• Summary
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• Background
• Clinical Diagnosis
• Investigation
• Treatment
• Non-Antimicrobial Treatment
• Empirical Antimicrobial Treatment
• Directed Antimicrobial Treatment (when microbiology results are known)

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, Community Acquired Pneumonia in ( CAP ) in Children ( >4 weeks old - <16 years age ).

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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, and can last up to 6 weeks (if generally improving picture).

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.

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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.

Indications for hospital referral or acute paediatric assessment

Pre-Hospital Assessment

Immediately refer children with bronchiolitis to hospital via an emergency ambulance if they have any of 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 <90% in air

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

• Poor feeding (<50% normal in preceding 24hrs)
• Tachypnoea >60 breaths per minute
• Signs of respiratory distress (nasal flare, tracheal tug, chest recession)
• Persistent oxygen saturation of <92%, in room air
• 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, trisomy 21 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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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
• CRP, should not be done routinely as is generally unhelpful in guiding management.
• 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.  PCR samples are evaluated for Influenza A, B; Rhinovirus; Adenovirus; Metapneumovirus; RSV; Parainfluenza 1,2,3,4, Covid-19. 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, for e.g. if spiking new temperatures unexpectedly (after a period of improvement) a COVID swab should be sent and consider extended viral NPA, 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 (in room air) persistently <90% for children aged 6 weeks and over, or <92% for children under 6 weeks of age or patients with underlying health conditions (see below)
• Inadequate oral fluid intake (50% usual volume), or difficulty with breastfeeding.
• 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)
• Trisomy 21
• 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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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:
• Give oxygen supplementation via nasal cannulae or facemask, to babies and children with bronchiolitis if their oxygen saturation is:
• persistently < 90%, for children aged 6 weeks and over
• persistently < 92%, for babies under 6 weeks or children of any age with underlying health conditions.
• Oximetry >90% should suggest consideration for discharge (aged 6 weeks and over)
• Oximetry 92-94% requires observation of feeding, consideration of management - such as admission or a prolonged period of observation (for babies under 6 weeks or children of any age with underlying health conditions).
• 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, apnoea’s, increasing oxygen requirement, worsening respiratory distress and / or commencing High Flow
• 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; day 2-3 of illness may deteriorate further so consider need for longer observation
• Post-conceptual age (infants born prematurely remain at risk beyond their third month of life)
• Significant co-morbidities
• 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 < 90% 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) High Flow Nasal Cannula Oxygen Therapy ( HFNCT ) for Infants and Children ( not for use in NICU ) (leedsth.nhs.uk)

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 viral wheeze 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 has 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 (BPD)
• Severe Combined Immunodeficiency (SCID)

Infants with respiratory diseases who are not necessarily pre-term but who remain in oxygen at the start of the RSV season are also considered to be at higher risk.  These infants may include those with conditions including:

• Pulmonary hypoplasia due to congenital diaphragmatic hernia
• Other congenital lung abnormalities (sometimes also involving congenital heart disease or lung malformation)
• Interstitial lung disease and including those receiving long term ventilation at the onset of the season.

As per the green book ch27a.
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
• taking adequate oral fluids, at or above 50% of  calculated requirements
• SpO2 >90% in air for at least 4 hours, including a period of sleep for children ages 6 weeks and over
• SpO2 >92% in air for at least 4 hours, including a period of sleep for children aged less than 6 weeks and any child with co-morbidity

The use of the LCH Bronchiolitis Criteria Led Discharges (CLD) should be used to facilitate nurse led discharges where appropriate (see Appendix 1 ).

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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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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There are no recognised treatments for viral bronchiolitis.

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