across Queensland and endorsed for statewide use by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.
Bronchiolitis is a clinical diagnosis, based on history and examination. It typically begins with an acute upper respiratory tract infection followed by onset of respiratory distress and fever. Illness usually resolves without intervention in 7 – 10 days, with peak severity two to three days post onset. The cough may persist for weeks. Bronchiolitis most commonly occurs in the winter months but can be seen throughout the year.
This guideline is based on the Australasian Bronchiolitis Guideline which has been developed by the Paediatric Research in Emergency Department International Collaborative (PREDICT) research network to provide an evidence-based clinical framework for the management of infants (0-12 months) with bronchiolitis.
A diagnosis of bronchiolitis requires a history of an upper respiratory tract infection followed by onset of respiratory distress with fever and at least one of the following:
- diffuse crackles or wheeze on auscultation
History should include specific information on:
- recent respiratory symptoms
- feeding including:
- duration of feeds (feeding more difficult with more severe illness)
- breast feeding
- underlying medical conditions including chronic lung disease, congenital heart disease and chronic neurological conditions
- chromosomal abnormalities including Trisomy 21
- indigenous status
- post-natal exposure to cigarette smoke
||Increasing irritability and/or lethargy, fatigue
||Normal – mild tachypnoea
||Marked increase or decrease
|Use of accessory muscles
||Nil to mild chest wall retraction
||Moderate chest wall retractions
|Marked chest wall retractions
Marked tracheal tug
Marked nasal flaring
|Oxygen saturations in room air
May not be corrected by O2
||May have brief apnoea
||May have increasingly frequent or prolonged apnoea
||May have difficulty with feeding or reduced feeding
||Reluctant or unable to feed
Risk factors for severe disease
- gestational age less than 37 weeks
- chronological age at presentation less than 10 weeks
- chronic lung disease
- congenital heart disease
- chronic neurological conditions
- Indigenous ethnicity
- failure to thrive
- Trisomy 21
- post-natal exposure to cigarette smoke
- breast fed for less than 2 months
Whilst bronchiolitis is the most common cause of respiratory distress in infants, less common diagnoses, or dual diagnoses must be considered in all children.
- bacterial pneumonia, including pertussis
- aspiration of milk/formula or foreign body
- cystic fibrosis
- congestive cardiac failure
- intrathoracic mass
- allergic reaction
Congenital cardiac disease
ALERT – Consider cardiac disease presenting with congestive cardiac failure in infants with no precipitating viral illness, hypoxia out of proportion to severity of respiratory disease and/or presence of abnormal or unequal peripheral pulses, cardiac murmur or hepatomegaly.
Congenital cardiac diseases affect approximately 1% of infants with up to one third diagnosed at over 12 weeks of age. Infants with congestive cardiac failure may present with respiratory distress and decreased feeding. Note that decompensation may be triggered by an intercurrent viral illness.
Investigations are not routinely recommended. Respiratory viral PCR has no role in the management of individual patients (cohorting infants based on virological testing has not been shown to improve outcomes). Chest X-rays (CXR) may lead to unnecessary antibiotic treatment.
Children aged less than three months with respiratory symptoms and fever ≥38⁰C may have a concurrent bacterial infection. Refer to Fever Guideline
for guidance on investigations and management.
Refer to flowchart
for a summary of the emergency management for a child with bronchiolitis.
The primary treatment of bronchiolitis is supportive. This involves ensuring appropriate oxygenation and maintenance of hydration.
Oxygen and respiratory support
Administer oxygen for children with saturations persistently below the target oxygen saturations (SpO2) as per local guidelines. Oxygen therapy is not recommended for infants with only brief episodes of mild/moderate desaturation.
There is no definitive evidence to determine the optimal target saturations. The Australasian Bronchiolitis Guideline recommends target oxygen saturation (SpO2) of ≥92% but lower saturations may be tolerated depending on institutional practice. A study on infants aged less than one year with bronchiolitis found that a target SpO2 >90% was as safe and as clinically effective as 94%.1
Low flow oxygen
|Maximum flow rate of 2 L/min
||Commence at a minimum flow rate of 4 L/min to ensure adequate delivery if oxygen requirement is greater than 2 L/min
High flow nasal cannula oxygen (HFNC) Therapy
Consider HFNC therapy in infants with bronchiolitis who are hypoxic (SpO2 <92%) with moderate to severe work of breathing.
The positive airway pressure provided improves oxygenation and relieves work of breathing. HFNC therapy applied early in the hospital admission in infants with bronchiolitis has been shown to be beneficial.2 It may help avoid intubation but can also provide pre-oxygenation whilst preparation for inevitable intubation is underway.
HFNC therapy is not recommend for infants without hypoxia.
Follow local policies and procedures for nursing ratios and ward location. View CHQ protocols (QH staff only).
Continuous positive airways pressure (CPAP)
Nasal CPAP therapy for infants with bronchiolitis may also be considered but is rarely used.
Observations should occur in line with local hospital guidelines and Early Warning Tools (EWTs). Continuous pulse oximetry is not routinely recommended for non-hypoxic infants or stable infants receiving oxygen.
- small frequent feeds are recommended for infants with mild bronchiolitis
- nasal saline drops may be considered prior to the time of feeding
- suctioning of the nares may assist feeding in infants with moderate distress
- NGT insertion is highly recommended for infants on HFNC. Advantages include:
- gastric decompression
- ability to feed without interrupting HFNC
- avoid potential for worsening of respiratory symptoms during feeding
- NG or IV hydration is recommended for infants with moderate -severe bronchiolitis who are feeding inadequately (less than 50% over 12 hours)
- if using IV route, isotonic IV fluids (0.9% sodium chloride with glucose, or similar) are recommended
- the volume of fluids required to maintain hydration is unclear
Treatments NOT recommended
- beta 2 agonists (e.g. Salbutamol) regardless of a personal/family history of atopy
- adrenaline (nebulised, IM, or IV) except in peri-arrest or arrest situation
- hypertonic saline
- deep nasal suction
- chest physiotherapy
When to consider discharge from ED
There is insufficient evidence to recommend absolute discharge criteria for infants attending the ED with bronchiolitis. Consider discharge for the following infants:
- able to maintain adequate oxygen saturations in room air
- feeding adequately
- parent/caregiver can safely manage the infant at home (consider time of day, parent/carer comprehension and compliance, access to transport and distance to the local hospital)
Admission for a further period of observation may be considered for infants who meet the above criteria but are early in their illness and have risk factors for more severe disease (refer to Assessment).
On discharge, parent/caregiver should be provided with a Bronchiolitis factsheet and advised to seek medical help prior to next appointment if worsening symptoms and inability to feed adequately.
- with GP within two to three days or earlier if symptoms worsen
When to consider admission
The decision to admit should be supported by clinical assessment, social and geographical factors and phase of illness.
Facilities without a Short Stay Unit (SSU)
Admission is required for infants who present with severe disease and likely for those with moderate disease.
Despite meeting the clinical discharge criteria, admission may be considered for infants:
- with risk factors for severe disease
- social issues including those that are geographically isolated from a hospital or have social issues affecting the ability to safely manage the child at home
Facilities with a Short Stay Unit (SSU)
Consider admission to SSU for infants who are responding to treatment but require a brief period of observation or trial of feeding prior to discharge.
When to consider admission to inpatient ward from SSU
Admission to an inpatient paediatric service is recommended for children who are failing to improve (persistent/recurring or worsening symptoms) after 12 hours of care.