Bronchiolitis Guidelines From The Royal Children’s Hospital Of Melbourne And The American Academy Of Pediatrics

Bronchiolitis Guideline 2011 from The Royal Children’s Hospital Melbourne:



Time course.

Is the child improving, stable, or likely to deteriorate over the next few days? Peak severity is usually at around day 2-3 of the illness with resolution over 7-10 days. The cough may persist for weeks.

Risk factorsfor severe bronchiolitis

Young, especially < 6weeks
Ex-premature infants
Congenital Heart disease
Neurological conditions
Chronic respiratory illness
Pulmonary hypertension


Features of bronchiolitis:

– increased  work of breathing (link)
– widespread wheeze and crepitations
– +/- fever
– May have reduced oxygen saturation
– Look for signs of dehydration (link)Assessment of Severity

 Behaviour Normal  Some/intermittent irritability Increasing irritability and/or lethargy
Respiratory Rate Normal Increased Resp rate
Tracheal Tug
Nasal Flaring
Marked increase or decrease
Tracheal Tug
Nasal Flaring
Accessory Muscle Use  None or minimal  Moderate chest wall retraction  Marked chest wall retraction
 Feeding Normal  May have difficulty with feeding or reduced feeding  Reluctant or unable to feed
 Oxygen No oxygen requirement (Sa02  > 93%)  Mild hypoxemia corrected by oxygen**
(Sa02 90 – 93%)
 Hypoxemia, may not be corrected by oxygen**
(Sa02 < 90%)
Apnoeic episodes None  May have brief apnoeas  May have increasingly frequent or prolonged apnoeas

** A child who has congenital cardiac disease may have low baseline Sa02 eg <90% Note: Correlation between Sa02 and Bronchiolitis severity may vary significantly. Do not use Sa02 as a primary determinant of severity


Diagnosis and Management of Bronchiolitis, 2007, American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis:

“The 2 goals in the history and physical examination of infants presenting with cough and/or wheeze, particularly in the winter season, are the differentiation of infants with probable bronchiolitis from those with other disorders and the estimation of the severity of illness. Most 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. Clinical signs and symptoms of bronchiolitis consist of rhinorrhea, cough, wheezing, tachypnea, and increased respiratory effort manifested as grunting, nasal flaring, and intercostal and/or subcostal retractions.

“Respiratory rate in otherwise healthy children changes considerably over the first year of life, decreasing from a mean of approximately 50 breaths per minute in term newborns to approximately 40 breaths per minute at 6 months of age and 30 breaths per minute at 12 months.1820 Counting respiratory rate over the course of 1 minute may be more accurate than measurements extrapolated to 1 minute but observed for shorter periods.21 The absence of tachypnea correlates with the lack of LRTIs or pneumonia (viral or bacterial) in infants.22,23 

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