DELL CHILDREN’S MEDICAL CENTER
EVIDENCE-BASED OUTCOMES CENTER
BRONCHIOLITIS PATHWAY GUIDELINES
This pathway was developed through the Evidence-Based Outcomes Center at Dell Children’s Medical Center of Central Texas. The
objectives of this guideline were to standardize care and reduce practice variation. Methods used to build the pathway included:
systematic literature review of relevant PICO (population, intervention, comparison, and outcome) questions, rapid cycle improvement
occurring in multiple cycles with multidisciplinary feedback, and use of default consensus from pediatric experts where evidence was
lacking.
The guidelines presented in this pathway are based on recommendations of care for the majority of patients. Special care should be taken
in considering treatment, as each patient has individual symptoms and treatment needs. Use of the Bronchiolitis Pathway Guideline should
be based on individual patient assessment and provider discretion. Should the provider feel that the child’s treatment would be bettersuited using a more individualized treatment plan; the clinician’s decision should be honored and the rational documented.
Definition:
Bronchiolitis is a disorder most commonly caused in infants by
viral lower respiratory tract infection and is the most common
lower respiratory infection in this age group. It is characterized
by acute inflammation, edema, and necrosis of epithelial cells
lining small airways, increased mucus production, and
bronchospasm (American Academy of Pediatrics).
Incidence:
Almost all children are exposed to RSV, one of the most
common viruses causing bronchiolitis by the age of 2. In
children exposed to RSV for the first time, 20 to 40% develop
bronchiolitis and 0.5 to 2% of those children require
hospitalization.
Etiology:
The most common etiology is the respiratory syncytial virus
(RSV). Other viruses identified as causing bronchiolitis are
human metapneumovirus, influenza, adenovirus, and
parainfluenza.
Differential Diagnosis:
Asthma
Foreign body
Myocarditis
Cystic fibrosis
BPD
Immunodeficiency
Guideline Eligibility Criteria:
Patients >28 days and <24 months with clinical symptoms of
increased WOB, persistent cough, feeding difficulty, +/- fever,
first episode of wheezing OR with a diagnosis of bronchiolitis.
Guideline Exclusion Criteria:
Patients with comorbid or complex medical conditions such
as: chronic lung diseases, CF, congenital heart disease,
immunodeficiency, toxic appearance/shock, neuromuscular
disease, artificial or abnormal airway, recurrent wheezing.
Physical Examination:
Assessment Guidelines for Symptom Severity
(Consensus; weak recommendation; low quality of evidence)
Mild Symptoms
• Alert, active, feeding well
• None to minimal retractions
• RR normal to mildly elevated (less than 50)
• >95% on RA
Moderate
• Alert, consoles, feeding decreased
• Minimal to moderate retractions
• RR is mildly to moderately elevated (50-69)
• 91-94% on RA
Severe
• Fussy, difficult to console, poor feeding
• Moderate to severe retractions
• RR moderately to severely elevated (>70)
• <90% on RA
Laboratory Tests:
Not routinely recommended for typical mild to moderate
(12-13,23-28,43-46)
bronchiolitis.
(Strong recommendation; Moderate quality evidence)
If patient is febrile and >28days and ≤90 days consider: UA,
(47-51)
(23-28)
, CBC, and blood culture.
urine culture
(Strong recommendation; High quality evidence)
Critical Points of Evidence:
Evidence Supports
(Strong recommendation; Moderate quality evidence)
•
Supportive care including supplemental oxygen to
maintain SaO2 >90%
Evidence Lacking/Inconclusive
(Consensus; Weak recommendation; Moderate quality evidence)
•
•
•
•
3% Saline Neb*
HFNC*
(29-30)
Use of dexamethasone
(*-4-11)
Clinical assessment tools
Diagnostic Evaluation:
History and exam should include history of rhinorrhea, with or
without cough and fever, possible exposure through others
infected, possible wheeze, difficulty breathing, feeding
difficulties, pallor or cyanosis and changes in behavior.
POSTED: November 2014
DELL CHILDREN’S MEDICAL CENTER
EVIDENCE-BASED OUTCOMES CENTER
Critical Points of Evidence Contiued:
Evidence Against
(Strong recommendation; Moderate quality evidence)
•
•
•
•
•
•
•
•
•
(14-22)
CXR
(43-46)
RSV testing
Deep suctioning
CPT*
(23-28)
CBC/blood culture (unless clinically indicated)
Antibiotics (unless confirmed bacterial source present)
Corticosteroids
Epinephrine*
Use of inhaled bronchodilators*
Practice Recommendations and Principles of Clinical
Management
The bronchiolitis diagnosis should consist of supportive care
treatments as the main foundation for care. Support of
respiratory symptoms, clearance of airways and dietary
support are essential in the care and treatment of a child with
bronchiolitis.
