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Home | Articles | Respiratory | Bronchiolitis


Last updated 9th March 2023


Bronchiolitis is a clinically diagnosed respiratory condition caused by a viral infection (most commonly RSV) with peak prevalence during the winter months. The symptoms usually peak in the first 72 hours of illness. This guideline refers to the management of infants <12 months of age.


This is made clinically on history & examination findings

  • Nasal discharge
  • Wheezy cough
  • Fine inspiratory crackles
  • High pitched expiratory wheeze
  • Signs of respiratory distress: tachypnoea, subcostal/intercostal recession, tracheal tug, nasal flare
  • Apnoea
  • Fever may be present. If ≥39oC careful evaluation for other causes should be undertaken before reaching a diagnosis
  • It is unusual for infants with bronchiolitis to appear ‘toxic’ (eg. drowsy, lethargic, pale, mottled, irritable and tachycardic). Infants who appear ‘toxic’ require immediate treatment and should be carefully evaluated for other causes.

Risk factors for severe disease

The following conditions increase the risk of severe disease and need for hospital admission:

  • chronic lung disease (including bronchopulmonary dysplasia)
  • haemodynamically significant congenital heart disease
  • age in young infants (under 3 months)
  • premature birth, particularly under 32 weeks
  • neuromuscular disorders
  • immunodeficiency.

There is also an increased risk of hospitalisation associated with parental smoking of standard cigarettes but not e-cigarettes

Assessment & Referral

Most infants with bronchiolitis have mild disease and can be managed at home with primary care support.

The following are indications for acute paediatric assessment:

  • Poor feeding (<50% usual intake in preceding 24 hours)
  • Lethargy
  • Apnoea
  • Respiratory rate >70/min
  • Presence of nasal flaring or grunting
  • Severe chest wall recession
  • Cyanosis
  • Oxygen saturation ≤92%
  • Uncertainty regarding diagnosis

When deciding whether to refer a baby or child to secondary care, take into account factors that might affect a carer’s ability to look after a child with bronchiolitis, for example:

  • social circumstances
  • the skill and confidence of the carer in looking after a child with bronchiolitis at home
  • confidence in being able to spot red flag symptoms
  • distance to healthcare in case of deterioration.

When to admit

Measure oxygen saturation using pulse oximetry in every baby and child presenting to secondary care with clinical evidence of bronchiolitis.

When assessing a baby or child in a secondary care setting, admit them to hospital if they have any of the following:

  • apnoea (observed or reported)
  • persistent oxygen saturation (when breathing air) of:
    • >90%, for children aged 6 weeks and over
    • >92%, for babies under 6 weeks or children of any age with underlying health conditions
  • inadequate oral fluid intake (50% to 75% of usual volume)
  • persisting severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute.


Viral throat swab with clinical information of respiratory distress will be analysed for Influenza A and B, RSV and COVID-19.

  • Blood gas analysis is not routinely done but may be used in the assessment of infants with severe worsening respiratory distress (when supplemental oxygen concentration is greater than 50%) or suspected impending respiratory failure
  • Do not routinely perform a chest X ray in babies or children with bronchiolitis, because changes on X ray may mimic pneumonia and should not be used to determine the need for antibiotics.
  • Do not routinely perform blood tests in the assessment of a baby or child with bronchiolitis

Consider performing a chest X ray if intensive care is being proposed for a baby or child.


Treatment is supportive.

  • Give oxygen supplementation to babies and children with bronchiolitis if their oxygen saturation is:
    • persistently less than 90%, for children aged 6 weeks and over
    • persistently less than 92%, for babies under 6 weeks or children of any age with underlying health conditions.
  • Do NOT use any of the following to treat bronchiolitis in babies or children:
    • antibiotics
    • hypertonic saline
    • adrenaline (nebulised)
    • salbutamol
    • montelukast
    • ipratropium bromide
    • systemic or inhaled corticosteroids
    • a combination of systemic corticosteroids and nebulised adrenaline.
  • Consider continuous positive airway pressure (CPAP) or Hi-Flow in babies and children with bronchiolitis who have impending respiratory failure
  • Do not routinely perform upper airway suctioning in babies or children with bronchiolitis.
  • Consider upper airway suctioning in babies and children who have respiratory distress or feeding difficulties because of upper airway secretions.
  • Perform upper airway suctioning in babies and children with bronchiolitis presenting with apnoea even if there are no obvious upper airway secretions.
  • Do not perform chest physiotherapy on babies and children with bronchiolitis who do not have relevant comorbidities (for example spinal muscular atrophy, severe tracheomalacia).
  • Consider requesting a chest physiotherapy assessment in babies and children who have relevant comorbidities (for example spinal muscular atrophy, severe tracheomalacia) when there may be additional difficulty clearing secretions.

Feeding and fluids

  • Intake and output should be recorded on a fluid chart.
  • Give fluids by nasogastric or orogastric tube in babies and children with bronchiolitis if they cannot take enough fluid by mouth
    • May be given as 3hourly, 2hourly or continuous feeds at 100ml/kg/day.
  • Give intravenous isotonic fluids (usually 100ml/kg/day 0.9% saline + 5% Dextrose) to babies and children who do not tolerate nasogastric or orogastric fluids or have impending respiratory failure.

Intensive care consultation

Indications are:

  • Failure to maintain oxygen saturations ≥90% with increasing oxygen therapy
  • Deteriorating respiratory status with increasing respiratory distress or exhaustion
  • Recurrent apnoea

Discharge Criteria

When deciding on the timing of discharge for babies and children admitted to hospital, make sure that they:

  • are clinically stable
  • are taking adequate oral fluids
  • have maintained an oxygen saturation in air at the following levels for 4 hours, including a period of sleep:
    • >90%, for children aged 6 weeks and over
    • >92%, for babies under 6 weeks or children of any age with underlying health conditions.

When deciding whether to discharge a baby or child, take into account factors that might affect a carer’s ability to look after a baby or child with bronchiolitis, for example:

  • social circumstances
  • the skill and confidence of the carer in looking after a baby or child with bronchiolitis at home
  • confidence in being able to spot red flag symptoms
  • distance to healthcare in case of deterioration

Provide parents or carers with key safety information when the baby or child is discharged.

Provide key safety information for parents and carers to take away for reference for babies and children who will be looked after at home. (Local D&G leaflet available) 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% to 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 baby or 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.