Bronchiolitis in Children - Guidance for the management of

Publication: 31/08/2010  --
Last review: 13/02/2020  
Next review: 13/02/2023  
Clinical Guideline
CURRENT 
ID: 1609 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Management of Bronchiolitis in Children

  • Treatment Algorithm
  • Summary
    Bronchiolitis in Children

    Diagnosis
    Bronchiolitis is a clinical diagnosis based upon typical history and examination. This includes breathing difficulties, cough, poor feeding, wheezes and crackles on auscultation. It may present with apnoeas. Bronchiolitis has a viral aetiology, the majority caused by Respiratory Syncytial Virus (RSV), and tends to have a seasonal prevalence- peaking in winter.
    Assess children as mild, moderate or severe according to algorithm (see below).

    Investigations required
    Bronchiolitis is a clinical diagnosis; routine investigations should not be performed.

    Non-Antimicrobial Management
    Treatment is primarily supportive. Supplemental oxygen and fluid support needs to be assessed as part of evaluation.

    Empirical (initial) antimicrobial treatment
    Whilst bacterial super infection is uncommon in bronchiolitis, severe cases should be considered for treatment according to children’s community acquired pneumonia guideline.

    Indications for hospital referral or acute paediatric assessment

    • Poor feeding (<50% normal in preceding 24hrs)
    • Tachypnoea >60 breaths per minute
    • Signs of respiratory distress (nasal flare, tracheal tug, chest recession)
    • Pulse oximetry (when performed) <=94%
    • Children with bronchiolitis not fulfilling above criteria, but presenting within 3 days of displaying symptoms, for whom there is concern that their condition may worsen to fulfil criteria.
    • Children with co-morbidities, those <3/12 age, those born <32/40 gestation, or those children who’s social/geographical situation raises concerns should they deteriorate

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    Background

    Bronchiolitis is an extremely common respiratory infection predominantly affecting children under one year of age, with a peak incidence at an age of 3- 6 months.
    The vast majority of children over three years of age demonstrate serological evidence of previous infection with respiratory syncytial virus (RSV) – the most common cause of bronchiolitis

    The incidence of bronchiolitis shows seasonal variation – peaking in winter.
    Approximately 30% of those infected with RSV express symptoms, and 3% require admission.
    In most infants the disease is self limiting, with symptoms peaking on days 3-5. Hospitalisation is generally for support of breathing or feeding. In 90% of patients the cough resolves within 3 weeks.

    Mortality is reported to be 8.4 per 100,000 population.

    This guidance sets out to refine management of this common and occasionally severe condition, in the light of recent national guidance.

    Pre-Hospital Assessment

    Immediately refer children with bronchiolitis to hospital via an emergency ambulance if they have the following signs:

    • Observed or reported apnoea
    • Infant looks seriously unwell to a healthcare professional
    • Severe respiratory distress, or RR greater than 70 per minute
    • Central Cyanosis
    • O2 saturations <92% in air

    Consider referring children with bronchiolitis to hospital if they have the following signs:

    • Poor feeding (50 -75% normal in preceding 24hrs)
    • Tachypnoea >60 breaths per minute
    • Signs of respiratory distress (nasal flare, tracheal tug, chest recession)
    • O2 saturations < 94%
    • Children with bronchiolitis not fulfilling above criteria, but presenting within 3 days of expressing symptoms, for whom there is concern that their condition may worsen to fulfil criteria.
    • Children with risk factors for more severe bronchiolitis, including young age (<3 months), prematurity (born <32 weeks), co-morbidities including congenital heart disease, neuromuscular disorders, technology dependent children, chronic or other underlying lung disease and immunodeficiency.
    • Children that have social/geographical situations that raise concerns should they deteriorate
    • Children that have parents/ carers that lack confidence in identifying a clinical deterioration

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    Clinical Diagnosis

    Bronchiolitis is a clinical diagnosis based upon typical history and examination.