Treatment Recommendations
(for full recommendations see attached pathway and addendums)
Supportive Care:
• Supplemental oxygen should be administered to
maintain SaO2 >90%
• Nasal suction using nasal aspirator to maintain and
clear airway
• Assess and treat hydration status
o Give PO challenge
o Administer fluids as needed
o Administer tube feeds as required (see
addendum 2)
3% Saline Neb:
• Care Provider can order 4ml Q4 hrs for severe
symptoms
• Multiple doses may be required to assess for
effectiveness
• Patient should be re-evaluated Q24 hours and the
treatment should be reordered if it is to be continued
• Once initiated: If the patient moves to a moderate
assessment, the treatment can be continued if it is
found to be effective
• If the treatment has been stopped, it can ONLY be
reordered if the patient is experiencing severe
symptoms
(31-39)
High Flow Nasal Cannula (Addendum 1)
• Patient to be watched for at least 30 minutes after
starting high Flow in the ER. If no worsening of
symptoms, PCRS IMC resident notified.
• Any flow rates above what is listed below require an
Intensivist consult:
•
For further guidelines and recommendations for use
please see addendum 1.
Pediatric Bronchiolitis Severity Score (BSS)*
The BSS serves as a method to document patient status and
acuity over the course of care. It can also be used to assess
response to interventions. The tool is based on five key
assessment areas; respiratory rate, oxygen need, wheezing,
work of breathing, and presence of retractions.
The Bronchiolitis Severity Score (BSS) is an assessment tool
and is not intended to determine admission and/or placement
of the patient.
Admission Criteria
Floor:
• Moderate WOB, tachypnea
• O2 requirement
• Requires frequent suctioning
• Dehydrated or unable to maintain oral feedings
• Parent unable to care for infant at home
Pulmonary Unit- High Acuity (Floor criteria + any of the
following):
• Moderate to severe WOB
• O2 requirement (< 50% FiO2)
• HFNC (see Addendum 1)
IMC (Floor, Pulmonary Unit criteria + any of the following):
• HFNC (see Addendum 1)
• Co-morbidities (CLD)
• BP requires close monitoring
PICU (Floor, Pulmonary Unit, IMC criteria + any of the
following):
• Positive pressure ventilation
• Witnessed episode of apnea
• Severe dehydration/shock
• HFNC (see Addendum 1) or if not improving on HFNC
after 30 minutes
POSTED: November 2014
DELL CHILDREN’S MEDICAL CENTER
EVIDENCE-BASED OUTCOMES CENTER
Consults and Referrals
Consults and referrals should be ordered on an individual basis
based on patient requirements.
Infection Control
Bronchiolitis/ RSV require CONTACT isolation.
Special Considerations:
• Patients with additional symptoms of influenza
should be placed into droplet isolation until the
diagnosis of influenza is confirmed as negative.
• Staff should wear additional personal protective
equipment when suctioning or performing
assessments or treatments bringing them into close
contact with the patient.
• Wash hands thoroughly after contact with the patient
Caregiver Education
• Hand washing after handling the patient or the
patients belongings
• Importance of not bringing other siblings to the
hospital for visits
• Understanding of signs/symptoms of increasing
respiratory distress
• Proper nasal suctioning (must demonstrate ability
with bulb suction)
• Risk of passive smoke exposure
• Encourage Direct Breastfeeding whenever possible
Discharge Criteria
• SpO2 ≥ 90% on RA for ≥ 2 hours
• Respirations less than 60 per minute and/or minimal
to no evidence of increased work of breathing
• Oral feedings tolerated at a level to maintain
hydration
• Parents comfortable with providing home care, and
parent education complete, including understanding:
o Signs/symptoms of increasing respiratory
distress
o Proper nasal suctioning (must demonstrate
ability with
o bulb suction)
o Risk of passive smoke exposure
o Need for PCP follow-up
Follow-Up Care
Ideally follow-up care should be planned for 2-3 days postdischarge with the patient’s primary care doctor
Prevention
Avoid contact with others who are ill
Wash hands
Outcome Measures
Length of stay
Cost (testing, antibiotics)
Pathway compliance
POSTED: November 2014
Exclusion Criteria: Children w/
Comorbid/ complex medical
conditions such as: chronic lung
diseases, CF, congenital heart
disease, immunodeficiency, toxic
appearance/shock, neuromuscular
disease, artificial or abnormal airway,
recurrent wheezing
ED Bronchiolitis Pathway
Bronchiolitis Severity Score (BSS)
If respiratory arrest imminent- triage and
initiate care in resuscitation room
Inclusion criteria:
>28 days and <24 months with clinical
symptoms of ↑WOB, persistent cough, feeding
difficulty, +/- fever, first episode of wheezing OR with
a diagnosis of bronchiolitis
NOT Recommended in ED
- CPT
- CXR
- RSV testing
- CBC/Blood culture for patients > 90 days
(unless clinically indicated)
- Antibiotics- unless confirmed bacterial
source present
- Hypertonic Saline
- Corticosteroids
- Inhaled bronchodilators
- Epinephrine
Supplemental oxygen should be administered to
maintain SaO2>90%
Nasal suction
If febrile and >28days & ≤90 days consider: UA, urine
culture, CBC, & blood culture
As s es s ment
0
1
Respiratory < 40 per
40-50 per mi n.
