The following are from the 2015 National Institute for Care and Health Excellence (NICE) Bronchiolitis Guidelines. Reference (1)
Summary of Recommendations
1. When diagnosing bronchiolitis, take into account that it occurs in children under 2 years of age and most commonly in the first year of life, peaking between 3 and 6 months.
2. When diagnosing bronchiolitis, take into account that symptoms usually peak between 3 and 5 days, and that cough resolves in 90% of infants within 3 weeks.
3. Diagnose bronchiolitis if the child has a coryzal prodrome lasting 1 to 3 days, followed by:
persistent cough and
either tachypnoea or chest recession (or both) and
either wheeze or crackles on chest auscultation (or both).
4. When diagnosing bronchiolitis, take into account that young infants with this disease (in particular those under 6 weeks of age) may present with apnoea without other clinical signs.
5. When diagnosing bronchiolitis, take into account that the following symptoms are common in children with this disease:
fever (in around 30% of cases, usually of less than 39°C)
poor feeding (typically after 3 to 5 days of illness).
6. Consider a diagnosis of pneumonia if the child has:
high fever (over 39°C), and/or
persistently focal crackles.
7. Think about a diagnosis of viral-induced wheeze or early-onset asthma rather than bronchiolitis in older infants and young children if they have:
persistent wheeze without crackles or
recurrent episodic wheeze or
a personal or family history of atopy.
Take into account that these conditions are unusual in children under 1 year of age
8. Immediately refer children with bronchiolitis for emergency hospital care (usually by 999 ambulance) if they have any of the following:
apnoea (observed or reported)
child looks seriously unwell to a healthcare professional
severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
central cyanosis
persistent oxygen saturation of less than 92% when breathing
air.
9. Consider referring children with bronchiolitis to hospital if they have any of the following:
a respiratory rate of over 60 breaths/minute
difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume, taking account of risk factors [see
recommendation 16] and using clinical judgement)
clinical dehydration.
10. When deciding whether to refer a child with bronchiolitis to secondary care, take account of the following risk factors for more severe bronchiolitis:
chronic lung disease (including bronchopulmonary dysplasia)
haemodynamically significant congenital heart disease
age in young infants (under 3 months)
premature birth, particularly under 32 weeks
neuromuscular disorders
immunodeficiency
11. When deciding whether to refer a child to secondary care, take into account factors that might affect a carer’s ability to look after a child with bronchiolitis, for example:
social circumstances
the skill and confidence of the carer in looking after a child with bronchiolitis at home
confidence in being able to spot red flag symptoms (see
recommendation 14)
distance to healthcare in case of deterioration.
12. Clinically assess the hydration status of children with bronchiolitis.
13. Do not routinely perform blood tests in the assessment of a child with bronchiolitis.
14. Provide key safety information for parents and carers to take away for reference for children who will be looked after at home. This should cover:
how to recognise developing ‘red flag’ symptoms:
worsening work of breathing (for example grunting, nasal
flaring, marked chest recession)
fluid intake is 50-75% of normal or no wet nappy for 12 hours
apnoea or cyanosis
exhaustion (for example, not responding normally to social
cues, wakes only with prolonged stimulation)
that people should not smoke in the child’s home because it
increases the risk of more severe symptoms in bronchiolitis
how to get immediate help from an appropriate professional if any red flag symptoms develop
arrangements for follow-up if necessary.
15. When assessing a child in a secondary care setting, admit them to hospital if they have any of the following:
apnoea (observed or reported)
persistent oxygen saturation of less than 92% when breathing
air
inadequate oral fluid intake (50-75% of usual volume, taking
account of risk factors [see recommendation 16] and using
clinical judgement)
persisting severe respiratory distress, for example grunting,
marked chest recession, or a respiratory rate of over 70
breaths/minute.
16. When deciding whether to admit a child with bronchiolitis, take account of the following risk factors for more severe bronchiolitis:
chronic lung disease (including bronchopulmonary dysplasia)
haemodynamically significant congenital heart disease
age in young infants (under 3 months)
premature birth, particularly under 32 weeks
neuromuscular disorders
immunodeficiency.