    Bronchiolitis presents with a coryzal prodrome, followed by breathing difficulties and a persistent cough. On chest auscultation widespread crackles and/ or wheeze can be heard. Common additional symptoms are a fever (usually < 39°C) and feeding difficulties (usually day 3-5). It may present with apnoeas, particularly in young infants (particularly those under 6 weeks of age). Bronchiolitis has a viral aetiology; the majority caused by Respiratory Syncytial Virus (RSV), and tends to have a seasonal prevalence- peaking in winter.

    Consider pneumonia as a differential diagnosis when the patient has a high fever over 39°C, and persistent focal crackles. Consider viral induced wheeze or early asthma as a differential diagnoses in older children (predominantly >1 year) with solely wheeze on examination, episodic symptoms and history of atopy (personal or family history), although recurrent viral wheeze is uncommon below the age of 1 year.

    Whilst treatment is primarily supportive, monoclonal antibodies against RSV are advocated for certain high risk groups (see Prophylaxis under Treatment).

    Dehydration is an important sequelae of bronchiolitis and all patients should have a hydration assessment.

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    Investigation

    Laboratory/ Radiological Investigations

    Bronchiolitis is a clinical diagnosis, do not routinely perform blood tests or blood gases. Do not perform chest X-rays, as changes seen in bronchiolitis mimic those in pneumonia, and will lead to inappropriate antibiotic use.

    Measure the oxygen saturation in every child presenting with a respiratory illness. Ideally pulse oximetry should be available in primary care. All staff using the pulse oximeter should be appropriately trained.

    The following investigations may be considered in specific circumstances where the diagnosis is uncertain, or in severe disease.

    • FBC, U&E
    • CXR, eg if intensive care is being considered. Note changes on the chest X ray may mimic bacterial pneumonia. A chest x ray does not rule bronchiolitis in or out of the differential diagnosis.
    • Blood gas estimation
    • Urine, blood culture
    • Nasopharyngeal aspirate (NPA) or nose and throat swabs are now evaluated by PCR, in the Virology department at the Old Medical School LGI.
      • Specimens are processed in the early morning- samples preferentially should arrive the day before, or at the very latest by 09:30hrs (after informing the lab on 28750)
      • PCR samples are evaluated for Influenza A, B; Rhinovirus; Adenovirus; Metapneumovirus; RSV; Parainfluenza 1,2,3,4
      • Samples may not be processed over the weekend, except in exceptional circumstances (immunocompromised children), when the sample may be investigated with immunofluorescence. This investigation is inferior to PCR. Such instances must be discussed with the on call virologist.
      • Repeat specimens are rarely required. This may be appropriate in patients who deteriorate after initial improvement (to determine whether they have acquired a second pathogen).

    Admission criteria

    Admit children to hospital if they have any of the following features:

    • Observed or reported apnoea
    • O2 saturations persistently <92%
    • Inadequate oral fluid intake (50-75% usual volume)
    • Persistent respiratory distress
    • RR >70

    The following are risk factors for more severe bronchiolitis, indicating a lower threshold for admission:

    • Congenital heart disease
    • Prematurity, particularly < 32 weeks
    • Young age at presentation (< 3 months)
    • Neuromuscular disorders
    • Technology dependent children (e.g. tracheostomy ventilated)
    • Immunodeficiency

    Consider the following social/ demographic factors when deciding whether to admit a child:

    • Ability of carers to look after a child with bronchiolitis at home and identify a clinical deterioration
    • Distance from hospital and availability of transport should the child’s condition deteriorate

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    Treatment
    Non-Antimicrobial Treatment

    Hospital Assessment

    Assessment should primarily define need for supplemental oxygenation, fluid support, or the likelihood that either or both will be required within the next 24hours. Oxygen saturations should be measured on all patients, by an appropriately trained health care professional.