Rate
mi n.
O2- >90%
SaO2
RA
Wheezing
none
WOB
none
Retractions
none
NC < 2L
2
>50 per
min.
NC > 2L
i ns pi ra toy
expira tory
&
expira tory
Grunti ng
Na s a l Fla ri ng +/- Hea d
Bobbing
Supra
s ubcos ta l +/Sterna l +/intercos ta l
Cla vicula r
The BSS is an assessment tool and is not intended to
determine admission and/or placement of the patient.
Assess
Disease Severity
*
*Moderate Symptoms
*Mild Symptoms
- Nasal suction using nasal aspirator
- Assess hydration status (PO ad lib OR NPO
w/IVF or NG feeds)
- Observe
- Nasal suction using nasal aspirator
- Assess hydration status
- Give po challenge
*Severe Symptoms
- Notify Provider
- Nasal suction using nasal aspirator
- Assess hydration status (consider IVF,
check glucose/electrolytes for significant
dehydration)
- Consider 3% Saline Neb- (4ml Q4hr)
- Consider starting high flow nasal
cannula****
Reassess
Disease Severity
*
Meets Discharge
Criteria**
Meets Admission
Criteria***
Admit to Inpatient Unit
Based on Admit Criteria (not score)
Discharge Home
INTERVENTIONS:
All interventions should have a pre and post score
to evaluate for effectiveness.
(including, but not limited to: suctioning, repositioning,
switch to NPO, implementation or discontinuation of O2)
*Assessment Guidelines
Mild
- Alert, active, feeding well
- None to minimal retractions
- RR normal to mildly elevated
(less than 50)
- >95% RA
Moderate
- Alert, consoles, feeding
decreased
- Minimal to moderate retractions
- RR is mildly to moderately
elevated (50-69)
- 91-94% on RA
Severe
- Fussy, difficult to console, poor
feeding
- Moderate to severe retractions
- RR moderately to severely
elevated (>70)
- <90% on RA
**Discharge Criteria
- SpO2 ≥ 90% RA
- Respirations less than 60 per
minute and/or minimal to no
evidence of increased work of
breathing
- Oral feedings tolerated at a
level to maintain hydration
- Parents comfortable with
providing home care, and
parent education complete,
including understanding:
- signs/symptoms of increasing
respiratory distress
- proper nasal suctioning (must
demonstrate ability with bulb
suction)
- risk of passive smoke exposure
- Need for PCP follow-up
- encourage continued DBF
- prevention education
- Need for PCP follow-up
***Admission (Unit) Criteria
Floor:
- Moderate WOB, tachypnea
- O2 requirement
- Requires frequent suctioning
- Dehydrated or unable to maintain oral
feedings
- Parent unable to care for infant at home
Pulmonary Unit- High Acuity (Floor criteria +):
- Moderate to severe WOB
- O2 requirement (< 50% FiO2)
- HFNC (see right)
IMC (Floor, Pulmonary Unit criteria +):
- HFNC (see right)
- Co-morbidities (CLD)
- BP requires close monitoring
PICU (Floor, Pulmonary Unit, IMC criteria +):
- Positive pressure ventilation
- Witnessed episode of apnea
- Severe dehydration/shock
- HFNC (see right) or if not improving on HFNC
after 30 minutes
High Flow Nasal Cannula Guidelines
****(see addendum 1)
Patient to be watched for at least 30
minutes after starting High Flow in the
ER. If no worsening of symptoms,
PCRS IMC resident is notified
Any flow rates above what is listed
below require an Intensivist consult.
