Bronchiolitis (Paediatric Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • Highland HSCP
  • Primary Care and GPs and Rural Practitioners at Community Hospitals 

Bronchiolitis is a common viral respiratory condition affecting the small airways of young children only. It rarely requires hospital supportive therapy.

In normal years it is common in the months of October to March, but this rule does not apply since national lockdown as a result of gross epidemiological distortion.

Presentation

Is it bronchiolitis? 

A diagnosis of bronchioloitis should be considered in cases of:Differential diagnoses
  • Child under age 2
  • 1 to 3 days of coryzal symptoms followed by: 
    • Persistent cough
    • Increases respiratory rate and/or increased work of breathing
    • Wheeze and/or widespread crackles heard on auscultation

Poor feeding and mild fever are also common in this condition. 

  • High fevers (>39o) are uncommon in bronchiolitis and sepsis should lbe considered. 
  • Persistently localising crackles indicate LRTI. 
  • Recurrent wheeze in children over 1 without crackles, particularly in atopy, may be viral induced wheeze. 

Are they sick?

Children with the following Red Flags require EMERGENCY review:

  • Apnoeic episodes (reported or witnessed)
  • Respiratory rate >70 and/or significant work of breathing (grunting, head bobbing, marked chest wall recession)
  • Central cyanosis (tongue or pink part of lips)
  • Listlessness or exhaustion
  • A child that looks seriously unwell to a medical professional

Transfer options will depend on location, clinical condition and proximity to services: 

  • 999 paramedic ambulance transfer to closest Emergency Department
  • 999 paramedic ambulance transfer to Paediatric Assessment Unit
  • Clinically unstable children may require retrieval by ScotSTAR 03333 990 222 (after discussion with Paediatrics).

Liaise with Paediatrics on-call via switchboard 01463 704000 to determine best transfer method, if not immediately apparent.

If sending a child to hospital, alert Paediatric on-call team via swithcboard immediately.
Unexpected arrivals can delay optimal treatment

  • Stay with unwell child until transfer and deliver high flow oxygen therapy where possible. 

Management

Many cases of bronchiolitis can be successfully managed in the community.
Be mindful that severity of symptoms peaks at days 3 to 5.
Cough resolves within 3 weeks in 90% of cases and recovery often takes at least 2 weeks (time taken for cilia cells to regenerate!).
Smoking is known to make bronchiolitis worse and parents should be counselled about smoking in the home or near their children.

Recommended:Not recommended:
  • Frequent small feeds; a full stomach makes breathing more difficult.
  • Saline dropped directly into the nostrils helps clear mucous and improves feeding. 
  • Paracetamol/ibuprofen for distress caused by fever; antipyretics are not required for temperature alone. 
  • Bronchodilators
  • Steroids (oral or inhaled)
  • Antibiotics
  • Nebulised adrenaline
  • Blood tests
  • Chest X-ray

Referral

Some children require supportive therapy in hospital such as O2 therapy, suction and naso-gastric feeding. Discuss with the paediatric on call team if:

  • Resp rate > 60
  • Reduced oral intake of 50 to 75% of usual volumes
  • Clinical dehydration (increased capillary refill time, reduced wet nappies)
  • Saturations persistently below 92%

Where possible, all potential bronchiolitis cases should have saturations checked in the community. Ideally this should be done using a paediatric probe.

Some children have risk factors that make them more vulnerable to serious illness. Consider discussion with the Paediatric on-call team in the following cases: 

  • Chronic lung disease
  • Significant congenital heart disease
  • Children under 3 months old
  • Ex-prem <32 weeks
  • Neuromuscular disorders
  • Immunodeficiency

Abbreviations

Abbreviation  Meaning
LRTI Lower respiratory tract infection

Editorial Information

Last reviewed: 30/04/2022

Next review date: 30/04/2025

Author(s): Paediatric Department .

Version: 1

Approved By: TAM subgroup of the ADTC

Reviewer name(s): Dr S Ghayyda, Consultant Paeditarics.

Document Id: TAM537

References

Further information for patients

Self management information