Pediatric Bronchiolitis (AAP 2014)

Algorithm Steps

1. ▶

   Start

   Suspected Bronchiolitis

   Infant 1-23 months with viral respiratory illness

   1. ●

      Action

      Clinical Diagnosis

      Bronchiolitis is a clinical diagnosis

      • History and physical exam based diagnosis
      • First episode of wheezing in infant <24 months
      • Viral prodrome (rhinorrhea, cough, low-grade fever)
      • DO NOT ROUTINELY:
      • • Order chest X-ray (unless pneumonia suspected)
      • • Perform viral testing (unless needed for cohorting)
      • • Order blood tests
      1. ●

         Action

         Assess Severity

         Clinical assessment of respiratory status

         • MILD:
         • • SpO2 ≥90%, minimal work of breathing
         • • Adequate oral intake
         • MODERATE:
         • • SpO2 90-92%, moderate retractions
         • • Decreased oral intake
         • SEVERE:
         • • SpO2 <90%, severe retractions
         • • Lethargy, apnea, poor perfusion
         • • Unable to feed
         1. ●

            Action

            Supportive Care (All Patients)

            Mainstay of treatment

            • NASAL SUCTIONING:
            • • Bulb suction or nasopharyngeal suction
            • • Before feeds and as needed
            • HYDRATION:
            • • Continue breastfeeding/formula if possible
            • • Small frequent feeds
            • • NG or IV fluids if unable to feed safely
            • OXYGEN: If SpO2 persistently <90%
            • Monitor for apnea in high-risk infants
            1. ✓

               Outcome

               Mild - Discharge Home

               Safe for outpatient management

               • Adequate hydration maintained
               • No hypoxia
               • Reliable parents with return precautions
               • Return if:
               • • Breathing gets worse
               • • Unable to feed
               • • Appears more tired or lethargic
               • • Color changes (blue lips)
            2. ●

               Action

               Moderate-Severe - Admit

               Hospital admission criteria

               • ADMIT IF:
               • • SpO2 <90% on room air
               • • Unable to maintain hydration orally
               • • Respiratory distress with accessory muscle use
               • • Age <12 weeks with RSV
               • • History of prematurity (<35 weeks)
               • • Underlying cardiopulmonary disease
               • • Immunodeficiency
               • • Apnea
               1. ●

                  Action

                  Inpatient Management

                  Hospital care

                  • Continuous pulse oximetry initially
                  • Nasal suctioning as needed
                  • IV or NG fluids if not feeding
                  • HIGH-FLOW NASAL CANNULA:
                  • • May use for moderate-severe
                  • • Not standard of care
                  • Wean O2 once improving
                  • Target SpO2 ≥90% (can discharge at this)
               2. ⚠

                  Warning

                  ICU Admission

                  Escalating support needed

                  • Respiratory failure
                  • Apnea requiring intervention
                  • Inability to maintain SpO2 ≥90%
                  • Impending respiratory failure
                  • Consider:
                  • • CPAP/BiPAP
                  • • Intubation if failing non-invasive support
                  • • Surfactant (off-label, limited evidence)
      2. ⚠

         Warning

         NOT Recommended Routinely

         Do NOT give these treatments

         • ❌ Bronchodilators (albuterol/salbutamol)
         • ❌ Epinephrine (nebulized)
         • ❌ Systemic corticosteroids
         • ❌ Antibiotics (unless bacterial infection)
         • ❌ Hypertonic saline (in ED setting)
         • ❌ Chest physiotherapy
         • These do NOT improve outcomes and may cause harm