Bronchiolitis – Emergency management in children

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. Infants older than 12 months can have similar disease processes but by convention, it is not called bronchiolitis.

Assessment

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

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.

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.

Congenital cardiac disease

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 in the absence of any diagnostic uncertainty. While respiratory viral PCR has no role in the management of individual patients, viral PCR testing may be required for infection control. Cohorting of patients based on PCR results should be in conjunction with current infection control practices at you site¹. Chest X-rays (CXR) may lead to unnecessary antibiotic treatment due to misinterpretation of changes expected in bronchiolitis.

Management

Refer to flowchart [PDF 589.69 KB] 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%.² Therefore targeting saturations > 90% is reasonable.

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

Low flow oxygen

High flow nasal cannula oxygen (HFNC) Therapy

Consider HFNC therapy in infants with bronchiolitis who are hypoxic (SpO2 <90%) with moderate to severe work of breathing if a trial of NPO2 is ineffective. HFNC therapy is not recommend for infants without hypoxia.

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.

Follow local policies and procedures for nursing ratios and ward location. View CHQ Nasal High Flow Therapy Guideline.

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
• superficial 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) and is a reason for admission even in the absence of need for respiratory support.
• 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 and advice outside of ED

Non critical child

Inter-hospital transfers

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 to maintain hydration
• 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

Guidelines

• Australasian Bronchiolitis Guideline

Factsheets

• Bronchiolitis