Management of Bronchiolitis in Infants - The Hospital for Sick Children

The Hospital for Sick Children Policies & Procedures Database 

Hospital-wide Patient Care 

Clinical Practice Guideline 

Valid only on date printed: 2011-11-16 08:12. Discard immediately after use! 

Management of Bronchiolitis in Infants 

Issuing 

Paediatrics Category: Patient Assessment & 

Department: 

Monitoring 

Issuing Authority: Denis Daneman Sub-Category: Management 

Section Name: Paediatric Medicine Publication Status: Approved 

Content Reviewer: Jeremy Friedman Last Modified: 2011-11-08 07:39 

Additional Editors: Amanda Hurdowar Additional Readers: Daniel Roth, Eyal Cohen, 

Chantelle Vankoughnet, 

Lisa-KE Robinson, Diane 

Soares 

Written By: Trey Coffey - Associate Staff - CPU 

Nora Constas - Nurse Practitioner 

Amanda Hurdowar - CPG Coordinator 

Review Committee 

Name: 

Co-issued by Paediatric Medicine and the Division of Paediatric Emergency Medicine . 

1.0 Introduction 

Inter-Professional Patient Care 

Committee 

This Clinical Practice Guideline (CPG) has been adapted from the Cincinnati Children’s Hospital Medical 

Center CPG, Evidence based care guideline for management of bronchiolitis in infants 1 year of age or 

less with a first time episode, (2010) and the American Academy of Paediatrics CPG , Diagnosis and 

management of bronchiolitis (2006) using the Adapte Framework. The development process is discussed 

in detail in section 4 of this document. 

Not all recommendations from the Cincinnati Children’s Hospital Medical Center (CCHMC) CPG, 

Evidence based care guideline for management of bronchiolitis in infants 1 year of age or less with a first 

time episode, (2006, 2010) and the American Academy of Paediatrics CPG , Diagnosis and management 

of bronchiolitis (2006) were adopted for the SickKids Management of Bronchiolitis in Infants Clinical 

Practice Guideline. Recommendations that were relevant to the care offered within SickKids were either 

(i) adopted (taken verbatim from CCHMC/AAP), or (ii) adapted (taken from CCHMC/AAP with slight 

modifications for use at SickKids. When any recommendation was adapted, the change noted in 

parentheses. In addition, there are a select number of SickKids consensus recommendations that were 

included that were not taken from the CCHMC/AAP guideline and these are clearly identified by "SickKids 

Consensus" in parentheses throughout the guideline text. The research considered when developing the 

recommendations are discussed in the original publications. Please click the links at the beginning of this 

paragraph to access the original publications for more detailed information. 

Bronchiolitis is an acute inflammatory disease of the lower respiratory tract, resulting from obstruction of 

small airways. It is initiated by infection of the upper respiratory tract by any one of a number of seasonal 

viruses , the most common of which is respiratory syncytial virus (RSV). 1 

There is considerable confusion and variability with respect to the clinical management of infants with 

bronchiolitis. Typical bronchiolitis in infants is a self-limited disease, usually due to an acute viral infection 

that is little modified by aggressive evaluations/interventions, use of antibiotics or other therapies. Most 

infants who contract bronchiolitis recover without sequelae; however, up to 40% may have subsequent 

wheezing episodes through five years of age and approximately ten percent will have wheezing episodes 

after age five. 1 

Several studies on the use of clinical guidelines for the management of infant bronchiolitis have shown a 

reduction in unnecessary resource utilization with a streamlining of medical care for these infants . 1 

Management of Bronchiolitis in Infants 1


1.1 Target Population 

Inclusion: This clinical practice guideline (CPG) is intended primarily for use in children age less than 12 

completed months of age (but may apply to children 12 - 18 months of age) and presenting for the first 

time with bronchiolitis typical in presentation and clinical course. 

Exclusion: This CPG is not intended for use in children: 

admitted to an intensive care unit 

requiring ventilator care 

with severe co-morbid conditions complicating care (including, but not limited to, cystic fibrosis (CF), 

bronchopulmonary dysplasia (BPD), and immunodeficiencies). 

� 

� 

� 

1.2 Target Users 

Include, but are not limited to: 

Emergency Medicine physicians, nurses, nurse practitioners, and trainees 

Inpatient physicians, nurses, nurse practitioners, and trainees 

Respiratory Therapists 

Pharmacists 

Patients and families 

� 

� 

� 

� 

� 

1.3 Objectives 

In the target population, the objectives of this guideline are to: 

decrease the use of unnecessary diagnostic studies 

decrease the use of medications and respiratory therapy without observed improvement 

improve the rate of appropriate admission 

decrease the rate of healthcare associated infection (HAI) 

improve the use of appropriate monitoring activities 

decrease length of stay 

� 

� 

� 

� 

� 

� 

2.0 Guideline Recommendations 

Table 1 serves as a guideline to the hierarchy of evidence available; with RCT or meta-analysis 

considered to be the highest level of evidence and expert opinion considered to be the lowest level of 

evidence that can be used to support each recommendation in this CPG. 

Table 1. Grades of Recommendation 

References in parentheses ( ). Grades of Recommendation in [ ] 

A. At least one randomized controlled trial, systematic review, or meta-analysis. 

B. At least one cohort comparison, case study or other experiment study. 

C. Expert opinion, experience of a consensus panel. 



[Grade of recommendation] 

Table 2. Bronchiolitis CPG Recommendation Highlights *Refer to full text within the 

guideline for more details 

Purpose and Scope : This CPG is intended primarily for use in children age less than 12 completed 

months of age (but may apply to children 12 - 18 months of age) and presenting for the first time with 

bronchiolitis typical in presentation and clinical course. This CPG is not intended for use in children: 

admitted to an ICU; requiring ventilator care; and/or with severe co-morbid conditions complicating care. 

