Bronchiolitis guideline, RHC

SaO2 – Oxygen Saturations

WOB – Work of Breathing

RR – Respiratory Rate

O2 – Oxygen

NC – Nasal Cannula

HFNC – High Flow Nasal Cannula (Optiflow)

FM – Face Mask

NPA – Nasopharyngeal Aspirate

TS – Throat swab

FBC – Full Blood Count

U+Es – Urea + Electrolytes

BC’s – Blood Cultures

CBG – Capillary Blood Gas

NaCl – Sodium Chloride

NG – Nasogastric

PPE – Personal Protective Equipment

It is the responsibility of all staff involved in the care of a patient receiving care for Bronchiolitis to have read and understood this guideline. If any staff have any concerns, they should address these with a trained member of staff before proceeding

In 2015 the NICE Guidance on acute bronchiolitis was published and was updated in August 2021. This guideline should be read in conjunction with this guidance. Overview | Bronchiolitis in children: diagnosis and management | Guidance | NICE

• A diagnosis of bronchiolitis should be considered in those under 2 years of age, most commonly in the first year of life, peaking between 3-6 months.
• When diagnosing bronchiolitis take into account that symptoms usually peak between 3-5 days and the cough resolves in 90% of infants in 3 weeks.
• The diagnosis of bronchiolitis should be considered if the child has a coryzal prodrome lasting 1-3 days followed by persistent cough and tachypnoea or chest recession and wheeze or crackles on auscultation (or both)
• Bronchiolitis is the commonest cause of hospital admission in children under six months, especially in the winter months
• RSV is the most common cause, other causative agents include parainfluenza, influenza, adenovirus, rhinovirus and metapneumovirus
• The vast majority of children with bronchiolitis do not require hospital admission
• No investigations are required for the majority of children
• In those who require admission the treatment is mainly supportive

A NPA or TS will be carried out on admission in the majority of cases. Other investigations are not routinely required.  

CXR indications include:

• Severe disease
• Uncertain diagnosis
• Focal signs

CBG – if severe respiratory distress

FBC – if spikes temperature >39 degrees (fever present in around 30% of cases, usually less than 39 degrees)

CRP – concern regarding sepsis

U+E – concern re hydration status

Blood Cultures – concern regarding sepsis

Any patient diagnosed with bronchiolitis in ED meeting the following criteria can be discharged home with an RHCG bronchiolitis leaflet and strict worsening advice.

1. Acceptable saturations for discharge after a period of observation

*Consider risk factors which include:

• Chronic Lung Disease
• Congenital Heart Disease
• Prematurity <32 weeks
• Immunodeficiency
• Neuromuscular disorders

A period of prolonged observation (likely in CDU) may be required in some cases to ensure that the oxygen saturations are maintained prior to discharge.  Examples may include when there are borderline oxygen saturations or when they are early into the illness.

2. Adequately feeding 50-75% of normal intake - with consideration to weight and age

Suggested feed volumes

^{Guidelines approved for use by dietetic department, Royal Hospital for Children Glasgow}

Patients who are not feeding adequately should be discussed with the medical registrar on (84678) for consideration of observation in CDU.

Oxygen administration thresholds:

Patients who are under 6 weeks old with saturations of > 92% in air who have moderate respiratory distress or risk factors, should not be commenced on oxygen and should be discussed with the medical registrar on (84678) for consideration of observation in CDU. If saturations are persistently below 92% in air, oxygen to be applied and discussion with medical registrar for admission. The patient may be transferred to CDU or admitted directly to ward 2C. 

Patients 6 weeks and above with saturations 90-92% in air who have moderate respiratory distress should not be commenced on oxygen and should be discussed with the medical registrar on (84678) for consideration of observation in CDU. If saturations persistently below 90% in air, oxygen to be applied and discussion with medical registrar for admission. The patient may be transferred to CDU or admitted directly to ward 2C.  

Any patient who requires admission to the ward and meets the criteria for the nurse-led pathway should be highlighted to medics during referral. A patient can be signed onto the pathway by a paediatric consultant only after discussion with the nurses managing the pathway. All appropriate paperwork should be signed.

When assessing a baby or child admission should be considered if they have any of the following:

• Apnoea
• Persistent oxygen saturations <90% in children aged >6 weeks and < 92% in babies under 6 weeks or with underlying health conditions (see risk factors below)
• Inadequate oral fluid intake 50-75% of suggested feeding volume noted above (taking into account the risk factors below)
• Persisting severe respiratory distress

It is also important to consider factors which may affect the carer’s ability to look after a child with bronchiolitis as well as distance from hospital, time of discharge etc.

The following risk factors should be considered when reviewing a child with suspected bronchiolitis:

• Chronic Lung Disease
• Congenital Heart Disease
• Prematurity <32 weeks
• Immunodeficiency
• Neuromuscular disorders

The treatment of Bronchiolitis is supportive.

