T.C. Thompson Children’s Hospital Evidence Based Clinical Practice
Guidelines for Infants with Bronchiolitis
(September 23, 2010)
Modified from the Cincinnati Children’s Hospital Medical Center Guidelines (August 15, 2005)
Target Population
1. Infants less than one year of age presenting to the hospital for the first time with
bronchiolitis typical in presentation and prehospital clinical course.
2. These Guidelines are not intended for use in the following types of bronchiolitis patients:
 Patients with a history of cystic fibrosis, bronchopulmonary dysplasia, asthma, or other
significant respiratory disease.
 Patients with immunodeficiencies.
 Patients admitted to an intensive care unit.
 Patients with other significant comorbid conditions complicating care, which may include
congenital heart disease, Down syndrome, and conditions which predispose to pulmonary
hypertension.
3. For those infants who initially meet guideline criteria but do not subsequently follow a
typical course, consideration for a pulmonary consult should be given.
4. The information provided is intended for informational purposes only. This information is
derived from clinical experience and clinical research and is intended as a guideline and not
as a replacement for any medical provider’s decision making, which shall at all times be and
remain in the sole discretion of such provider.
Introduction
Bronchiolitis is an acute inflammatory disorder of the lower respiratory tract, occurring
most commonly in infants and young children, caused by infection with seasonal viruses.
Respiratory syncytial virus (RSV) accounts for 50% to 80% of cases.1 Other causes include
parainfluenza virus, influenza virus, adenovirus, and human metapneumovirus.2 Viral etiology
does not reliably predict illness severity.
Typical bronchiolitis is a self-limited disease that is little modified by aggressive
evaluations, use of antibiotics, or other therapies. The median duration of illness for children
with bronchiolitis is 12 days; after 21 days approximately 18% will remain ill, and after 28 days
9% will remain ill.3 Most infants who contract RSV infection recover without sequelae;
however, up to 40% may have subsequent wheezing episodes through five years of age and
approximately 10% will have wheezing episodes after age five.4 The average hospital stay is 3-7
days.5-7 RSV associated infant deaths number less than 500 per year in the U.S.; most deaths
occur in children without concurrent cardiac or pulmonary disease.8
“Recognizing the pathologic picture that occurs in the airways of children with
bronchiolitis is important in understanding the clinical manifestations and developing rational
management. The viral infection occurs through the upper respiratory tract and spreads lower
within a few days. This results in inflammation of the bronchiolar epithelium, with peribronchial
infiltration by mostly mononuclear cells and edema of the submucosa and adventitia. Plugs of
sloughed, necrotic epithelium and fibrin in the airways cause partial or total obstruction to
1
airflow. The degree of obstruction may vary as these areas are cleared, resulting in rapidly
changing clinical signs that confound an accurate assessment of the severity of illness. A ‘ballvalve’ mechanism can result in trapping of air distal to obstructed areas, with subsequent
absorption, atelectasis, and a mismatch of pulmonary ventilation and perfusion that may lead to
hypoxemia. Atelectasis may be accelerated by the lack of collateral channels in young children
and potentially by the administration of high concentrations of supplemental oxygen, which is
absorbed more rapidly than room air. Smooth muscle constriction seems to have little role in the
pathologic process, which may explain the limited benefit of bronchodilators observed in
clinical studies.” 9 (p 343)
Several studies of the use of clinical guidelines for the management of bronchiolitis have
shown a reduction in unnecessary resource utilization with a streamlining of medical care for
these infants.5,10-15
This document provides a practical, evidence based approach to the diagnosis and
management of acute bronchiolitis in infants and children less than two years of age. The
recommendations are based on the most current and best scientific information available. In the
absence of quality evidence, expert opinion and group consensus were used.
Guideline Recommendations
Prevention:
1. High Risk Patients: Infants with the following conditions are at increased risk of significant
morbidity from bronchiolitis and are at increased risk for hospitalization:





age < 3 months
prematurity (<35 weeks corrected gestational age)
chronic lung disease
congenital heart disease
immune deficiency syndromes8,16-19
Prevention of bronchiolitis in these patients is of primary importance. Specific measures to
prevent bronchiolitis include:



limiting exposure to contagious settings (i.e., daycare) and siblings
eliminating exposure to second-hand tobacco smoke
careful handwashing to minimize spread of viruses.
