Bronchiolitis

Key considerations: Respiratory failure requiring escalation, Apnea (especially <2 months or premature infants), Myocarditis mimicking bronchiolitis

Cannot miss

history: Duration of URI prodrome; Cough character and progression; Feeding: amount and frequency; Wet diapers in last 24 hours; Gestational age at birth; Prior wheezing episodes; Apneic episodes or color changes; Household exposures, daycare, siblings; exam: Respiratory rate and effort; SpO2 on room air; Nasal flaring, grunting, retractions; Auscultation: wheezes, crackles (often both); Hydration status; Mental status: alert and interactive?; Assess work of feeding — can they coordinate suck-swallow-breathe?; labs: RSV/viral panel if it will change management (cohorting, admission decisions); CBC and CRP NOT routinely recommended; Blood gas only if impending respiratory failure; imaging: CXR NOT routinely recommended (AAP 2014); CXR increases unnecessary antibiotic use (incidental atelectasis read as infiltrate); bedside: Continuous SpO2 monitoring; Trial of nasal suctioning to assess improvement

immediate: Nasal suctioning (bulb suction or wall suction); Supplemental O2 to maintain SpO2 ≥90% (AAP 2014 guideline — NOT 92-94%); Assess hydration and feeding ability; general: Bronchiolitis is primarily supportive care; The main interventions that matter: suctioning, O2, and hydration; Most treatments (albuterol, steroids, antibiotics) do NOT help; specific: diagnosis: Mild bronchiolitis; steps: Nasal saline drops and suctioning before feeds; Small, frequent feeds; Educate caregivers on nasal suctioning at home; Follow-up in 24-48 hours; Return if difficulty breathing, poor feeding, apnea; diagnosis: Moderate bronchiolitis; steps: Nasal suctioning as needed; Supplemental O2 if SpO2 <90%; High-flow nasal cannula (HFNC) if increasing O2 requirement or persistent work of breathing; IV or NG fluids if unable to feed adequately; Admission for monitoring; diagnosis: Severe bronchiolitis; steps: HFNC: start 2L/kg/min (max 8-10L/min in infants); If failing HFNC: CPAP 5-7 cmH2O; If failing CPAP: prepare for intubation; NG feeds if tolerating or IV fluids if not; PICU admission

admit: SpO2 <90% on room air; Apneic episodes; Inadequate oral intake (<50% normal); Age <2 months; Prematurity with respiratory distress; Moderate-severe work of breathing not improving; Need for supplemental O2 or HFNC; discharge: Mild respiratory distress with adequate feeding; SpO2 ≥90% on room air consistently; Adequate oral intake demonstrated in ED; Reliable caregivers with return precautions; Follow-up arranged within 24-48 hours; consults: PICU for respiratory failure or escalating support; Pulmonology if underlying lung disease

Albuterol does NOT help bronchiolitis — AAP 2014 recommends AGAINST routine use. Save it for children with prior wheezing history
Steroids do NOT help bronchiolitis — unlike croup and asthma, steroids have no benefit in bronchiolitis
AAP target SpO2 is ≥90% (not 92-94%) — overtreating O2 leads to unnecessary admissions. Brief desaturations during sleep are common and expected
Peak illness severity is days 3-5 after symptom onset — discharge counseling should include that symptoms may worsen before improving
Hypertonic saline (3%) nebulization may shorten length of stay for admitted patients but is NOT recommended in the ED

AAP Bronchiolitis Clinical Practice Guideline 2014, Cochrane Review on Bronchiolitis Treatment. Last reviewed: 2024-11-01