5. It is recommended to consider starting supplemental oxygen when the saturation is consistently less than 91% and consider weaning oxygen when consistently higher than 94% (National Institutes of Health (NIH), 1997 [E]; Local Expert Consensus [E]).

   Oxygen therapy is frequently required in the treatment of bronchiolitis. See Monitoring section for recommendation regarding oxygen saturation monitoring to maintain blood oxygen levels within a normal range. This range is variable in definition and patient-specific.

6. It is recommended that scheduled or serial albuterol aerosol therapies not be routinely used (Kellner et al., 2005 [M]; Flores & Horwitz, 1997 [M]; Kellner et al., 1996 [M]; Goh et al., 1997 [A]; Dobson et al., 1998 [B]; Chowdhury et al., 1995 [B]; Lugo, Salyer, & Dean, 1998 [C]; Lenney & Milner, 1978 [D]).

   Note 1: Although in some cases bronchiolitis may be a prelude to asthma (Martinez et al., 1995 [C]; Stark & Busse, 1991 [S]), 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 (Hall, 2001 [S]; Klassen, 1997 [S]).

   Note 2: Two meta-analyses of randomized, controlled trials have not shown dramatic effects on clinical scores or hospitalization rates from therapy with nebulized albuterol in children with bronchiolitis (Flores & Horwitz, 1997 [M]; Kellner et al., 1996 [M]).

   Note 3: Deterioration and desaturation has been associated with inhalation therapies (Flores & Horwitz, 1997 [M]; Ho et al., 1991 [B]).

7. It is recommended that a single administration trial inhalation using epinephrine or albuterol may be considered as an option, particularly when there is a family history for allergy, asthma, or atopy (Hartling et al., 2003 [M]; Klassen, 1997 [S]).

   Note 1: Nebulized racemic epinephrine was shown to result in better improvement in pulmonary physiology and clinical scores compared with albuterol 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 (Hartling et al., 2003 [M]; Wainwright et al., 2003 [A]; Numa, Williams, & Dakin, 2001 [O]).

   Note 2: See Respiratory Care Therapy section regarding the importance of suctioning before any inhalation therapy.

   Note 3: The expected disposition of a patient may influence the choice of beta-agonist when a single administration trial is given. There is a lack of research regarding the appropriateness of routine epinephrine use outside the acute care setting (Local Expert Consensus [E]).

8. It is recommended that inhalation therapy not be repeated nor continued if there is no improvement in clinical appearance between 15 to 30 minutes after a trial inhalation therapy (Klassen, 1997 [S]; Bausch & Lomb Pharmaceuticals, 1999 [O]).

   Note: In order to determine appropriateness of repeated therapy, use the Bronchiolitis Respiratory Sheet to record pre- and post-clinical score (Conway et al., 2004 [C]).

9. It is recommended that antibiotics not be used in the absence of an identified bacterial focus.

   Note 1: 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 et al., 1984 [B]; Kuppermann et al., 1997 [C]; Purcell & Fergie, 2004 [D]; Purcell & Fergie, 2002 [D]; Liebelt, Qi, & Harvey, 1999 [D]; Antonow et al., 1998 [D]). See the National Guideline Clearinghouse (NGC) summaries of the following CCHMC Evidence Based Clinical Practice Guidelines Evidence Based Clinical Practice Guideline for Fever of Uncertain Source in Infants 60 Days of Age or Less or Evidence Based Clinical Practice Guideline for Fever of Uncertain Source in Children 2 to 36 Months of Age, Evidence Based Clinical Practice Guideline for Medical Management of Acute Otitis Media in Children 2 Months to 13 Years of Age, and Evidence-based Care Guideline for Medical Management of First Urinary Tract Infection in Children 12 Years of Age or Less.

   Note 2: In almost 75% of patients with RSV infections, the virus may be isolated from the middle ear (Heikkinen, Thint, & Chonmaitree, 1999 [C]; Andrade et al., 1998 [C]; Pitkaranta et al., 1998 [C]). In patients with RSV and otitis media, a bacterial pathogen has been isolated in 25 out of 26 (Andrade et al., 1998 [C]) and one out of eight (Pitkaranta et al., 1998 [C]) middle ear fluid specimens after tympanocentesis.

