Heart failure due to congenital heart disease (Q20 to Q28)
Diaphoresis with feeds
Hepatomegaly
Poor weight gain
Sepsis (A41.9)
Lethargy
Poor perfusion
Temperature instability
Common
Common causes
Viral bronchiolitis (J21.9)
Age under 24 months
URI prodrome
Diffuse wheeze and crackles
Viral induced wheeze
Prior wheeze episodes
Response to bronchodilator
Asthma in young child (J45)
Recurrent wheeze
Atopy history
Nocturnal cough
Less common
Less common causes
Croup with lower airway involvement (J05.0)
Barky cough
Stridor
GERD with aspiration (K21.9)
Feeding related symptoms
Recurrent cough
Pertussis (A37.9)
Paroxysmal cough
Post tussive emesis
Cannot miss in this population
Infant specific cannot miss
Bronchiolitis with apnea risk
Age under 2 months
Prematurity
Bronchopulmonary dysplasia exacerbation (P27.1)
Baseline oxygen use
Increased oxygen requirement
Zebras and mimics
Zebras and mimics
Vascular ring or sling (Q25.4)
Feeding related distress
Recurrent symptoms since birth
Tracheomalacia or bronchomalacia (Q32.0)
Noisy breathing since infancy
Worse when supine
Cystic fibrosis (E84)
Failure to thrive
Recurrent respiratory infections
Past Medical History
Birth and neonatal history
Birth history factors
Gestational age
NICU admission
Intubation history
Neonatal lung disease
Chronic conditions
Relevant chronic conditions
Prior bronchiolitis admissions
Prior ICU admissions
Congenital heart disease
Chronic lung disease
Procedures and devices
Devices and procedures
Tracheostomy
Home oxygen
Feeding tube
Physical Exam
General and vitals interpretation
General appearance and perfusion
Toxic appearance
Consolability
Hydration status
Capillary refill
Vital sign patterns
Fever interpretation
Tachypnea interpretation
Oxygen saturation trend
Respiratory exam
Work of breathing
Nasal flaring
Retractions
Subcostal
Intercostal
Suprasternal
Grunting
Head bobbing
Auscultation findings
Wheeze
Diffuse
Focal
Unilateral
Crackles
Diminished air entry
Prolonged expiratory phase
HEENT and upper airway
Upper airway findings
Nasal congestion
Stridor
Drooling
Oropharyngeal swelling
Cardiovascular
Cardiac findings
Murmur
Hepatomegaly
Gallop
Skin and allergy
Allergic signs
Urticaria
Angioedema
Flushing
Neurologic
Neuro status
Alertness
Tone
Fatigue signs
Lab Studies
Point of care and targeted labs
Lab selection logic
No routine labs for typical mild bronchiolitis
Glucose if lethargy or poor feeding
Capillary or venous blood gas if impending respiratory failure
Electrolytes if dehydration or prolonged poor intake
Infection evaluation when indicated
Infection labs when higher risk
CBC if toxic appearance
Blood culture if sepsis concern
Urinalysis and urine culture if fever without source in young infant
Viral testing considerations
Viral testing use cases
Cohorting or infection control needs
High risk infant where result changes disposition
Local protocol dependent testing pathways
Imaging
Scoring Systems
Severity and risk tools
Bronchiolitis severity scoring use
Components often used
Work of breathing
Respiratory rate
Oxygen saturation
Feeding tolerance
Limitations
Not validated for disposition alone
Local protocol dependent
MRI
MRI considerations
Rare in acute wheeze evaluation
Indications
Suspected vascular ring evaluation
Mediastinal mass evaluation
Contraindications
Unstable respiratory status
Need for sedation risk
CT
CT considerations
Indications
Suspected airway foreign body with unclear radiographs
Suspected vascular ring evaluation if MRI not feasible
Radiation caution
Use pediatric dose protocols
Prefer alternative imaging when possible
Ultrasound
Ultrasound and POCUS
Lung ultrasound for pneumonia features
Focal consolidation
Pleural effusion
Cardiac POCUS for shock or heart failure features
Ventricular function estimate
Pericardial effusion screen
Special Tests
Bedside assessment tools
Bedside tests
Nasal suction trial response
Feeding trial response
Bronchodilator trial response interpretation
Procedures and specialty tests
Advanced diagnostics when indicated
Flexible bronchoscopy for suspected foreign body
Swallow evaluation for aspiration concern
Echocardiography for congenital heart disease concern
ECG
Indications and patterns
ECG indications in wheezing infant