Assessment: Clinical history and physical examination should be the basis for a diagnosis of 

bronchiolitis. 1[A] 

Laboratory & Radiological Tests: Routine diagnostic studies such as chest x-rays, cultures, capillary 

or arterial blood gases and nasopharyngeal swab for viral PCR need NOT be performed to guide clinical 

management, to determine viral infection status or to rule out serious bacterial infections. [A] 

Management 

Basic The basic management of typical bronchiolitis is anchored in the provision of therapies that 

Management assure that the patient is clinically stable, well oxygenated, and well hydrated. The main 

benefits of hospitalization of infants with acute bronchiolitis are: [B,C] 

� the careful monitoring of clinical status with frequent reassessment 

� maintenance of a patent airway (through positioning, suctioning, and mucus 

clearance) 

� maintenance of adequate hydration and oxygenation 

� parental education 

Oxygen � There is a lack of evidence to specify an oxygen saturation (by pulse oximetry) 

threshold below which supplemental oxygen is indicated. The SickKids Development 

Groups suggests starting supplemental oxygen when the saturation is consistently 

less than 88% while asleep and less than 90% when awake while breathing room air. [C] 

Bronchodilator Scheduled or serial Salbutamol aerosol therapies are not recommended. [A] 

� 

� 

HOWEVER, a single administration trial inhalation using epinephrine or Salbutamol 

may be considered as an option, particularly when there is a family history for allergy, 

asthma, or atopy. [A] 

Inhalation therapy should not be repeated nor continued if there is no documented 

� 

improvement in respiratory rate and effort between 15 to 30 minutes after a trial 

inhalation therapy. [A] 

Antibiotics Antibiotics should not be used in the absence of an identified bacterial focus. [A] 

� 

Ribavirin Ribavirin should not be used routinely in children with bronchiolitis. [A] 

� 

Steroid 

Therapy 

Steroid therapy should not routinely be given by any route. [A] 

� 

See 2.2.j for more details. 

The infant should receive oral or nasal suctioning when clinically indicated. [C] 

Respiratory 

Therapy 

� 

� Routine respiratory care therapies should NOT be used, as they have not been found 

to be helpful. These include: 

(i) Cardiopulmonary (chest) physiotherapy (CPT) [A] 

(ii) cool mist therapy [A] 

(iii) aerosol 

therapy with saline [A 

Monitoring: 

� Repeated clinical assessment should be conducted, as this is the most important aspect of 

monitoring for deteriorating respiratory status 

Consider scheduled spot checks of pulse oximetry (q 4-6 hr) in infants with bronchiolitis [C] 

� 

Discharge (See table 3 for Bronchiolitis Discharge Checklist) 

The interdisciplinary team should begin discharge planning on admission. [C] 

� 



Table 3. Bronchiolitis Discharge Criteria Checklist 

respiratory status is consistently improving 

Respiratory Status 

tachypnea and increased work of breathing are normal, mild or 

moderate 

oxygen saturation is in an acceptable range on room air (greater 

than 88% when sleeping and greater than 90% when awake) 

Nutritional Status the patient is on oral feedings sufficient to prevent dehydration 

Parent & Family Education 

Social 

Follow-up 

nature of illness and expected clinical course of bronchiolitis 

to call their primary care provider or return to the ED when the 

following signs of worsening clinical status are observed (Parent 

friendly language in parentheses) 

increasing respiratory rate and/or work of breathing as 

indicated by accessory muscle use 

(i.e. breathing very fast and/or skin sucking in around the neck or ribs 

with each breath) 

inability to maintain adequate hydration 

(i.e. unable to feed or drink by mouth or has not had a wet diaper in 

more than 6 to 8 hours) 

worsening general appearance 

(has new symptoms not present while in the hospital such as vomiting 

or fever, looks lethargic or does not respond normally to touch or 

sound, change in baby's colour) 

importance of handwashing before and after contact with the child 

to prevent spread of disease. 1[A] 

eliminating exposure to environmental smoking. 1[A] 

limiting exposure to contagious settings and siblings 

provide a general information printout See ==> About Kids Health – 

Bronchiolitis Fact Sheet for parents 

language skills to understand discharge instructions 

parent or guardian is competent and confident they can provide 

care at home 

parents have purchased and demonstrated correct use of bulb 

suction 

instructions of when to follow-up with own primary care provider 

(generally 1-2 days) 



2.1 Assessment and Diagnosis 

Clinical History and Physical Examination 

2.1a Clinical history and physical examination should be the basis for a diagnosis of bronchiolitis . 

(Adapted from CCHMC, 2010 Rec #3) [Grade A] 

NOTE : The diagnosis of bronchiolitis and 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 

(Bordley 2004) 

test . Infants with acute bronchiolitis may present with a wide range of clinical symptoms and severity, 

from mild upper respiratory infections (URI) to impending respiratory failure. 

Presenting features for bronchiolitis include, but are not limited to, the following: 

� 

� 

� 

� 

� 

(Adapted from CCHMC, 2010 Rec #3) 

Preceding upper respiratory illness and/or rhinorrhea 

First episode of respiratory distress associated with the following signs 


Wheezing 

(SickKids Consensus) 

Accessory muscle use, lower chest wall indrawing 


Crepitations 


Low O saturation 2 


Elevated respiratory rate for age 


Colour change 


Nasal flaring 


Fever 


Signs of dehydration 

Exposure to persons with viral upper respiratory infection 


Presentation typically between November and April 

� 

� 

� 

� 

� 

� 

� 

� 

Admission criteria 

2.1b Patients should be considered for critical care admission if : 

Recurrent apneas 

� 



(Ralston, 2009) 

NOTE: The risk of apnea in previously healthy infants born at term is


Laboratory and Radiologic Studies 

2.1d Routine diagnostic studies need not be performed to guide clinical management , to determine 

viral infection status or to rule out serious bacterial infections . Such studies are not generally helpful and 

may result in increased rates of unnecessary admission , further testing, and unnecessary therapies . 