These measures should be discussed regularly with parents of newborns upon nursery
discharge and at primary care visits for all high risk patients listed above during bronchiolitis
season.
Additionally, preventive medical therapy such as palivizumab (Synagis®, MedImmune) may
be considered for selected, high-risk patients. Please refer to the current edition of the AAP's
RedBook for recommendations on palivizumab's indications and dosing.
2
2. Nosocomial Prevention: Transmission of RSV and other respiratory viruses occurs by direct
inoculation of contagious secretions from the hands or by large-particle droplets into the eyes
and nose, but rarely the mouth.20,21 Nosocomial infection may place medically fragile patients at
increased risk for morbidity and mortality.22 It is therefore recommended that droplet and
contact isolation measures be followed for all patients with bronchiolitis.23









"Droplet Precautions" and "Contact Precautions" signs are to be placed on the patient's
door
A private room is preferred
Patients are not allowed in common areas (i.e., playroom) or other patient rooms
A surgical mask is to be worn by all healthcare workers within 3 feet of the patient
Protective eyewear is encouraged
Strict hand washing should precede and follow all patient encounters and gloves should
be worn by all who enter room
Impervious cover gowns should be worn when it is anticipated that clothing will have
contact with the patient or patient's environment
Dedicated patient equipment should remain in the patient's room and not be shared with
other patients.
A disposable stethoscope provides a sub-optimal auscultory exam. A dedicated
stethoscope should remain in the patient’s room and be sanitized upon discharge.
General:
The basic management of typical bronchiolitis is anchored in the provision of therapies
that ensure the patient is clinically stable, well oxygenated, and well hydrated. The main
benefits of hospitalization of infants with bronchiolitis are the careful monitoring of clinical
status, maintenance of a patent airway (through positioning, suctioning, and mucus
clearance), maintenance of adequate hydration, and parental education24-27 (Local Expert
Consensus).
Diagnosis and Assessment:
The diagnosis of bronchiolitis and assessment of its severity is rooted in the
clinician’s interpretation of the constellation of characteristic findings and is not dependent
on any specific clinical finding or diagnostic test.
“Clinicians recognize bronchiolitis as a constellation of clinical symptoms and signs
including a viral upper respiratory prodrome followed by increased respiratory effort and
wheezing in children less than 2 years of age.”28 (pp1776-7)
Clinical signs and symptoms of bronchiolitis may include rhinorrhea, cough, auscultatory
findings of wheezing or crackles, tachypnea, and increased respiratory effort manifested by
grunting, nasal flaring, and intercostal and/or subcostal retractions. The physical exam reflects
the variability in the disease state and benefits from serial observations over time to fully assess
3
the child’s status. Upper airway obstruction may contribute to the work of breathing, and nasal
suctioning and positioning of the child may affect the assessment.
Other important issues to assess in the patient with bronchiolitis include the impact of
respiratory symptoms on feeding and hydration and the response, if any, to therapy. The ability
of the family to care for the child and return for further care should also be assessed. A history of
underlying conditions such as prematurity, cardiac or pulmonary disease, immunodeficiency, or
previous episodes of wheezing should be identified.
Several studies have associated premature birth (less than 37 weeks) and young age (less
than 6-12 weeks) with an increased risk of severe disease.6,29,30 Other underlying conditions that
have been associated with an increased risk of progression to severe disease or mortality include
hemodynamically significant congenital heart disease, chronic lung disease (bronchopulmonary
dysplasia, cystic fibrosis, congenital anomaly), and the presence of an immunocompromised
state.28
Apnea is a specific and important concern in the management of young infants with
bronchiolitis, especially with RSV. In a retrospective study of 691 infants younger then 6 months
of age hospitalized for bronchiolitis, apnea occurred in 19 (2.7%).31 Risk factors included either
(1) history of an apneic event having already occurred or (2) young age, defined as less than 1
month for term infants or a postconceptional age of less than 48 weeks for premature infants.
Laboratory and Radiographic Tests:
Routine laboratory studies are generally not necessary and may result in increased rates of
unnecessary hospital admissions and therapies and unwarranted diagnostic testing.