Weight (kg)
<7
7 –9
>9
Initial flow Max flow
rate (lpm) rate (lpm)
4
6
6
8
6
10
PC 02-19-15
DELL CHILDREN’S MEDICAL CENTER
EVIDENCE-BASED OUTCOMES CENTER
Addendum 1
High Flow Nasal Cannula (HFNC)
Recommended Guidelines for Use by PCRS
Recommendations:
1. It is desirable that all PCRS faculty have the same general approach for this technology in the interest
of safety, mutual understanding of what to expect when cross covering, and to be consistent in our
education roles
2. This document is not a protocol but rather an internal document to guide us
3. Variation from this guideline is appropriate so long as documentation exists
4. Patient to be watched for at least 30 minutes after starting High Flow in the ER. If patient improves
or there is no worsening of symptoms, PCRS IMC resident is notified.
5. Criteria for use on the Pulmonary Unit:
• “Classic Bronchiolitis” w/o significant comorbidity (e.g. no chronic lung disease [abn
compliance], no symptomatic congenital heart disease and without suggestion of impending
respiratory failure)
• Post-conceptual age > 44 wks but < 2 yrs
• Moderate to severe disease (further definition of this pending)
• FiO2 < 50% to maintain SaO2> 90%
• Flow Rates are recommended within the following parameters:
Weight (kg)
Initial flow rate (lpm)
Max flow rate (lpm)
<7
4
6
7–9
6
8
>9
6
10
6. Use of HFNC in IMC:
• Same age criteria as the floor
• Comorbidities above may be managed in IMC
• Patients with mild respiratory acidosis may be managed in IMC at provider’s discretion
7. Critical Care consultation suggested for:
• Any patient worsening after 30 minutes on HFNC
• Any patient in severe distress not improving after 30 minutes on HFNC
• FiO2 >50%
• Flow rates above the recommended parameters
• Apnea
8. Feeding while on HFNC (see addendum 2):
• No evidence exists regarding risks of feeding while on HFNC
• Consider NPO initially with decision for NGT or PO trial made after some stability reached
9. Weaning:
• O2 wean by RT based on SaO2 goals
• Flow wean to start by a physician’s order but generally not until stabilized for 8 -12 hrs.
• Decrease flow by 2 lpm every 4 hrs
Change to NC when on 2 lpm for 4 hrs
prepared by: Duc, Cossey, Iyer & Holt
POSTED: November 2014
Inpatient Bronchiolitis Pathway
Exclusion Criteria:
Children with Comorbid or
complex medical conditions
such as: chronic lung diseases,
CF, congenital heart disease,
immunodeficiency, toxic
appearance/shock,
neuromuscular disease,
artificial or abnormal airway,
recurrent wheezing
NOT RECOMMENDED on
Inpatient Units
Inclusion criteria: >28 days and <24 months with clinical
symptoms of ↑WOB, persistent cough, feeding difficulty, +/- fever,
first episode of wheezing OR with a diagnosis of bronchiolitis
- CPT
- CXR
- RSV test
- Blood tests (CBC/Blood
culture): unless clinically
indicated
- Antibiotics unless confirmed
bacterial source present
- Corticosteroids
- Use of inhaled bronchodilators
Supplemental oxygen should be administered to maintain SaO2>90%
If febrile and >28days & ≤90 days consider: UA, urine culture, CBC, and
blood culture
α
Assess Disease Severity
NO
*Mild Symptoms
YES
Meets
Discharge
Criteria
- Supportive Care
- BSS Score Q4hrs and prn
- PO ad lib
- Strict I&O
- Nasal suction using nasal aspirator
*Assess
Disease
Severity
STOP
Notify Provider
NOT
Effective
NO
*Moderate Symptoms
YES
YES
**Discharge Using
Discharge Criteria
- Supportive Care
- BSS Score Q4hrs and prn
- PO ad lib OR NPO w/ IVF or NG feeds
- Strict I&O
- Nasal suction using nasal aspirator
NO
***
Transfer to
Pulmonary Unit, IMC
OR
Consult w/Intensivist for
transfer to PICU
*Severe Symptoms
NO Improvement
After Interventions,
Initiation of HFNC,
OR Minimal Improvement
- Notify Provider
- NPO w/ IVF
- Interventions as ordered
- Consider initiation of HFNC****
Treatment
Option
Treatment OPTION (Ordered by MD):
3% Saline Neb-Order 4ml Q4 hrs
- Multiple doses are required to assess
for effectiveness
- Pt should be re-evaluated Q24 hrs and
the treatment should be reordered if
it is to be continued
- Once initiated: If the pt moves to a
moderate assessment, the
treatment can be continued if it is
found to be effective
- If the treatment has been stopped,
it can ONLY be reordered if the pt is
experiencing severe symptoms
Effective
NO
Improvements
After
Interventions
YES
α
INTERVENTIONS:
All interventions should have a pre and post score to evaluate for effectiveness.