(Bordley 2004 [A], Swingler 1998 [A], El-Radhi 1999 [B], Kuppermann 1997 [B], Liebelt 1999 [B], Antonow 1998 [B], Schwartz 1995 [B], Chiocca 1994 [B], 

� 

� 

� 

� 

Lugo 1993 [B], Stark 1991)1,2[ (Adapted from CCHMC, 2010, Rec #21, SickKids change text order only) 

These diagnostic studies include : 

(Swingler 1998 [A], El-Radhi 1999 [B], Schuh 2007) 

chest X-rays 

(Adopted from CCHMC, 2010, Rec #21) 

cultures 

capillary or arterial blood gases 

nasopharyngeal swab for viral PCR 

[Grade A] 


[Grade A] 


[Grade B] 

(Bordley 2004, Levine 2004) (Adopted from CCHMC, 2010, Rec #21) 

NOTE 1: The risk of serious bacterial infection in children over 2 months of age with bronchiolitis is less 

than 2%. 

However, consider co-existent UTI particularly in toxic-appearing or febrile young infants 

(Kuppermann, 1997, Purcell, 2004, Leibelt, 1999, Antonow, 1998. Levine et al 2004) 

NOTE 2: One exception is that nasopharyngeal swab for viral PCR results may be used for the purpose of 

cohorting admitted patients as per SickKids Infection Prevention and Control practices. 

NOTE 3: Another consideration is that rapid viral testing (not currently available at SickKids) has been 

(Byington 2002.) 

shown to decrease inappropriate antibiotic use in children with bronchiolitis. 

2.1e Chest X-rays may be obtained as clinically indicated when the diagnosis of bronchiolitis is not 

clear and the presentation is atypical . 

(Swingler 1998 [A], El-Radhi 1999 [B], Schuh 2007[A]) (Adapted from CCHMC, 2010 #21, SickKids addition: "and presentation is atypical") 

[Grade A] 

NOTE 1: For infants with typical bronchiolitis, omitting radiography is cost saving without compromising 

diagnostic accuracy of alternative diagnoses and of associated pneumonia.3[B] The rate of 

superimposed bacterial pneumonia is extremely low and infiltrates/ atelectasis associated with RSV alone 

often result in over-reads and unnecessary antibiotics. In one study of 265 children with “simple” 

bronchiolitis routine radiography identified findings inconsistent with bronchiolitis in only 2 cases, and in 

neither case did the findings change acute management. After reviewing the radiographs, clinicians were 

(Schuh, 2007) 

more likely to treat with antibiotics, although the findings did not support treatment. 

NOTE 2: Examples of when a chest X-ray may be useful is when the hospitalized child does not improve 

at the expected rate, if the severity of disease requires further evaluation, or if another diagnosis is 


suspected. [Grade C] 

2.2 Management 

General 

2.2a The basic management of typical bronchiolitis is anchored in the provision of therapies that 

assure that the patient is clinically stable , well oxygenated, and well hydrated. The main benefits of 

hospitalization of infants with acute bronchiolitis are : 

(Klassen 1997 [B], Lugo 1993 [B], Panitch 1993 [B], Nicolai 1990 [B]) (Adopted from CCHMC 2010, pg. 2 General Section) 

[Grade B,C] 

� the careful monitoring of clinical status with frequent reassessment See Vital Signs Monitoring ==> 

� maintenance of a patent airway (through positioning, suctioning, and mucus clearance) 

� maintenance of adequate hydration and oxygenation 

� parental education 

See Breastfeeding Support ==> 

See Use of a Lactation Aid to Support Breastfeeding ==> 



NOTE 1: Breastfeeding without interruption should be encouraged for all breastfed infants who are able to 

feed. Some issues for the team to consider are (SickKids Consensus): 

the safety of oral feeding should be carefully assessed among infants with respiratory rates above 60 

breaths per minute, copious oral secretions, or a history suggestive of possible swallowing 

dysfunction or pulmonary aspiration. For infants who cannot breastfeed during the acute illness, 

lactating mothers should be encouraged to express breast milk to be provided to the infant by 

alternate routes (e.g., nasogastric tube). 

nasogastric tube feeding may be considered in infants who are clinically stable enough to tolerate 

enteral feeds, but whose elevated respiratory rate precludes safe or efficient oral feeding. However, 

there is no evidence for or against the use of nasogastric tube feeding in infants with bronchiolitis. 

(Kennedy 2005) 

appropriate intravenous maintenance fluids (D5 & 0.9 NaCl) should be provided to infants who cannot 

tolerate oral or enteral feeds See Fluid & Electrolyte Administration in Children ==> 

among infants in whom intravenous fluids are initiated, the safety of resuming oral feeding should be 

frequently reassessed to avoid delays in restarting feeds. 

� 

� 

� 

� 

Isolation Precautions 


2.2b Droplet/Contact precautions are to be followed when caring for a patient with bronchiolitis . 

[Grade C] See Enhanced Droplet/Contact Precautions ==> 

Oxygen 

2.2c There is a lack of evidence to specify an oxygen saturation threshold (by pulse oximetry) below 

which supplemental oxygen is indicated . The SickKids Bronchiolitis Guideline Group suggests to 

consider starting supplemental oxygen when the saturation is consistently less than 88% while asleep 


and less than 90% when awake while breathing room air . [Grade C] 

NOTE 1: Time for suctioning and repositioning should be allowed prior to starting supplemental 

oxygen. However, clinical judgement should be used if consistent suctioning is required or if 

the infant is asleep. 