   Note 3: Antibiotics have little, if any, effect on outcomes from otitis media (Glasziou et al., 2005 [M]; Marcy et al., 2001 [M]; Del Mar, Glasziou, & Hayem, 1997 [M]; Rosenfeld et al., 1994 [M]).

10. It is recommended that antihistamines, oral decongestants, and nasal vasoconstrictors not be used for routine therapy.

    Note 1: There is no evidence to date for efficacy of these medications in reduction of cough or congestion in infants with upper and lower respiratory tract infections (Clemens et al., 1997 [B]; Hutton et al., 1991 [B]; "Use of codeine," 1997 [S]; Gadomski & Horton, 1992 [O]).

    Note 2: Some components of these medications have been shown to be harmful to humans (Kernan et al., 2000 [D]).

11. It is recommended that steroid therapy not be given (as inhalations, intravenously, orally, or intramuscularly) (King et al., 2004 [M]; Garrison et al., 2000 [M]).

    Note: One well-conducted systematic review found a reduction in length of stay of 0.43 days (95% confidence interval [CI] 0.8 to 0.05) with steroid therapy for bronchiolitis (Garrison et al., 2000 [M]). 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.

Respiratory Care Therapy

12. It is recommended the infant be suctioned, when clinically indicated:
    • Before feedings
    • As needed (PRN)
    • Prior to each inhalation therapy

    (Local Expert Consensus [E])

    In order to appropriately measure improvement in clinical status due to the therapeutic effects of the medication, the following reasons for suctioning are considered:

    • Suctioning itself may improve respiratory status such that inhalation therapy is not necessary. Thus, it is important to document the pre-and post-suction clinical score prior to treatment.
    • Suctioning may improve the delivery of the inhalation treatment.

    (Local Expert Consensus [E]).

    Note: Normal saline nose drops may be used prior to suctioning (Local Expert Consensus [E]).

13. It is recommended that other routine respiratory care therapies not be used, as they have not been found to be helpful. These include:
    • Chest physiotherapy (CPT) (Perrotta, Ortiz, & Roque, 2005 [M])
    • Cool mist therapy (Gibson, 1974 [S])
    • Aerosol therapy with saline (Gadomski et al., 1994 [A]; Chowdhury et al., 1995 [B]; Ho et al., 1991 [B]).

Monitoring

14. It is recommended that repeated clinical assessment be conducted, as this is the most important aspect of monitoring for deteriorating respiratory status (Local Expert Consensus [E]).
15. It is recommended to consider cardiac and respiratory rate monitoring in hospitalized patients during the acute stage of bronchiolitis when the risk of apnea and/or bradycardia is greatest (Anas et al., 1982 [C]; Church et al., 1984 [D]).

    Note 1: Premature infants, infants with underlying chronic conditions, and infants less than three months of age who contract RSV are at particular risk of severe complications such as apnea and mechanical ventilation (Wang, Law, & Stephens, 1995 [C]; Anas et al., 1982 [C]; Krasinski, 1985 [D]; Church et al., 1984 [D]).

    Note 2: Several studies have reported more severe progression of disease in children with bronchiolitis who present with low initial oxygen saturations (Wang, Law, & Stephens, 1995 [C]; Shaw, Bell & Sherman, 1991 [C]; Mulholland, Olinsky, & Shann, 1990 [D]).

16. It is recommended that scheduled spot checks of pulse oximetry be utilized in infants with bronchiolitis (Local Expert Consensus [E]).

    Note 1: Continuous oximetry measurement has been associated with increased length of stay of 1.6 days (95% CI, 1.1 to 2.0) on average (Schroeder et al., 2004 [D]).

    Note 2: Wide variability has been demonstrated in the manner in which clinicians use and interpret pulse oximetry readings in children with bronchiolitis. This variability has been shown to be associated with increased preferences for hospital admission and increased length of stay for children admitted with bronchiolitis (Schroeder et al., 2004 [D]; Mallory et al., 2003 [O]).