    • Oximetry <92%- requires admission, and supplemental oxygenation by nasal cannulae or face mask if remaining persistently below 92%
      • Oximetry >94% should suggest consideration for discharge
      • Oximetry 92-94% requires observation of feeding, consideration of management- admission/ next day review in Rapid Access Clinic.
    • Feeding (consider supplement to 2/3 of calculated intake- risk SIADH)
      • Clinically assess the hydration status of all children
      • Nasogastric supplementation should be considered first
      • Intravenous support should be reserved for children with severe disease, apnoeas, increasing oxygen requirement, worsening respiratory distress. Fluids should be prescribed as per the fluids guideline.
    • Additional factors, which increase the likelihood of deterioration, fulfilling either of the above criteria
      • Weight
      • Length of illness
      • Post-conceptual age (infants born prematurely remain at risk beyond their third month of life)
      • Significant co-morbidities (chronic lung disease, congenital heart disease or those with congenital or acquired immuno-compromising diseases)
    • Upper airway suctioning should not be performed routinely, although it should be performed in all children with a history of apnoea, and considered in children who have respiratory distress or feeding difficulties due to secretions.

    Ward Admission

    Remember that RSV carriage is primarily by hands.
    Management of children requiring admission should include:

    • General management including considering  nasal suction, minimal handling and infection control procedures. Please refer to Respiratory Virus Policy on Infection prevention pages on Trust intranet.
      • Hand decontamination in line with infection control policy
      • Glove and apron usage
      • Cohort management of cases
        • When capacity for isolation of children with respiratory tract infections in single rooms is exceeded, all children with respiratory tract infections compatible with viral bronchiolitis can be nursed as a cohort, before the results of the NPA are available.
        • However, babies/children with chronic lung disease, congenital heart disease or those with congenital or acquired immuno-compromising diseases, should be nursed separately from known RSV babies until their RSV status is known.
        • Source isolation should continue until 7 days after onset of clinical illness or until symptoms resolve, if longer than 7 days. Please refer to Infection Prevention & Control precautions for bronchiolitis in IPC Policy No.25 “Respiratory viruses.”

    Regular review is a key to in-patient management

      • Review of feeding
      • Review of oxygen requirement
      • Review of work of breathing

    Signs of deterioration and impending respiratory failure, requiring treatment on intensive care:

    • Signs of exhaustion, e.g. listlessness or decreased respiratory effort
    • Recurrent apnoea
    • O2 sats <92% despite adequate supplemental oxygen
    • CO2 greater than 6.5 or increasing from baseline

    In children with the above signs of impending respiratory failure, the following may be considered whilst assessing for referral to intensive care:

    • Blood gas testing (also consider in children requiring >50% O2)
    • Chest X -ray
    • High Flow Nasal Cannula Oxygen Therapy (HFNCT) - see separate guideline
    • Continuous Positive Airway Pressure (CPAP)

    See also the NICE guideline on sepsis and risk stratification tool for sepsis in under 5s.

    Drug Treatment

    Do not use any of the following to treat uncomplicated bronchiolitis in children:

    • Ribavirin
    • Antibiotics
    • Beta-2 agonists, ipratropium, epinephrine(adrenaline) nebulisers*
    • Steroids- oral/ inhaled
    • Hypertonic sodium chloride nebulisers
    • Montelukast
    • Combination of steroids and nebulised adrenaline

    (*except as part of an APLS algorithm for children with cardiorespiratory arrest and poor access or upper-airway obstruction)
    *A trial of ipratropium or salbutamol may be considered in cases where there is a clinical suspicion of asthma rather than bronchiolitis.

    Physiotherapy

    Do not perform chest physiotherapy routinely on patients with bronchiolitis. Consider chest physiotherapy on patients with background conditions such as spinal muscular atrophy, other neuromuscular disease, cystic fibrosis and tracheomalacia as they may have difficulty clearing secretions. In other conditions please discuss with a physiotherapist and/or on-call consultant.