NOTE 2: Different thresholds may be appropriate in infants with relevant chronic underlying conditions, 

oxygen therapy should be started at a higher O saturation or earlier in the illness course. 

2 

NOTE 3: If oxygen is delivered, it should be done using a method that enables quantification of the 

amount of oxygen and titration to the minimum required (e.g., nasal prongs, mask, head box 

rather than “blow by”). 

See General Oxygen Therapy ==> 

See Electronic Patient Monitoring ==> 

See Vital Signs Monitoring ==> 

Medications 

2.2d Scheduled or serial aerosol therapies are not recommended . 

(Kellner 2005 [A], Flores 1997 [A], Kellner 1996 [A], Goh 1997 [A], Dobson 1998 [A], Chowdhury 1995 [A], Lugo 1998 [B], Lenney 1978 [B)]1,2 (Adopted from CCHMC 2010, Rec. #14) 

[Grade A] 

NOTE 1: 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 

(Hall 2001 [B], Klassen 1997[A]) 

typical of bronchiolitis. 

NOTE 2: Two meta-analyses of randomized, controlled trials have not shown dramatic effects on 

clinical scores or hospitalization rates from therapy with nebulized Salbutamol in children with 

(Flores 1997 [A], Kellner 1996 [A]) [A] 

bronchiolitis. 

2.2e A single administration trial inhalation using epinephrine or salbutamol may be considered as an 

(Hartling 2011 [A], Hartling 2003 [A], Klassen 1997 [A]) (Adapted from CCHMC 2010, Re 

option, particularly when there is a family history for allergy , asthma, or atopy. 



[Grade A] 

A respiratory assessment including 0 saturation, respiratory rate, auscultatory findings, and work of 

2 

administered. (SickKids Consensus) 

breathing must be assessed before and 15-30 minutes after an inhalation treatment is 

NOTE 1: Nebulized racemic epinephrine was shown to result in better improvement in pulmonary 

physiology and clinical scores compared with albuterol (salbutamol) or placebo in several studies and one 

systematic review. These effects predominated in mildly ill children and were transient (30 to 60 minutes) 

in duration . 

(Langley 2005, Hartling 2003 [A], Wainwright 2003 [A], Numa 2001, Hartling 2011) 1[A] (Adopted form CCHMC 2010, Rec. #7, Note 2) 

2.2f Inhalation therapy should not be repeated nor continued if there is no documented improvement 

in respiratory rate and effort between 15 to 30 minutes after a trial inhalation therapy . 

[Grade A] 

Management of Bronchiolitis in Infants 8 

[Grade C] 

(Klassen 1997 [S], Bausch & Lomb Pharmaceuticals 1999[A])(Adopted C 

Zhang, 2008, Ralston, 2010 (SickKids Consensus) 

2.2g The use of nebulized 3% saline may be considered . [Grade A] 

NOTE 1: A meta-analysis and systematic review suggest that 3% saline significantly reduces length of 

(Zhang, 2008) 

hospital stay and improves clinical severity score in infants with bronchiolitis. [Grade A]) 

NOTE 2: Historically it has been recommended that RTs be present for the first dose to ensure the patient 

can tolerate this treatment. If patients tolerate the first dose, the RT does not have to be present during 

subsequent treatments. The incidence of significant adverse events (i.e. bronchospasm) with nebulized 

(Ralston, 2010) 

saline is approximately 0.3% . 

2.2h Antibiotics should not be used in the absence of an identified bacterial focus . 

(Adapted from CCHMC 2010, Rec. #17. SickKids change in text, not content) 

[Grade A] 

NOTE1: The incidence of serious bacterial illness (SBI) has been reported to be less than 2% in 

bronchiolitis patients 60 days of age or younger 

(Friis 1984 [A], Kuppermann 1997 [B], Purcell 2004 [B], Purcell 2002 [B], Liebelt 1999 [B], Antonow 1998 [B].) 1[A] 

The most common infection is a UTI. Be cautious in interpretation of chest x-rays findings in bronchiolitis 

since bacterial pneumonia is rarely seen and RSV itself may cause pulmonary 

infiltrates and/or atelectasis. 

2.2i Ribavirin should not be used routinely in children with bronchiolitis . 

(King VJ, 2004 )(Adopted from AAP 2006, Rec. #4) 

[Grade A] 

2.2j Steroid therapy should not routinely be given by any route . 

(King 2004 [C], Garrison 2000 [A]) (Adapted from CCHMC 2010, Rec. #16. SickKids change in text, not content) 

[Grade A] 

NOTE: One well-conducted systematic review found a reduction in length of stay of 0.43 days (95% CI 

0.8 to 0.05) with steroid therapy for bronchiolitis (Garrison 2000 [C] 

). However, when only the more 

methodologically rigorous studies with more specific definitions of bronchiolitis were analyzed in this 

meta-analysis, there was no significant effect of steroids on clinical status or length of stay. Recent 

evidence suggests that patients who received dexamethasone combined with 2 doses of nebulized 

epinephrine results in a lower admission rate. (Plint, 2009) Further study is needed to determine if the 

(Zorc, 2010) 

small treatment effect seen can be reproduced and warrant widespread recommendation. 

Respiratory Care Therapy 

2.2k The infant should receive oral or nasal suctioning when clinically indicated : 

(Adapted from CCHMC 2010, Rec. #8, SickKids added "oral or nasal") 

[Grade C] 

� before feedings 

� on a 'PRN' basis 

� prior to inhalation treatment 

� 

at clinical discretion


2.2l Routine respiratory care therapies should NOT be used , as they have not been found to be 

helpful. 