17. When deciding whether to admit a child, take into account factors that might affect a carer’s ability to look after a child with bronchiolitis, for example:
social circumstances
the skill and confidence of the carer in looking after a child with bronchiolitis at home
confidence in being able to spot red flag symptoms (see
recommendation 14)
distance to healthcare in case of deterioration.
18. Provide parents or carers with key safety information (see
recommendation 14) if the child is not admitted.
19. When deciding on the timing of discharge for children admitted to
hospital, make sure that the child:
is clinically stable
is taking adequate oral fluids
has maintained oxygen saturation over 92% in air for 4 hours,
including a period of sleep.
20. When deciding whether to discharge a child, take into account factors
that might affect a carer’s ability to look after a child with bronchiolitis,
for example:
social circumstances
the skill and confidence of the carer in looking after a child with
bronchiolitis at home
confidence in being able to spot red flag symptoms (see
recommendation 14)
distance to healthcare in case of deterioration.
21. Provide parents or carers with key safety information (see
recommendation 14) when the child is discharged.
22. Give fluids by nasogastric or orogastric tube in children with
bronchiolitis if they cannot take enough fluid by mouth.
23. Give intravenous isotonic fluids (see NPSA guidance c) to children who:
do not tolerate nasogastric or orogastric fluids or
have impending respiratory failure.
24. Measure oxygen saturation in every child presenting with suspected bronchiolitis, including those presenting to primary care if pulse oximetry is available.
25. Measure oxygen saturation using pulse oximetry in every child presenting to secondary care with clinical evidence of bronchiolitis.
26. Ensure healthcare professionals performing pulse oximetry are appropriately trained in its use specifically in infants and young children.
27. Do not routinely perform a chest X-ray in children with bronchiolitis, because changes on X-ray may mimic pneumonia and should not be used to determine the need for antibiotics.
28. Consider performing a chest X-ray if intensive care is being proposed for a child.
29. Do not routinely carry out blood gas testing in children with bronchiolitis.
30. Consider carrying out capillary blood gas testing in children with severe worsening respiratory distress (when supplemental oxygen concentration is greater than 50%) or suspected impending respiratory failure (see recommendation 31).
31. Suspect impending respiratory failure, and take appropriate action as these children may need intensive care, (see recommendations 8 and 36), if any of the following are present:
signs of exhaustion, for example listlessness or decreased
respiratory effort
recurrent apnoea
failure to maintain adequate oxygen saturation despite oxygen supplementation.
32. Do not perform chest physiotherapy on children with bronchiolitis who do not have relevant comorbidities (for example spinal muscular atrophy, severe tracheomalacia).
33. Consider requesting a chest physiotherapy assessment in children who have relevant comorbidities (for example spinal muscular atrophy, severe tracheomalacia) when there may be additional difficulty clearing secretions.
34. Do not use any of the following to treat bronchiolitis in children:
antibiotics
hypertonic saline
adrenaline (nebulised)
salbutamol
montelukast
ipratropium bromide
systemic or inhaled corticosteroids
a combination of systemic corticosteroids and nebulised
adrenaline
35. Give oxygen supplementation to children with bronchiolitis if their oxygen saturation is persistently less than 92%.
36. Consider continuous positive airway pressure (CPAP) in children with bronchiolitis who have impending respiratory failure (see recommendation 31).
37. Do not routinely perform upper airway suctioning in children with bronchiolitis.
38. Consider upper airway suctioning in children who have respiratory distress or feeding difficulties because of upper airway secretions.
39. Perform upper airway suctioning in children with bronchiolitis presenting with apnoea even if there are no obvious upper airway secretions.
Resources:
(1) Bronchiolitis: Diagnosis and Management of Bronchiolitis in Children. [PubMed Citation] [Full Text PDF]
Editors:National Collaborating Centre for Women’s and Children’s Health (UK).
Source:
London: National Institute for Health and Care Excellence (UK); 2015 Jun.
National Institute for Health and Care Excellence: Clinical Guidelines.
