›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
17Disposition/dispo23
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
18Discharge Instructions/di12
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
19References/r5
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
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
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