(Adopted from CCHMC 2006, Rec. #13) 

These include: 

(Perrotta 2005) 

cardiopulmonary (chest) physiotherapy (CPT) [Grade A] 

(Gibson 1974) 

cool mist therapy [Grade A] 

(Gadomski 1994[A], Chowdhury 1995[A], Ho 1991[A].) 

aerosol therapy with saline [Grade A] 

� 

� 

� 

2.3 Monitoring 

2.3a Repeated clinical assessment to be conducted , as this is the most important aspect of 

monitoring for deteriorating respiratory status . 

(Adapted from CCHMC 2010, Rec. #4) 

[Grade C] See Vital Sign Monitoring Policy ==> 

2.3b Consider scheduled spot checks of pulse oximetry (q 4-6 hr) in infants with bronchiolitis [C] 

. 

Assessments for oxygen weaning should be conducted at this time as well , when applicable. 

[Grade C] 

See Electronic Patient Monitoring ==> 

Management of Bronchiolitis in Infants 9 

(Adapted from CCHMC 2010, Rec. #9. SickKids added (q 

NOTE 1: Continuous monitoring of oxygen saturation by pulse oximetry is not routinely required in the 

(Adopted from CCHMC 2010, Rec. #9, Note 2) 

inpatient management of infants with bronchiolitis, and may contribute to longer hospital stays. 

2.3c Consider pulse oximetry , cardiac and continuous respiratory rate monitoring in hospitalized 

patients during the early (i.e. first 4-6 hours) stage of bronchiolitis, for patients with meeting high risk 

criteria (see recommendation 2.1c) and/or major comorbidities, when the risk of apnea and /or 

(Sickkids Consensus) 

bradycardia is greatest . [Grade C] 

2.4 Discharge Criteria 

2.4a The interdisciplinary team should begin discharge planning on admission . 

i. Respiratory Status 

(SickKids change: removed specific resting respiratory rate) 

(Adapted from CCHMC 2010, Rec. #13) 

respiratory status is consistently improving 


tachypnea and increased work of breathing are normal, mild or moderate 

oxygen saturation is in an acceptable range on room air (greater than 88% when sleeping and greater 

(SickKids change: O2 Saturation percentage changed to SickKids Consensus) 

than 90% when awake) 

ii. Nutritional Stats 

(Adopted from CCHMC 2010) 

the patient is on oral feedings sufficient to prevent dehydration 

iii. Social 

parent or guardian is competent and confident they can provide care at home 

iv. Follow-up 

instructions of when to follow-up with own primary care provider (generally 1-2 days) 


[Grade C] 

(SickKids changed to reflect own follow-up process) 

v. Parent & Family Education 

The family should be educated on the following topics regarding prevention and the care of a child with 

(Adapted from CCHMC 2010, Rec. #10, SickKids addition "Before discharge") 

bronchiolitis before discharge : [Grade C] 

i. basic pathophysiology and expected clinical course of bronchiolitis including lingering symptoms 


which may continue to disrupt child and family routines 

� 

NOTE 1: The median duration of illness for children < 24 months with bronchiolitis is 12 days;


ii. 

iii. 

i. 

ii. 

iii. 

iv. 

v. 

after 21 days approximately 18% will have persistent symptoms (i.e. cough), and after 28 days 

(Swingler 2001[A]) 

9% will have persistent symptoms (i.e. cough). 

proper techniques for suctioning the nose and making breathing easier . 


[Grade C] 

to call their primary care provider when the following signs of worsening clinical status are observed . 


[Grade C] 

(Parent friendly language in parentheses) 

� increasing respiratory rate and /or work of breathing as indicated by accessory muscle use 

(i.e. breathing very fast and/or skin sucking in around the neck or ribs with each breath) 

� inability to maintain adequate hydration 

(i.e. unable to feed or drink by mouth or has not had a wet diaper in more than 6 to 8 hours) 

� worsening general appearance 

(i.e. has new symptoms not present while in the hospital such as vomiting or fever, looks lethargic or 

does not respond normally to touch or sound, change in baby's colour) 

importance of handwashing by all caregivers before and after contact with the child to prevent 

(Hall 1981 [A]) (Adapted from CCHMC 2010. SickKids Added "by all caregivers.... of disease") 

spread of disease. [Grade A] 

(Celedon 1999) (Adopted from CCHMC 2010) 

limiting exposure to contagious settings and siblings [Grade C] 


wash clothing, toys, and eating utensils between uses by different children [Grade C] 

(Mahabee-Gittens 2002 [A]) (Adopted from CCHMC 2010) 

eliminating exposure to environmental smoking . [Grade C] 


provide a general information printout [Grade C] See ==> About Kids Health – Bronchiolitis 

Fact Sheet for parents 

3.0 Development Process 

3.1 CPG Search: A systematic search for existing Clinical Practice Guidelines was conducted in 

October 2009 using the Internet and the OVID database (MEDLINE, Embase) to search for CPGs. To be 

included as a potential CPG to adapt for use at SickKids, the CPG must have met the following criteria: 

1. Published or updated within the past 5 years (2005 or after) 

2. Included clearly articulated and directive recommendation statements (i.e. easily extracted for 

practice) 

3. Included paediatric specific recommendations 

4. Included at least one section relevant to: 

� Assessment/Diagnosis 

� Pharmacological/Non-Pharmacological Treatments 

� General Management 

� Education 

� Referral/follow-up 

3.2 CPG Selection: Identified guidelines were screened to ensure that the clinical questions 

developed by the working group were covered within the retrieved guidelines. Cincinnati Children’s 

Hospital Medical Center CPG For medical management of Bronchiolitis in infants less than 1 year of age 

presenting with a first time episode, and the American Academy of Paediatrics CPG , Diagnosis and 

management of bronchiolitis (2006, update 2010) were selected and assessed using the AGREE tool. 

Group consensus was to adapt these 2 guidelines and modifications were discussed & agreed upon by 

consensus. 

