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Bronchiolitis – Emergency

Bronchiolitis – Emergency management in children

Key points

  • Bronchiolitis is a lower respiratory tract illness in infants (0-12 months) caused by a viral illness that is usually self-limiting within 7-10 days (peaking day two to three).
  • In most cases, no investigations are required, and treatment is supportive.
  • High flow oxygen via nasal cannulae is recommended for infants with bronchiolitis who are hypoxic.
  • Medications such as beta-2-agonists (e.g. salbutamol), corticosteroids, and hypertonic saline are not indicated.
  • Refer to the Pre-school Wheeze Guideline for the management of wheeze in children aged 1-5 years.

Purpose

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.

Introduction

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.

Assessment

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:

  • cough
  • tachypnoea
  • retractions
  • diffuse crackles or wheeze on auscultation

History

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
  • prematurity
  • post-natal exposure to cigarette smoke

Examination

Assessment of severity of acute bronchiolitis
Mild Moderate Severe
Behaviour Normal Some/intermittent irritability Increasing irritability and/or lethargy, fatigue
Respiratory rate Normal – mild tachypnoea Increased Marked increase or decrease
Use of accessory muscles Nil to mild chest wall retraction Moderate chest wall retractions
Tracheal tug
Nasal flaring
Marked chest wall retractions
Marked tracheal tug
Marked nasal flaring
Oxygen saturations in room air SpO2 >92% SpO2 90-92% SpO2 <90%
May not be corrected by O2
Apnoeic episodes None May have brief apnoea May have increasingly frequent or prolonged apnoea
Feeding Normal May have difficulty with feeding or reduced feeding Reluctant or unable to feed

 

  • Consider seeking senior emergency/paediatric advice as per local practice for infant with moderate bronchiolitis.
  • Seek senior emergency/paediatric advice as per local practice for a child with severe bronchiolitis.

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

Differential diagnoses

Whilst bronchiolitis is the most common cause of respiratory distress in infants, less common diagnoses, or dual diagnoses must be considered in all children.

Less common causes of respiratory distress in infants
Respiratory
  • bacterial pneumonia, including pertussis
  • aspiration of milk/formula or foreign body
  • tracheo/bronchomalacia
  • cystic fibrosis
Other
  • congestive cardiac failure
  • sepsis
  • 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

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.

  • ALERT – 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.

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.

  • Seek urgent paediatric critical care advice (onsite or via Retrieval Services Queensland (RSQ)) for infants with any of the following:
    ● significant or recurrent apnoeas
    ● persistent desaturations
    ● severe disease who are failing to improve with initial treatment

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%.

  • Consider seeking senior emergency/paediatric advice as per local practice if unsure of oxygen requirement for a child with bronchiolitis.

Low flow oxygen

Low flow oxygen for infants with bronchiolitis by method of delivery
Nasal prongs Hudson mask
Maximum flow rate of 2L/min Commence at a minimum flow rate of 4L/min to ensure adequate delivery if oxygen requirement is greater than 2L/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.

Monitoring

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.

Hydration/nutrition

  • 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
  • ALERT – Deep suctioning of the nasopharynx is not recommended as may cause oedema and irritation of the upper airway resulting in increased length of illness.
  • 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
  • corticosteroids
  • adrenaline (nebulised, IM, or IV) except in peri-arrest or arrest situation
  • hypertonic saline
  • antibiotics
  • antivirals
  • deep nasal suction
  • chest physiotherapy

Escalation outside of ED

Clinicians can contact the services below to escalate the care of a paediatric patient as per local practices. Transfer is recommended if the child requires care beyond the level of comfort of the treating hospital.

  • Critically unwell or rapidly deteriorating child

Service Reason for contact by clinician Contact
Paediatric critical care For urgent advice/assistance for infants with severe bronchiolitis and any of:

  • significant or recurrent apnoeas
  • persistent desaturations
  • failing to improve with initial treatment.
  • increasing oxygen requirement
  • need for airway management
Onsite or via Retrieval Services Queensland (RSQ).
If no onsite service contact RSQ on 1300 799 127:

  • for access to paediatric critical care telephone advice
  • to coordinate the retrieval of a critically unwell child

RSQ (access via QH intranet)
Notify early of children potentially requiring transfer.

In the event of retrieval, inform your local Paediatric service.

Immediate assistance with airway For onsite help with the management of airway, including intubation and ventilation. The most senior resources available onsite at the time as per local practices.
Options may include:

  • paediatric critical care
  • critical care
  • anaesthetics
  • paediatrics
  • Non-critical child

Reason for contact by clinician Contact
For specialist advice on the management, disposition and follow-up of the following infants:

  • if considering admission
  • with risk factors for severe disease (refer to Assessment section for details)
Onsite/local paediatric service as per local practice.
For assistance with local inter-hospital transfers of non-critical patients. Onsite/local paediatric service as per local practice.
For assistance with inter-hospital transfer of non-critical patients into and out of Queensland Children’s Hospital.

View the QH Inter-hospital transfer request form (QH only).

Children’s Advice and Transport Coordination Hub (CATCH)

(07) 3068 4510 (24-hour service)

For assistance with decision making regarding safe and appropriate inter-hospital transfer of children in Queensland. View the Queensland Paediatric Transport Triage tool – Medical or call CATCH  (07) 3068 4510 (24-hours)
For access to generalist and specialist acute support and advice via videoconferencing, as per locally agreed pathways, in regional, rural and remote areas in Queensland. Telehealth Emergency Management Support Unit (TEMSU)

1800 11 44 14 (24-hour service)

TEMSU (access via QH intranet)

To request aeromedical inter-hospital transfer in Queensland. Retrieval Services Queensland (RSQ)

1300 799 127 (24-hour service)

RSQ (access via QH intranet)

Disposition

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.

Follow-up

  • 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.

Related documents

References

  1. Cunningham et al. Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial, Lancet 2015; 386: 1041–48.
  2. Franklin et al. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018 Mar 22;378(12):1121-1131

Guideline approval

Guideline approval history
Document ID CHQ-GDL-60012 Version no. 1.0 Approval date 19/6/19
Executive sponsor Executive Director Medical Services Effective date 19/6/19
Author/custodian Queensland Emergency Care Children Working Group Review date 19/6/22
Supersedes CHQ-GDL-00701 and CHQ-GDL-00701-1
Applicable to Queensland Health medical and nursing staff
Document source Internal (QHEPS) + External
Authorisation Executive Director Clinical Services QCH
Keywords Bronchiolitis, lower respiratory tract, Paediatric, emergency, guideline, children, 60012
Accreditation references NSQHS Standards (1-8): 1, 8

Disclaimer

This guideline is intended as a guide and provided for information purposes only. View full disclaimer.
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