    Note 3: In a prospective study of healthy, term infants, transient oxygen desaturation episodes were documented and were determined to be representative of normal breathing and oxygenation behavior. This study excluded any decreases in oxygen saturation related to the infants' movement which would interfere with measurement (Hunt et al., 1999 [C]).

Discharge Criteria

17. It is recommended to begin discharge planning on admission (Local Expert Consensus [E]). Discharge criteria are:

    Respiratory Status

    • Respirations less than 70 per minute and no clinical evidence of increased work of breathing
    • Parent can clear the infant's airway using bulb suctioning.
    • Patient is either on room air or on stable oxygen therapy that is at a level considered consistent with being able to effectively continue the therapy at home.

    Nutritional Status

    • The patient is on oral feedings at a level to prevent dehydration.

    Social

    • Home resources are adequate to support the use of any necessary home therapies.
    • Parent or guardian is confident they can provide care at home.
    • Family education complete

    Follow Up

    • When indicated, home care and durable medical supply (DMS) agencies have been notified and arrangements for visits finalized.
    • Primary care provider identified, notified, and agrees with discharge decision
    • Follow-up appointments have been scheduled.

Education

18. It is recommended that the family be educated on the following topics regarding the care of a child with bronchiolitis:
    • Basic pathophysiology and expected clinical course of bronchiolitis

    Note: The median duration of illness for children <24 months with bronchiolitis is 12 days; after 21 days approximately 18% will remain ill, and after 28 days 9% will remain ill (Swingler, Hussey, & Zwarenstein, 2000 [C]).

    • Proper techniques for suctioning the nose and making breathing easier (Local Expert Consensus [E])
    • To call their primary care provider when the following signs of worsening clinical status are observed (Local Expert Consensus [E]).
      1. increasing respiratory rate and/or work of breathing as indicated by accessory muscle use
      2. inability to maintain adequate hydration
      3. worsening general appearance

19. It is recommended that the family be educated on the following topics regarding prevention of respiratory infection in infants:
    • Eliminating exposure to environmental tobacco smoke (Mahabee-Gittens, 2002 [O])
    • Limiting exposure to contagious settings and siblings (e.g., daycare centers) (Celedon et al., 1999 [C])
    • An emphasis on handwashing in all settings (Hall et al., 1981 [C])

Definitions:

Evidence Grading Scale:

A: Randomized controlled trial: large sample
B: Randomized controlled trial: small sample
C: Prospective trial or large case series
D: Retrospective analysis
E: Expert opinion or consensus
F: Basic laboratory research
S: Review article
M: Meta-analysis
Q: Decision analysis
L: Legal requirement
O: Other evidence
X: No evidence

References open in a new window

Electronic copies: Available in Portable Document Format (PDF) from the Cincinnati Children's Hospital Medical Center Web site.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Children's Hospital Medical Center Health Policy and Clinical Effectiveness Department at HPCEInfo@cchmc.org.

• Bronchiolitis. Guideline highlights. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2005 Nov. 1 p. Electronic copies: Available in Portable Document Format (PDF) from the Cincinnati Children's Hospital Medical Center Web site.
• Bronchiolitis respiratory sheet. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2005 Oct. 1 p. Electronic copies: Available in Portable Document Format (PDF) from the Cincinnati Children's Hospital Medical Center Web site.
• Emergency department algorithm. Cincinnati (OH): Cincinnati Children's Hospital Medical Center. 2003. 2 p. Electronic copies: Available in Portable Document Format (PDF) from the Cincinnati Children's Hospital Medical Center Web site.

Additional implementation tools, including computerized provider order entry forms can be found in the original guideline document.

• Bronchiolitis -- essential facts. Cincinnati Children's Hospital Medical Center, 2004 Sep. Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site.
• Bronchiolitis. Cincinnati Children's Hospital Medical Center, 2004 Sep. Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site.
• Suctioning the nose with a bulb syringe. Cincinnati Children's Hospital Medical Center, 2004 Aug. Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site.
• Second hand smoke dangers. Cincinnati Children's Hospital Medical Center, 2005 Jun. Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site.

The following is also available:

• Bronchiolitis: patient/family pathway. Cincinnati Children's Hospital Medical Center, 2 p. Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site.

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