3.3 Adaptation Process: A small writing group of (physician, nurse, guideline developer) produced 

the first iteration of this guideline. The first draft was circulated to an interdisciplinary development group 

of health care professionals (see section 4.5) from within the emergency department and inpatient 

interprofessional teams for review and input. This group was also convened in June 2010 to discuss and 

finalize the guideline. Once internal consensus was obtained, the guideline was sent to external 

reviewers for review. Feedback from both internal and external reviewers was included in the final 

version. This group was convened again in June 2011 to review the literature from the past year and 



make minor updates to the content prior to the planned roll-out of this CPG in the fall/winter of 2011/12. 

Once the guideline has been in place for three years, the development team will reconvene to explore the 

continued validity of the guideline. This phase can be initiated at any point that evidence indicates a 

change is needed. 

Table 1 serves as a guideline to the hierarchy of evidence available; with RCT or meta-analysis 

considered to be the highest level of evidence and expert opinion considered to be the lowest level of 

evidence that can be used to support each recommendation in this CPG. 

Table 1. Grades of Recommendation 

A. At least one randomized controlled trial, systematic review, or meta-analysis. 

B. At least one cohort comparison, case study or other experiment study. 

C. Expert opinion, experience of a consensus panel. 

3.4 Guideline Group and Reviewers 

Guideline Group Membership : 

1. Trey Coffey, Staff Paediatrician 

2. Nora Costas CNS/NP, Paediatric Medicine 

3. Amanda Hurdowar, Clinical Practice Guideline Coordinator, QRM 

4. Daniel Roth, Staff Paediatrician, Paediatric Medicine 

5. Suzanne Schuh, ED Staff Paediatrician 

6. Jennifer Thull-Freedman, ED Staff Paediatrician 

7. Lisa K.E. Robinson, Advance Nursing Practice Educator, Emergency Medicine 

8. Jeremy Friedman, Head, Division of Paediatric Medicine, Paediatric Medicine Division 

9. Eyal Cohen, Staff Paediatrician, Paediatric Medicine 

10. Leonette Georges, Quality Leader, 7BCD, General Paediatrics 

11. Karen Breen-Reid, Advanced Nursing Practice Educator, Paediatric Medicine, Respiratory Medicine 

& Infectious Disease 

12. James Tjon, Clinical Pharmacist, Paediatric and Respiratory Medicine 

13. Merianne Castellarin, Respiratory Therapist, Clinician Educator, BLS Co-ordinator 

14. Sanjukta Basak , Paediatric Resident 

Internal reviewers: 

1. Upton Allen Chief,Division of Infectious Diseases, Senior Scientist, Infect 

2. Peter Cox, Associate Chief and Division Head, Paediatric Intensive Care Unit 

3. Krista MacMurdo, Registered Nurse, Emergency Medicine 

4. Hadi Mohseni-Bod, Staff Physician Paediatric Intensive Care Unit 

5. Katherine Nash, Registered Nurse, Emergency Medicine 

6. Michael Rotstein, Infection Control Practitioner 

7. Diane Soares, Clinical Manager - Respiratory Therapy 

8. Padmaja Subbarao, Staff Respirologist 

9. Jason French, Paediatric Medicine Fellow 

10. Lisa Robertson, ED Advanced Nurse Practice Educator 

11. Chantelle Vankoughnet, 7BCD Advanced Nurse Practice Educator 

12. Lynn Mack, 7BCD Quality Leader 

External reviewers: 

1. Patrick H. Conway, Cincinnati Children’s Hospital Medical Centre, Director of Hospital Medicine 

2. 

Ronik Kanani, Community Hospitalist, North York General Hospital 



4.0 References 

1. Bronchiolitis Guideline Team , Cincinnati Children's Hospital Medical Center : Evidence based 

care guideline for management of bronchiolitis in infants 1 year of age or less with a first time 

epsode. Cincinnati Children’s Hospital Medical Center Guideline 1, pages 1-16, 2010. 

2. American Academy of Pediatrics. Diagnosis and management of bronchiolitis. Pediatrics, 2006, 

Volume 118 (4) pg 1774-1793. 

http://aappolicy.aappublications.org/cgi/reprint/pediatrics;118/4/1774.pdf Diagnosis and 

management of bronchiolitis (2006, update 2010) 

3. American Academy of Pediatrics. Bronchiolitis: Recent Evidence on Diagnosis and Management. 

Pediatrics 2010, Volume 125(2) pg 1774-1793. 

4. Andrade, M. A.; Hoberman, A.; Glustein, J.; Paradise, J. L.; and Wald, E. R.: Acute otitis media in 

children with bronchiolitis. Pediatrics, 101(4 Pt 1): 617-9, 1998, [C] 

5. 

6. 

7. 

8. 

9. 

10. 

11. 

12. 

13. 

14. 

15. 

16. 

17. 

18. 

Antonow, J. A.; Hansen, K.; McKinstry, C. A.; and Byington, C. L.: Sepsis evaluations in 

hospitalized infants with ronchiolitis. Pediatr Infect Dis J, 17(3): 231-6., 1998, [D] 

Bausch & Lomb Pharmaceuticals, I.: Albuterol Sulfate Inhalation Solution, 0.5%. Clinical 

Pharmacology, Clinical Trials Tampa, FL, 1999, [O]. 