• Consider upper airway suctioning in babies and children if a baby or child presents with apnoea or consider it for those who have respiratory distress of feeding difficulties because of upper airway secretions. Suction should not be carried out routinely.
• Supplemental oxygen if required (see below)
• NG feeds or IV fluids if required
• The routine use of salbutamol and saline nebulisers are not recommended. In those over one year of age it may be considered, however the effectiveness should be clearly documented.

The NICE Guidance was updated in 2021 recommending the change in acceptable oxygen saturation levels. A Randomised Controlled Trialfound that using an oxygen saturation of 90% (compared with 94%) for deciding whether to provide supplemental oxygen and discharge from hospital significantly reduced the need for supplemental oxygen and the time to discharge. The trial also showed that readmission rates were not higher with a 90% threshold, compared with 94%. As there was no evidence for babies and children at higher risk (babies under 6 weeks and children of any age with underling health conditions) it was agreed to retain the threshold of 92% for these groups.

In summary:

Give supplemental oxygen if the saturations are persistently less than

• 90% in those over 6 weeks of age with no risk factors
• 92% in those under 6 weeks of age or have risk factors

If there is evidence of severe respiratory distress then escalation of treatment with respiratory support may be required. Please refer to the Medical Acute Receiving Unit Guide for Hi-Flo (AIRVO) Use in Bronchiolitis.

• Every baby and child must have a weight on admission and ideally weighed every 2^nd day

• Try minimum volume, target feeds if still tolerating oral intake (consider consequences of dehydration, hyponatraemia and reduction in fluid intake

• Ask how the baby is being fed (breast, formula, combination, and whether solids have been introduced for older infants).

• For breastfed infants, encourage continuing breastfeeding and support the mother to maintain her breastmilk supply:
  • If the infant is able to feed, encourage the mother to offer frequent breastfeeds (the infant is likely to take shorter, but more frequent, feeds)
  • Ensure she is offered a double electric hospital pump and the necessary bottles and flanges, as she may wish to also express milk if her baby is not feeding as much as usual
  • If the infant is going to be NG fed (see below) expressed breastmilk can be stored in the ward and given via this route
  • Contact infant feeding support at the QEUH maternity unit if there are any difficulties

• If not tolerating oral feeds, consider a trial of NG feeds

• Nasogastric feeds –The intermittent bolus gavage method is thought to be more physiologic than continuous feeding, and should be the method of choice for those children able to tolerate it. Nasogastric feeds should be given in accordance with West of Scotland Paediatric Gastroenterology, Hepatology and Nutrition network (WoSPGHaN) (2012) guidance.

• Intravenous Fluids – Should be considered for infants with severe illness, or those with continued vomiting, not tolerating NG feeds or with impending respiratory failure. A fluid balance chart should be accurately maintained throughout a patient’s stay and should include a feeding plan for the shift. Intravenous fluid guidance for previously well children aged >7 days to 16 years.

• Adequate hydration – aim to ensure child achieves a minimum of 75% (for inpatients) of recommended daily oral intake (use table below). Smaller, more regular feeds are advised during acute bronchiolitis. Beware of fluid overload due to inappropriate secretion of antidiuretic hormone.
• Suggested feed volumes (G.O.S. Guidelines)

^{These volumes have been agreed by dietetic department, Royal Hospital for Children Glasgow}

The infection control policy is available at:

PPE when undertaking Aerosol Generating Procedures (AGPs) within health & social care settings (v22, July 2022)

NHSGGC PPE Donning & Doffing (last amended 2020)

ARHAI Scotland. Appendix 16: Aerosol Generating Procedures (AGPs) and post AGP Fallow time (PAGPFT). (v1 2021)

Most children with bronchiolitis do not benefit from physiotherapy to support airway clearance. Upright sitting positions should be avoided along with unnecessary handling. Instead, we would encourage supportive positioning to help reduce work of breathing such as side lying or up for cuddles with parents. 

However, for children with co-morbidities such as a neuro-disability, cystic fibrosis or neuro-muscular disease or for those not following a typical pathway, a physiotherapy review can be requested.

As per nurse led pathway guidance

• Maintaining oxygen saturations in air for 4 hours including a period of sleep ( 90% > 6 weeks and 92% <6 weeks and risk factors)
• Feeding adequately
• Parents confident

Nurse led pathway (pdf)

RHSC PROTOCOL 8.16: NURSE DISCHARGING

1. Statement:
   The registered nurse is personally accountable for his/her own practice and in exercising professional accountability may expand their practice to include nurse-initiated discharging of the patient with bronchiolitis.
2. Objectives:
   • To ensure practice is safe and does not put the patient at risk.
   • To ensure more timely discharges.
   • To reduce discharge delays.
   • To promote autonomy for the professional carrying out the discharge.
   • To reduce the length of in-patient stays to a minimum.
   • To assist with the development of new roles.