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Croup
Bronchiolitis
Acute Wheeze or Asthma in Paediatrics
Inhalers for Adults with Asthma
Greener Inhaler Prescribing
Bi-Level NIV S/T Guidelines for CCU Phase
Bi-Level NIV S/T Guidelines for ED Phase
Chronic Cough Pathway
Paediatric Bronchiolitis
Exacerbation of COPD
Chronic Obstructive Pulmonary Disease
Legionnaires Disease
Interstitial Lung Disease
Oxygen Therapy
Acute Asthma
Pleural Effusion
Spontaneous Pneumothorax
Community Acquired Pneumonia (CAP)
Breathlessness with Abnormal CXR
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Paediatric Bronchiolitis
Last updated 19th January 2024

Bronchiolitis is a clinically diagnosed respiratory condition caused by a viral infection (most commonly RSV and Human Metapneumovirus) 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.
Diagnosis
made clinically on history & examination findings
- Nasal discharge
- Wheezy cough
- Fine inspiratory crackles
- High pitched expiratory wheeze
- 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:
- Infants born at <35 weeks gestation
- Congenital heart disease
- Chronic lung disease of prematurity
There is also an increased risk of hospitalisation associated with parental smoking of standard cigarettes but not e-cigarettes.
Treatment
Treatment is supportive and can include the following measures:
- Normal saline nasal drops and nasal suction to clear secretions and ease respiratory distress
- Feeding – Small frequent feeds are encouraged. If an infant is not tolerating oral feeds then nasogastric feeds should be given. Sometimes, IV fluids may be required if illness is severe – restricted to 2/3 of maintenance. Intake and output should be recorded on a fluid chart.
- Supplemental oxygen in infants who cannot maintain adequate oxygen saturations
- The following are not generally recommended: nebulised hypertonic saline, corticosteroids, antibiotics, beta agonists, ipratroprium, adrenaline, ribavirin, percussion/vibration chest physiotherapy
- However in some situations where children are clinically very unwell a trial of beta agonists and ipratropium may be considered on a case by case basis. Older infants tend to be more responsive to bronchodilators than younger infants. A discussion should take place with the duty consultant and documented in the medical notes.
- In very sick infants antibiotic cover may be considered by the duty Paediatric Consultant
- Nasal High Flow Humidified Oxygen (Optiflow/ Airvo and CPAP have been used successfully in infants where standard treatment with oxygen is failing. Early involvement of senior staff in managing infants with severe bronchiolitis allows a timely Consultant decision about whether this is an appropriate strategy.
Intensive Care Consultation
Indications are:
- Failure to maintain oxygen saturations ≥92% despite increasing oxygen therapy
- Deteriorating respiratory status with increasing respiratory distress or exhaustion
- Recurrent apnoea
Limiting Disease Transmission
- Healthcare staff should be educated about epidemiology and control of RSV
- Staff should decontaminate their hands (with soap & water or alcohol gel) before and after caring for patients with viral respiratory symptoms
- Gloves, masks and plastic aprons should be used for any direct contact with the patient and their environment
- FFP3 masks, visors, full gowns and gloves for patients receiving high flow humidified oxygen / CPAP
- Infected patients should be placed in single rooms. Patients may later be allocated into cohorts based on lab-confirmed infection if inadequate isolation facilities are available.
- Hospital visiting by those with respiratory tract infections should be restricted