Tachycardia out of proportion to fever and distress
Suspected myocarditis
Suspected congenital heart disease
High risk findings
Arrhythmia
Conduction abnormality
Ischemia like changes in myocarditis context
Assessment
Problem representation
Wheezing infant working problem list
Severity level
Mild
Moderate
Severe
Probable syndrome
Bronchiolitis pattern
Reactive airway pattern
Upper airway noise mimic
Complications and alternatives
Complications to rule out
Apnea risk
Dehydration
Secondary bacterial pneumonia
Diagnostic uncertainty flags
Focal findings
Unilateral wheeze
No viral prodrome
Poor growth history
Plan
First 5 minutes
Initial stabilization workflow
Triage triggers
Apnea history
Central cyanosis
Severe retractions
Monitoring
Continuous pulse oximetry if moderate or severe distress
Cardiorespiratory monitoring if severe or apnea risk
Oxygen escalation
Start oxygen if saturation below 90 percent on room air
Escalate to high flow nasal cannula if persistent distress or hypoxemia
Airway adjuncts
Nasal suctioning
Positioning upright
Diagnostic sequencing
Testing strategy
Typical bronchiolitis with mild symptoms
No routine imaging
No routine labs
Atypical or severe presentation
Chest radiograph if focal findings or severe illness
Blood gas if fatigue or rising oxygen requirement
Therapeutics
Supportive care
Nasal suctioning with saline
Hydration strategy
Oral feeding if safe
NG hydration if poor intake and stable respiratory effort
IV fluids if unsafe oral intake or significant distress
Bronchodilator approach
Trial of inhaled salbutamol may be considered in selected infants
Continue only if clear objective improvement
Corticosteroids
Not routine for bronchiolitis
Consider systemic steroids if strong asthma phenotype or recurrent wheeze with bronchodilator response
Anaphylaxis treatment if suspected
IM epinephrine weight based local protocol
Airway edema monitoring
Monitoring and reassessment loop
Reassessment loop
Recheck work of breathing every 30 to 60 minutes until stable
Recheck feeding tolerance after interventions
Escalate respiratory support if worsening retractions or rising oxygen need
Consultation
Consult triggers
PICU for high flow escalation needs
ENT for upper airway obstruction concern
Pediatric surgery or pulmonology for foreign body concern
Disposition
Level of care criteria
ICU criteria
Apnea or recurrent apnea
Need for noninvasive ventilation
Persistent hypoxemia despite high flow support
Inpatient admission criteria
Oxygen requirement to maintain saturation 90 percent or higher
Moderate or severe work of breathing
Inadequate oral intake with dehydration risk
High risk comorbidities
Prematurity
Chronic lung disease
Congenital heart disease
Observation pathway criteria
Borderline feeding with mild work of breathing
Need for serial reassessments after bronchodilator trial
Discharge criteria and follow up
Discharge criteria
Stable oxygen saturation 90 percent or higher on room air
Mild work of breathing
Adequate feeding and hydration
Reliable caregiver and access to follow up
Follow up timing
Primary care within 24 to 48 hours
Earlier follow up for young infants or comorbidities
Discharge Instructions
Copy discharge instructions
Patient instructions text
Your child has noisy breathing from irritated airways that often happens with viral colds
Use saline drops and gentle suction before feeds and sleep
Offer smaller more frequent feeds and watch wet diapers
Return to the emergency department now for
Blue lips or face
Pauses in breathing
Breathing very fast or working very hard to breathe
Too tired to feed
Fewer wet diapers than usual
New rash with swelling of the lips or face
Follow up with your clinician in the next 1 to 2 days
References
Guidelines and core sources
Evidence based references
American Academy of Pediatrics clinical practice guideline bronchiolitis 2014 reaffirmed 2019
National Institute for Health and Care Excellence bronchiolitis in children guideline NG9 2015 updated
Canadian Paediatric Society bronchiolitis position statement updated regularly local protocol dependent
Global Initiative for Asthma strategy documents for diagnosis and management in children updated annually
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