 Chest X-Rays are not routinely recommended and should only be obtained as
clinically indicated when the diagnosis of bronchiolitis is unclear or when the
presentation is severe.13,32-34
 Routine testing for the presence of RSV antigen or other viral infections by PCR from
nasopharyngeal washings is not recommended for infants >8 weeks of age. Similarly, risk
of serious bacterial infection in infants >8 weeks of age with bronchiolitis is extremely
low, and so routine cultures of blood and CSF are not recommended.13,14,25,35-40
 Those infants not following a typical course may, however, warrant a rapid
respiratory panel for diagnostic purposes (Local Expert Consensus).
 In the infant <8 weeks of age with clinical symptoms of bronchiolitis and a positive RSV
antigen, routine blood and spinal fluid cultures are not indicated.41 There is, however, a
clinically relevant rate (approximately 5%) of UTI in these infants, thus urinalysis and
urine culture should be considered.36,37,42,43
 Capillary or arterial blood gas testing is recommended only as clinically indicated for
individual patients28 (Local Expert Consensus).
4
Medications:
1. Oxygen therapy is frequently required in the treatment of bronchiolitis. It is recommended
that oxygen saturation monitoring be utilized to maintain blood oxygen levels within a
normal range. This range is variable in definition and patient specific, though in general
adequate arterial oxygen levels are achieved when the oxygen saturation is between 90% and
94%. Therefore, starting supplemental oxygen when the saturation is consistently less than
90% and weaning oxygen when it is consistently higher than 94% is considered reasonable44
 See the Monitoring section for recommendation regarding oxygen saturation monitoring.
2. Hypertonic saline
 In 2008, a Cochrane review stated: “Current evidence suggests nebulized 3% saline may
significantly reduce length of stay and improve the clinical severity score in infants with
acute viral bronchiolitis.” 45 There are many other studies that suggest hypertonic saline
may be of some clinical benefit in bronchiolitis improving clinical scores and length of
hospital stay.46-50 However, these studies allowed the use of bronchodilators with the
hypertonic saline for fear of inducing bronchospasm as a complication of hypertonic
saline as single therapy. One study has recently shown that the overall adverse event rate
for single therapy hypertonic saline is relatively low at 1%.51
 Hypertonic 3% saline may be used to promote airway clearance. Evidence suggests that
adverse events are uncommon, but may result in deterioration of clinical status and
bronchiolitis clinical score. If that occurs consideration should be given to stopping this
treatment.46,47,51,52
3. Bronchodilators:
 Although widely used and studied, the efficacy of inhaled bronchodilators in the
treatment of bronchiolitis is uncertain, and the published results have been variable. For
this reason, multiple evidence-based systemic reviews and meta-analysis studies have
been done regarding their use. Based on the evidence reviewed by this committee,
bronchodilators should not routinely be used among inpatients as there has been no
proven benefit in length of hospital stay or long term clinical outcome.9,28,53-55
 Deterioration has been associated with bronchodilator inhalation therapies.56,57
Therefore, if a trial of bronchodilator inhalation therapy is undertaken, and there is no
significant improvement in clinical appearance between 15-30 minutes,24,58 it is
recommended that the therapy not be continued or repeated (Local Expert Consensus).