Bordley, W. C.; Viswanathan, M.; King, V. J.; Sutton, S. F.; Jackman, A. M.; Sterling, L.; and Lohr, 

K. N.: Diagnosis and testing in bronchiolitis: a systematic review. Arch Pediatr Adolesc Med, 

158(2): 119-26, 2004, [M] 

Byington,C.L., Castillo, H., Gerber, Kl, Daly J., Brimley, L., Adams S., Christenson, J, and Pavia, 

T. The Effect of Rapid Respiratory Viral DiagnosticTesting on Antibiotic Use in a Children’s 

Hospital. Archives of Pediatrics & Adolescent Medicine 156: 1230-1234, 2002 

Celedon, J. C.; Litonjua, A. A.; Weiss, S. T.; and Gold, D. R.: Day care attendance in the first year 

of life and illnesses of the upper and lower respiratory tract in children with a familial history of 

atopy. Pediatrics, 104(3 Pt 1): 495-500, 1999, [C] 

Chiocca, E. M.: RSV and the high-risk infant. Pediatr Nurs, 20(6): 565-8., 1994, [S] 

Chowdhury, D.; al Howasi, M.; Khalil, M.; al-Frayh, A. S.; Chowdhury, S.; and Ramia, S.: The role 

of bronchodilators in the management of bronchiolitis: a clinical trial. Ann Trop Paediatr, 15(1): 

77-84, 1995, [B] 

Corneli HM, Zorc JJ, Mahahan P. Et al. A multicentre, randomized controlled trial of 

dexamethasone for brochiolitis. N Engl J Med 2007, 357(4),:331-339 

Dobson, J. V.; Stephens-Groff, S. M.; McMahon, S. R.; Stemmler, M. M.; Brallier, S. L.; and Bay, 

C.: The use of albuterol in hospitalized infants with bronchiolitis. Pediatrics, 101(3 Pt 1): 361-8, 

1998, [B] 

El-Radhi, A. S.; Barry, W.; and Patel, S.: Association of fever and severe clinical course in 

bronchiolitis. Arch Dis Child, 81(3): 231-4, 1999, [C] 

Flores, G., and Horwitz, R. I.: Efficacy of beta2-agonists in bronchiolitis: a reappraisal and 

meta-analysis. Pediatrics, 100(2 Pt 1): 233-9, 1997, [M] 

Friis, B. et al.: Antibiotic treatment of pneumonia and bronchiolitis. A prospective randomised 

study. Arch Dis Child, 59(11): 1038-45., 1984, [B] 

Gadomski, A. M.; Aref, G. H.; el Din, O. B.; el Sawy, I. H.; Khallaf, N.; and Black, R. E.: Oral 

versus nebulized albuterol in the management of bronchiolitis in Egypt. J Pediatr, 124(1): 131-8, 

1994, [A] . 

Garrison, M. M.; Christakis, D. A.; Harvey, E.; Cummings, P.; and Davis, R. L.: Systemic 

corticosteroids in infant bronchiolitis: A meta-analysis. Pediatrics, 105(4): E44, 2000, [M] . 



19. 

20. 

21. 

22. 

23. 

24. 

25. 

26. 

27. 

28. 

29. 

30. 

31. 

32. 

33. 

34. 

35. 

36. 

37. 

38. 

Gibson, L. E.: Use of water vapor in the treatment of lower respiratory disease. Am Rev Respir 

Dis, 110(6 Pt 2): 100-3, 1974, [S] . 

Goh, A.; Chay, O. M.; Foo, A. L.; and Ong, E. K.: Efficacy of bronchodilators in the treatment of 

bronchiolitis. Singapore Med J, 38(8): 326-8, 1997, [A] 

Hall, C. B.; Douglas, R. G., Jr.; Schnabel, K. C.; and Geiman, J. M.: Infectivity of respiratory 

syncytial virus by various routes of inoculation. Infect Immun, 33(3): 779-83, 1981, [C] 

Hartling L, Fernandes RM, Bialy L, Milne A, Johnson D, Plint A, Klassen TP, Vandermeer 

B.Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic 

review and meta-analysis. BMJ. 2011 Apr 6;342:d1714. doi: 10.1136/bmj.d1714. 

Heikkinen, T.; Thint, M.; and Chonmaitree, T.: Prevalence of various respiratory viruses in the 

middle ear during acute otitis media. N Engl J Med, 340(4): 260-4, 1999, [C] 

Hunt, C. E.; Corwin, M. J.; Lister, G.; Weese-Mayer, D. E.; Neuman, M. R.; Tinsley, L.; Baird, T. 

M.; Keens, T. G.; and Cabral, H. J.: Longitudinal assessment of hemoglobin oxygen saturation in 

healthy infants during the first 6 months of age. Collaborative Home Infant Monitoring Evaluation 

(CHIME) Study Group. J Pediatr, 135(5): 580-6, 1999, [C] 

Kellner, J. D.; Ohlsson, A.; Gadomski, A. M.; and Wang, E. E.: Efficacy of bronchodilator therapy 

in bronchiolitis. A meta-analysis. Arch Pediatr Adolesc Med, 150(11): 1166-72, 1996, [M] 

Kellner, J. D.; Ohlsson, A.; Gadomski, A. M.; and Wang, E. E. L.: Bronchodilators for bronchiolitis. 

Cochrane Database Syst Rev, (2), 2005, [M] 

Kennedy N, Flanagan N. Is nasogastric fluid therapy a safe alternative to the intravenous route in 

infants with bronchiolitis? Arch Dis Child. 2005;90(3):320-1. 

King, V. J.; Viswanathan, M.; Bordley, W. C.; Jackman, A. M.; Sutton, S. F.; Lohr, K. N.; and 

Carey, T. S.: Pharmacologic treatment of bronchiolitis in infants and children: a systematic review. 

