BronchiolitisMANAGEMENT

RESPIRATORY PRESENTATIONS · 12 SECTIONS

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478 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Acute bronchitis Acute Respiratory Distress Syndrome (ARDS)Acute respiratory failure Apparent Life-Threatening Event (ALTE-BRUE)Aspiration pneumonia Asthma exacerbation Bacterial Tracheitis Bronchiolitis Bronchiolitis (RSV)Chylothorax Community-acquired pneumonia COPD exacerbation COVID-19 pneumonia Croup Croup (laryngotracheobronchitis)Cystic Fibrosis Exacerbation Empyema Epiglottitis Epiglottitis (Pediatric)Fat Embolism Syndrome Foreign Body Aspiration Foreign Body Aspiration (Pediatric)Healthcare-Associated Pneumonia Hemothorax Hospital-acquired pneumonia Legionnaires' Disease Lung Abscess Pertussis Pleural effusion Pleurisy Pneumocystis jirovecii Pneumonia Pneumocystis Pneumonia Pneumomediastinum Pneumothorax (Simple)Pneumothorax (traumatic)Psittacosis Pulmonary Alveolar Proteinosis Pulmonary contusion Pulmonary Edema (Non-cardiogenic)Sarcoidosis Exacerbation Smoke Inhalation Injury Spontaneous pneumothorax Status Asthmaticus Sudden Infant Death Syndrome (SIDS)Tension Pneumothorax Tracheal Stenosis Viral Pneumonia