    Prophylaxis
    NHS England have funded palivizumab for children at high risk of severe RSV disease needing hospitalisation. This includes patients with very specific criteria within the following patient groups:

    • Congenital Heart Disease  (CHD)
      Bronchopulmonary dysplasia (DPD)
    • Severe Combined Immunodeficiency (SCID)

    Note:  the commissioning agreement is reviewed each year, so please check for current recommendations in the Green Book.  Immunisation against infectious disease - GOV.UK

    Discharge

    This should be considered at least twice daily, and should include written and verbal information (see below).
    The child should be clinically stable and taking adequate oral fluids.
    Specific criteria to be met prior to discharge:

    • O2 saturations >92% in air for at least 4 hours, including a period of sleep
    • Feeding should be at or above 75% of that calculated

    Consider the following social/ demographic factors when deciding whether to discharge a child:

    • Ability of carers to look after a child with bronchiolitis at home and identify a clinical deterioration
    • Social circumstances
    • Distance from hospital and availability of transport should the child’s condition deteriorate

    Prior to discharge the parents/carers should be educated in identifying a deterioration and be given the LCH bronchiolitis leaflet.

    Specifically:

    Parents and carers of children with bronchiolitis should be informed that medication is not being used because the condition is usually self-limiting.

    Provide key safety information for parents and carers to take away for reference for children who will be looked after at home. This should cover:

    • how to recognise developing 'red flag' symptoms:
      • worsening work of breathing (for example grunting, nasal flaring, marked chest recession)
      • fluid intake is 50–75% of normal or no wet nappy for 12 hours
      • apnoea or cyanosis
      • exhaustion (for example, not responding normally to social cues, wakes only with prolonged stimulation)
    • that people should not smoke in the child’s home because it increases the risk of more severe symptoms in bronchiolitis
    • how to get immediate help from an appropriate professional if any red flag symptoms develop
    • arrangements for follow-up if necessary.

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    Empirical Antimicrobial Treatment

    In severe cases one should strongly consider secondary bacterial super infection, and treat pneumonia as detailed in the community acquired pneumonia guideline.

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    Directed Antimicrobial Treatment (when microbiology results are known)
    There are no recognised treatments for viral bronchiolitis.

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    Treatment Algorithm

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    Provenance

    Record: 1609
    Objective:
    • To improve the diagnosis and management of bronchiolitis
    • To provide evidence-based recommendations for appropriate diagnosis and investigation of bronchiolitis
    • To provide evidence-based recommendations for appropriate non-antimicrobial management of bronchiolitis
    • To provide evidence-based recommendations for appropriate empirical and directed antimicrobial therapy of bronchiolitis
    • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
    • To advise in the event of antimicrobial allergy.
    • To set-out criteria for referral to specialists.
    Clinical condition:

    Bronchiolitis

    Target patient group: Children with bronchiolitis
    Target professional group(s): Secondary Care Doctors
    Secondary Care Nurses
    Pharmacists
    Adapted from:

    Evidence base

    Evidence Bases: References

    • The National Institute for Health and Care Excellence (NICE). Bronchiolitis in children, diagnosis and management. 2015. Available at: https://www.nice.org.uk/guidance/ng9
    • The Treatment of Bronchiolitis M Yanney, H Vyas; Arch Dis Child 2008;93; 793-798
    • Ribavirin for respiratory syncytial virus infection of the lower respiratory tract in infants and young children (Cochrane Review). In the Cochrane Library, Issue 4, 2004. London: Wiley
    • A multicentre, randomised, double-blind, controlled trial of nebulised epinephrine in infants with acute Bronchiolitis. Wainwright C, Altamirano L et al, N Engl J Med 2003;349(1):27-35
    • Randomised placebo controlled trial of nebulised corticosteroids in acute respiratory syncytial viral Bronchiolitis. Cade A, Brownlee KG, Arch Dis Child 2000;82(2):126-30
    • Glucocorticoids for acute viral Bronchiolitis in infants and young children (Cochrane Review). In The Cochrane Library, Issue 3, 2004. London: Wiley
    • Pharmacologic treatment of Bronchiolitis in infants and children: A Systematic Review. Chowdhury D, al Howasi M et al Arch Pediatr Adolesc Med 2004; 158(2):127-37s

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    Approved By

    Improving Antimicrobial Prescribing Group

    Document history

    LHP version 1.0

    Related information

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