 Inhaled Beta Agonists:
 From a recent Cochrane review: “Bronchodilators [other than epinephrine] produce
small short-term improvements in clinical scores among infants with bronchiolitis
and may slightly improve oxygenation in those treated as outpatients. However,
given the high costs, incidence of adverse effects and uncertain efficacy based on the
findings of this meta-analysis, bronchodilators cannot be recommended for routine
management of first time wheezers who present with the clinical findings of
5

bronchiolitis. Bronchodilators should not be used in patients who are hospitalized
with bronchiolitis.” 53 (p8)
 Other studies support that it is reasonable to give a trial of nebulized albuterol therapy
with close monitoring for clinical improvement to patients with significant risk
factors for asthma. These include a prior history of wheezing or eczema, or a firstdegree relative with asthma. Scheduled or serial use of bronchodilator aerosol
therapies is not recommended unless there is documented objective clinical
improvement.9,28,54,59,60
 Three meta-analysis and several randomized controlled trials have not shown
dramatic effects on clinical scores or hospitalization rates from therapy with
nebulized albuterol.53,61-63
 In the majority of cases the use of inhalation therapies and other treatments effective
for treating the bronchospasm characteristic in asthma will not be efficacious for
treating the airway edema typical of bronchiolitis.20,24
Inhaled Epinephrine:
 In 2004, a Cochrane review stated: “There is insufficient evidence to support the use
of epinephrine for the treatment of bronchiolitis among inpatients. There is some
evidence to suggest that epinephrine may be favorable to salbutamol and placebo
among outpatients.”55 (p2)
 Among the 5 inpatient studies comparing nebulized epinephrine to placebo, only
one showed a statistically significant outcome that favored epinephrine. That
outcome was an improvement in clinical score at 60 minutes. Among the 4
inpatient studies comparing epinephrine and salbutamol, only one had statistically
significant clinical improvement favoring epinephrine. That improvement was a
better respiratory rate at 30 minutes. In all studies reviewed, there were no long
term clinical improvements favoring epinephrine.55
 One older study showed that nebulized racemic epinephrine reduced hospitalizations
rates by 59%, but other studies had inconsistent results.57,64-69 Two studies have
shown that nebulized epinephrine does not reduce hospital length of stay.57,69
4. Antibiotics are not recommended in the treatment of bronchiolitis unless a specific
coexisting bacterial infection has been identified. Multiple randomized controlled trials have
shown no benefit in antibiotic use.70-72 A meta-analysis in 2007 again found no evidence to
support the use of antibiotics for bronchilitis.73 A recent summary article on the management
of bronchilitis does not even mention antibiotics.9 When coexisting bacterial infections are
identified (urinary tract infection, acute otitis media) they should be managed in the same
manner as in the absence of bronchiolitis.
5. Over-the-counter cough and cold medications are not recommended for routine therapy.
There is no evidence to date for their efficacy in the reduction of cough or congestion in
infants with upper and lower respiratory tract infections.74-78 The FDA recommends that
“these drugs not be used to treat children under 2 years of age because serious and potentially
life-threatening side effects can occur.” 79 (p1)
6
6. Steroid therapy given as by inhalation, intravenously, orally, or intramuscularly is not
routinely recommended due to a lack of effect on clinical status or on absolute length of
stay in the hospital.24-26,80-84 A single study using a high dose of dexamethasone in
outpatients with bronchiolitis has shown decreased hospitalization rates in the treated group
compared to placebo. However, the side effects and relative risks and benefits with these
doses of dexamethasone require further study before advocating routine implementation.85
 One large study of 147 infants <24 months of age showed no benefit of prednisolone in
the acute phase, at 1 month follow up and 1 year follow up. The conclusion was that such
therapy should not be prescribed. 86
 A more recent study evaluated the use of high dose inhaled steroids for 3 months after
hospitalization for severe RSV infection. The intent was to prevent recurrent wheezing
which occurs following severe infection in young infants. No benefit was found and such
treatment should not be advocated. 87
 A final word of caution should be given concerning steroids in young children.
Significant alveolar development occurs in the postnatal lung. Animal studies have
demonstrated a deleterious effect on alveolar development with both parenteral and
inhaled steroids.88,89 An editorial in the New England Journal of Medicine also warned
of possible effects in young children.89
7. Montelukast:
 It is known that the airway obstruction in viral induced bronchiolitis is due to
inflammation. One inflammatory mediator is cysteinyl-leukotriene (cys-LT). Because
montelukast is a leukotriene receptor antagonist, there has been interest in using this
medication in both treatment for bronchiolitis and in reducing recurrent wheezing after
bronchiolitis. A promising pilot study seemed to show a reduction in respiratory
symptoms in this population.90 A much larger study by the same authors failed to show
any benefit for montelukast in reducing post RSV respiratory symptoms. However, post
hoc analysis suggested that a subgroup with more persistent symptoms showed some
improvement.91 Another study looked at the reduction in post-RSV respiratory
symptoms92 and again failed to show benefit.
 A single study has looked at the use of montelukast in the treatment of acute
bronchiolitis. Although small, no benefit (length of stay, clinical score, and cys-LT
levels) was seen in the treatment group.93
 Based on these studies, it is recommended to not routinely use montelukast in the
treatment of bronchiolitis. A subgroup of patients with persistent symptoms in the months
following a severe episode of bronchiolitis might, however, benefit from montelukast
Respiratory Care Therapies:
1. It is recommended that the infant be suctioned before feedings, as needed, and prior to
any aerosol therapy (Local Expert Consensus). Suction should be performed with either a
7
nasal olive or a bulb syringe. Normal saline drops may be used prior to suctioning (Local
Expert Consensus). Deep catheter suctioning should be avoided.