Arch Pediatr Adolesc Med, 158(2): 127-37, 2004, [M] 

Klassen, T. P.: Recent advances in the treatment of bronchiolitis and laryngitis. Pediatr Clin North 

Am, 44(1): 249-61., 1997, [S] 

Kuppermann, N.; Bank, D. E.; Walton, E. A.; Senac, M. O., Jr.; and McCaslin, I.: Risks for 

bacteremia and urinary tract infections in young febrile children with bronchiolitis. Arch Pediatr 

Adolesc Med, 151(12): 1207-14, 1997, [C] 

Kuzik BA, Al-Qadhi SA, Kent S, et al. Nebulizedhypertonic saline in the treatment of viral 

bronchiolitis in infants. J Pediatr. 2007;151(3):266 –270, 270e1 

Langley JM, Smith MB, LeBlanc JC, Joudrey H, Ojah CR, Pianosi P. Recemic epinephrine 

compared to salbutamol in hospitalized young children with bronchiolitis; a randomized controlled 

trial. BMC Peadiatr. 2005 May 5; 5(1):7. 

Lenney, W., and Milner, A. D.: Alpha and beta adrenergic stimulants in bronchiolitis and wheezy 

bronchitis in children under 18 months of age. Arch Dis Child, 53(9): 707-9., 1978, [D] 

Levine D et al. Risk of serious bacterial infection in young febrile infants with respiratory syncytial 

virus infections. Pediatrics. 2004 Jun;113(6):1728-34. 

Liebelt, E. L.; Qi, K.; and Harvey, K.: Diagnostic testing for serious bacterial infections in infants 

aged 90 days or younger with bronchiolitis. Arch Pediatr Adolesc Med, 153(5): 525-30, 1999, [D] . 

Lugo, R. A.; Salyer, J. W.; and Dean, J. M.: Albuterol in acute bronchiolitis--continued therapy 

despite poor response? Pharmacotherapy, 18(1): 198-202, 1998, [C] 

Mahabee-Gittens, M.: Smoking in parents of children with asthma and bronchiolitis in a pediatric 

emergency department. Pediatr Emerg Care, 18(1): 4-7, 2002, [O]. 

Hartling, L.; Wiebe, N.; Russell, K.; Patel, H.; and Klassen, T. P.: A meta-analysis of randomized 

controlled trials evaluating the efficacy of epinephrine for the treatment of acute viral bronchiolitis. 



39. 

40. 

41. 

42. 

43. 

44. 

45. 

46. 

47. 

48. 

49. 

50. 

51. 

52. 

53. 

Arch Pediatr Adolesc Med, 157(10): 957-64, 2003, [M] 

Lugo, R. A., and Nahata, M. C.: Pathogenesis and treatment of bronchiolitis. Clin Pharm, 12(2): 

95-116., 1993, [S] 

Mallory, M. D.; Shay, D. K.; Garrett, J.; and Bordley, W. C.: Bronchiolitis management 

preferences and the influence of pulse oximetry and respiratory rate on the decision to admit. 

Pediatrics, 111(1): e45-51, 2003, [O] 

Pitkaranta, A.; Jero, J.; Arruda, E.; Virolainen, A.; and Hayden, F. G.: Polymerase chain 

reaction-based detection of rhinovirus, respiratory syncytial virus, and coronavirus in otitis media 

with effusion. J Pediatr, 133(3): 390-4, 1998, [C] 

Plint et al, Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med 

2009;360(20):2079-89. 

Purcell, K., and Fergie, J.: Concurrent serious bacterial infections in 912 infants and children 

hospitalized for treatment of respiratory syncytial virus lower respiratory tract infection. Pediatr 

Infect Dis J, 23(3): 267-9, 2004, [D] 

Ralston, S., Hill, V., Martinez, M. Nebulized hypertonic saline without adjunctive bronchodilators 

for children with bronchiolitis. Pediatrics, 126: e520-e525, 2010 

Ralston, S. and Hill V. Incidence of Apnea in Children Hospitalized with RSV Bronchiolitis: A 

Systematic Review. Journal of Pediatrics. 155(5):728-33, 2009 

Schroeder, A. R.; Marmor, A. K.; Pantell, R. H.; and Newman, T. B.: Impact of pulse oximetry and 

oxygen therapy on length of stay in bronchiolitis hospitalizations. Arch Pediatr Adolesc Med, 

158(6): 527-30, 2004, [D] 

Schuh S, Lalani A, Allen U, et al. Evaluation of the Utility of Radiography in Acute Bronchiolitis. J 

Pediatr. 2007;150:429-33 

Schwartz, R.: Respiratory syncytial virus in infants and children. Nurse Pract, 20(9): 24-9., 1995, 

[S] 

Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. J 

Pediatr. 2007;150(4):429–433 

Stark, J. M., and Busse, W. W.: Respiratory virus infection and airway hyerreactivity in children. 

Pediatr Allergy Immunol, 2: 95-110, 1991, [S]. 

Swingler, G. H.; Hussey, G. D.; and Zwarenstein, M.: Randomised controlled trial of clinical 

outcome after chest radiograph in ambulatory acute lower-respiratory infection in children. 

Lancet, 351(9100): 404-8., 1998, [A] 

Zhang L, Mendoza-Sassi RA, Wainwright C,Klassen TP. Nebulized hypertonic saline solution for 

acute bronchiolitis in infants. CochraneDatabase Syst Rev. 2008;(4):CD006458 

Zorc, J.J. and Hall, C.B. Bronchiolitis: Recent Evidence on Diagnosis and Management Pediatrics 

2010;125;342-349 

© 2011 The Hospital for Sick Children ("SickKids"). All rights reserved. This document may be reproduced or used 

strictly for non-commercial clinical purposes. However, by permitting such use, SickKids does not grant any broader 

licence or waive any of its exclusive rights under copyright or otherwise at law; in particular, this document may not be 

used for publication without appropriate acknowledgement to SickKids. This Clinical Practice Guideline has been 

developed to guide the practice of clinicians at The Hospital for Sick Children. Use of this guideline in any setting 

must be subject to the clinical judgment of those responsible for providing care.SickKids does not accept 

responsibility for the application of this guideline outside SickKids.

Management of Bronchiolitis in Infants - The Hospital for Sick Children

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?