(including, but not limited to: suctioning, repositioning, switch to NPO, implementation or discontinuation of O2, nebs)
Scoring- RN: Q4 hrs and pre/post intervention and RT: pre/post intervention
*Assessment Guidelines
Mild
- Alert, active, feeding well
- None to minimal retractions
- RR normal to mildly elevated
(less than 50)
- >95% RA
Moderate
- Alert, consoles, feeding
decreased
- Minimal to moderate
retractions
- RR is mildly to moderately
elevated (50-69)
- 91-94% on RA
Severe
- Fussy, difficult to console, poor
feeding
- Moderate to severe retractions
- RR moderately to severely
elevated (>70)
- <90% on RA
**Discharge Criteria
- SpO2 ≥ 90% RA for ≥ 2 hours
- Respirations less than 60 per minute
and/or minimal to no evidence of
increased work of breathing
- Oral feedings tolerated at a level
to maintain hydration
- Parents comfortable with
providing home care, and parent
education complete, including
understanding:
- signs/symptoms of increasing
respiratory distress
- proper nasal suctioning (must
demonstrate ability with bulb
suction)
- risk of passive smoke
exposure
- encourage continued DBF
- prevention education
- Need for PCP follow-up
***Admission (Unit) Criteria
Floor:
- Moderate WOB, tachypnea
- O2 requirement
- Requires frequent suctioning
- Dehydrated or unable to maintain oral feedings
- Parent unable to care for infant at home
Pulmonary Unit- High Acuity (Floor criteria +):
- Moderate to severe WOB
- O2 requirement (< 50% FiO2)
- HFNC (see right)
IMC (Floor, Pulmonary Unit criteria +):
- HFNC (see right)
- Co-morbidities (CLD)
- BP requires close monitoring
PICU (Floor, Pulmonary Unit, IMC criteria +):
- Positive pressure ventilation
- Witnessed episode of apnea
- Severe dehydration/shock
- HFNC (see right) or if not improving on HFNC
after 30 minutes
High Flow Nasal Cannula Guidelines
HFNC**** (see addendum 1)
Any flow rates above what is listed
below require an Intensivist consult.
(See addendum 2 for feeding
guidelines)
Weight (kg)
<7
7 –9
>9
Initial flow Max flow
rate (lpm) rate (lpm)
4
6
6
8
6
10
PC 02-19-15
DELL CHILDREN’S MEDICAL CENTER
EVIDENCE-BASED OUTCOMES CENTER
Addendum 2
Bronchiolitis and High Flow Nasal Cannula FEEDING Guidelines
Recommended Guidelines for Use by PCRS
Nutrition remains an important element to the treatment and healing of a child with
bronchiolitis. There is little research that specifically addresses the safety of PO feeding a child
with bronchiolitis AND has been started on high flow nasal cannula (HFNC). Below are
guidelines based on literature review and the medical opinion of the DCMC Bronchiolitis
workgroup.
Upon initiation of HFNC, the child should remain NPO to assess clinical response for
approximately 1 hour. At that time, a discussion amongst the medical team and led by the
attending physician will determine the appropriate method of nutrition.
• Should the child’s hydration status at the induction of HFNC be of concern, the medical
team can choose from the following options:
o Nasogastric tube (NGT)*
o IVF
o NGT + IVF
o NJT ( Nasojejunal tube)
If PO feeds have been started, it is strongly recommended to make the child NPO and consider
the above options if:
• Choking/gasping and/or an increase in work of breathing during or acutely after PO
feeding
• Respiratory rate consistently >60 bpm beyond 15 minutes
• Child is titrated to the maximum flow rate of HFNC for weight
At any time, the physician has the option to make the child NPO and hydrate the child by other
means.
*Recommend initial NGT trial of pedialyte before (EBM or formula) to assess the child’s
tolerance gastric distention while experiencing respiratory distress.
PCRS/ GMiner
POSTED: November 2014
DELL CHILDREN’S MEDICAL CENTER
EVIDENCE-BASED OUTCOMES CENTER
References
*American Academy of Pediatrics Recommendations
Shawn L. Ralston, Allan S. Lieberthal, H. Cody Meissner, et. al., Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis.
Pediatrics: The official journal of the Americal Academy of Pediatrics. 2014. E1474-e1503.
Link: http://pediatrics.aappublications.org/content/early/2014/10/21/peds.2014-2742
Albuterol
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Basic Metabolic Panel Testing
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Chest X-ray
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