 3% saline, given in doses of 4mL nebulized q2 hours x 3, then q4 hours x 5, then q6
hours until discharge, is a reasonable, evidence-based therapy to promote airway
clearance in infants with bronchiolitis.46,47
2. Other routine respiratory care therapies are not helpful and are not generally recommended.
 Chest physiotherapy (CPT) is not recommended.94,95
 Cool mist therapy is not recommended.96
 Aerosol therapy with normal saline alone is not recommended.56,97,98
Monitoring:
Serial clinical assessments by skilled physicians, nurses, and respiratory therapists are the
mainstay of monitoring for worsening respiratory distress. Electronic monitoring of heart rate,
respiratory rate, and oxygen saturation can provide useful additional clinical data, but may also
increase length of stay and impede a patient’s transition to home.
1. Serial assessments using the bronchiolitis respiratory care flow sheet should be used pre- and
post-respiratory care intervention.
2. Cardiorespiratory monitors are not routinely recommended for patients with bronchiolitis.
3. Consider cardiorespiratory monitoring for those hospitalized patients at highest risk for apnea
during their first 48-hours of illness. Because RSV-associated apnea is usually of short
duration, there is no indication for home monitoring after hospitalization.99,100
4. In hospitalized patients, it is recommended that scheduled spot checks of pulse oximetry be
utilized in infants with bronchiolitis as opposed to continuous pulse oximetry (Local Expert
Consensus).
 Due to the technical complexity and variability in readings in infants, continuous pulse
oximetry may increase duration of hospitalization through unnecessary continuation of
supplemental oxygen after resolution of other clinical symptoms.6,101,102
 Pulse oximetry has not been shown to be helpful in predicting morbidity or length of stay
in wheezing infants or infants with bronchiolitis.103-105
Parent Education
1. Educate parents on the basic pathophysiology and expected clinical course of bronchiolitis,
emphasizing that it is a self-limited disease.
 Refer to Introduction section.
2. Educate parents on the proper techniques for suctioning, airway maintenance, and feeding
techniques (Local Expert Consensus).
3. Educate parents about when to call their health care provider by explaining the signs of
worsening clinical status:
 Increasing respiratory rate and work of breathing as indicated by accessory muscle use.
 Inability to maintain adequate hydration.
8
 Worsening general appearance.
4. Infection Control Education
 Refer to Prevention Section.
ED Discharge Criteria
Respiratory Status
1.
2.
3.
4.
Baby relatively comfortable on room air.
Respiratory rate < 70/min.
Parents demonstrate ability to perform nasal suctioning.
Oxygen saturation is consistently > 90%.
Nutritional Status
1. The patient is not dehydrated and demonstrates an ability to feed by mouth.
Treatment Modalities
1. Patient is able to tolerate oral medications if indicated.
Social
1. Parents demonstrate an understanding of discharge instructions and education on signs of
worsening clinical status.
Follow Up
1. Patient has a reasonable availability of medical care if respiratory status worsens.
Hospital Discharge Criteria
Respiratory Status
1. Respiratory rate usually < 70/min and baby relatively comfortable.
2. Parent can clear the infant’s airway using bulb suctioning.
3. Patient is stable in room air with oxygen saturation consistently > 90%.
Nutritional Status
1. The patient is on oral feedings at a level to prevent dehydration.
Treatment Modalities
1. The patient is on oral medications if indicated.
9
Social
1. Home resources are adequate to support the use of any necessary home therapies.
2. Parent is proficient with therapies required.
3. Family has participated in the processes leading to the discharge decision.
Follow Up
1. When indicated, home care and durable medical supply agencies have been notified and
arrangements for visits finalized.
2. The primary care provider has been identified, notified, and agrees with discharge decision,
and follow-up appointments have been scheduled.
Committee: Joel Ledbetter, MD, Annamaria Church, MD, Jennifer Hamm, MD, Kourtney
Santucci, MD, and Robert Wood, MD
Ad Hoc Committee: Tina Borey, RN, Linda Hill, RT, Toni Karimian, RN, Darcy Knowles,
and Alan Kohrt, MD
10
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