Bronchiolitis in Children - Guidance for the management of
|Last review: 09/11/2016|
|Next review: 01/10/2019|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2016|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Management of Bronchiolitis in Children
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.
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.
Remember that RSV carriage is primarily by hands.
Regular review is a key to in-patient management
Signs of deterioration and impending respiratory failure, requiring treatment on intensive care:
In children with the above signs of impending respiratory failure, the following may be considered whilst assessing for referral to intensive care:
Do not use any of the following to treat uncomplicated bronchiolitis in children:
(*except as part of an APLS algorithm for children with cardiorespiratory arrest and poor access or upper-airway obstruction)
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.
Note: the commissioning agreement is reviewed each year, so please check for current recommendations in the Green Book. Immunisation against infectious disease - GOV.UK
This should be considered at least twice daily, and should include written and verbal information (see below).
Consider the following social/ demographic factors when deciding whether to discharge a child:
Prior to discharge the parents/carers should be educated in identifying a deterioration and be given the LCH bronchiolitis leaflet.
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:
|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.
|Directed Antimicrobial Treatment (when microbiology results are known)|
|There are no recognised treatments for viral bronchiolitis.|
|Target patient group:||Children with bronchiolitis|
|Target professional group(s):||Secondary Care Doctors
Secondary Care Nurses
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
Improving Antimicrobial Prescribing Group
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