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp64

Immediate priorities

›First look triage

›Apnea

›Cyanosis

›Severe work of breathing

›Altered mental status

›Poor perfusion

›Immediate escalation triggers

›Recurrent apnea

›SpO2 persistently <90% on room air

›Exhaustion with rising CO2

›Airway and breathing

›Positioning

›Sniffing position for infant

›Head tilt chin lift if obstructed

›Suction strategy

›Nasal suction prior to feeds

›Deep suction only if obstruction not relieved and deterioration

›Oxygenation targets

›SpO2 goal 90% or higher for most infants

›Higher target if significant cardiopulmonary disease

›Ventilatory support escalation

›If persistent hypoxemia, low flow nasal cannula

›If persistent distress, high flow nasal cannula

›If failure of noninvasive support, CPAP or intubation

›Circulation and hydration

›Hydration assessment

›Intake reduction

›Urine output decline

›Clinical dehydration

›Fluid strategy

›Oral feeds if safe

›NG feeds if respiratory status allows

›IV isotonic fluids if unable to feed

›Shock differential if hypotension

›Sepsis

›Dehydration

›Congenital heart disease

›Isolation and infection prevention

›Droplet and contact precautions

›Cohorting during outbreaks

›Key concepts

›Primary disease frame

›Viral lower airway inflammation and edema

›Increased mucus and small airway obstruction

›Air trapping with atelectasis risk

›High risk phenotypes

›Age under 12 weeks

›Prematurity

›Chronic lung disease

›Hemodynamically significant congenital heart disease

›Immunodeficiency

›Neuromuscular weakness

Monitoring and reassessment

›Monitoring plan

›Continuous pulse oximetry for moderate to severe disease

›Intermittent SpO2 checks for improving mild disease

›Respiratory rate trend

›Work of breathing trend

›Feeding tolerance trend

›Failure criteria

›Rising oxygen requirement

›Persistent tachypnea with fatigue

›Recurrent apnea

›Worsening hypercapnia on blood gas

›Inability to maintain hydration

02History/hx37

Presentation pattern

›Typical course

›Upper respiratory prodrome

›Rhinorrhea

›Cough

›Low grade fever

›Progression to lower respiratory symptoms

›Wheeze or crackles

›Increased work of breathing

›Feeding difficulty

›Peak severity day 3 to 5

›Worst work of breathing

›Highest risk of dehydration

›Red flag symptoms

›Apnea episodes

›Cyanosis

›Lethargy

›Poor feeding with minimal urine output

›Persistent vomiting with dehydration

›Exposure context

›Sick contacts

›Daycare exposure

›Household smoke exposure

Risk factors and comorbidities

›Host risk

›Age under 12 weeks

›Prematurity history

›Prior ICU admission for respiratory illness

›Medical comorbidities

›Bronchopulmonary dysplasia

›Congenital heart disease

›Immunodeficiency

›Neuromuscular disease

›Airway anomalies

›Atopy and wheeze history

›Prior recurrent wheeze episodes

›Eczema

›Family history of asthma

›Prior response to bronchodilator

03Physical Exam/exam42

Respiratory severity

›Work of breathing

›Nasal flaring

›Intercostal retractions

›Subcostal retractions

›Head bobbing

›Grunting

›Respiratory rate and pattern

›Tachypnea

›Periodic breathing

›Apnea

›Auscultation

›Diffuse crackles

›Wheeze

›Prolonged expiration

›Diminished air entry

›Oxygenation and ventilation

›Room air SpO2

›Central cyanosis

›Signs of hypercapnia

›Somnolence

›Poor respiratory effort

General and hydration

›General appearance

›Alertness

›Consolability

›Toxic appearance

›Hydration indicators

›Mucous membranes

›Tears

›Capillary refill

›Fontanelle fullness

›Urine output estimate

›Perfusion and cardiac findings

›Heart rate

›Murmur

›Hepatomegaly

›Edema

PITFALLS

›Pitfall set

›Early bronchiolitis with minimal wheeze

›Apnea predominant presentation in young infants

›High fever suggesting alternative diagnosis

›Focal lung findings suggesting pneumonia or atelectasis

›Poor feeding as primary sign of severity

04Differential Diagnosis/ddx35

Life threatening and must not miss

›Critical alternatives

›Bacterial pneumonia ICD-10 J13 to J18

›Focal crackles

›High fever

›Toxic appearance

›Sepsis ICD-10 A41.9

›Hypothermia or fever

›Poor perfusion

›Lethargy

›Congenital heart disease with heart failure ICD-10 Q20 to Q28

›Hepatomegaly

›Poor weight gain

›Diaphoresis with feeds

›Foreign body aspiration ICD-10 T17

›Sudden onset

›Unilateral wheeze

›Asymmetric breath sounds

›Upper airway emergencies

›Croup ICD-10 J05.0

›Barky cough

›Stridor

›Epiglottitis ICD-10 J05.1

›Drooling

›Tripod posture

Mimics and overlaps

›Wheezing illnesses

›Early childhood asthma ICD-10 J45

›Recurrent episodes

›Atopy

›Viral induced wheeze SNOMED CT 442696006

›Older infant or toddler

›Prior wheeze history

›Structural and chronic

›Tracheomalacia SNOMED CT 95434002

›Cystic fibrosis ICD-10 E84

›Primary ciliary dyskinesia SNOMED CT 127665003

05Laboratory Tests/lt28

Routine testing strategy

›Default approach

›No routine labs for typical mild to moderate bronchiolitis

›Testing driven by severity and alternative diagnosis concern

›Viral testing limited utility for routine management

›Consider if cohorting or high risk admission decisions

›Sepsis evaluation triggers

›Age under 28 days with fever

›Toxic appearance

›Hemodynamic instability

Targeted labs when indicated

›Hydration and metabolic

›Serum electrolytes for significant dehydration

›Sodium for free water and feeding issues

›Potassium for vomiting or poor intake

›Glucose for lethargy or poor feeding

›Hypoglycemia risk in young infants

›Blood gas for severe disease

›Capillary or venous blood gas if impending failure

›Rising PaCO2 surrogate

›Acidemia trend

›Oxygenation assessment limited on venous sample

›Arterial blood gas if ventilation strategy decisions critical

›PaCO2 in mmHg

›PaO2 in mmHg

›Infection evaluation if bacterial concern

›Complete blood count for toxic appearance

›Limited discrimination for viral vs bacterial

›Blood culture for sepsis concern

›Higher yield in neonates

06Diagnostic Tests/dt60

Scoring Systems

›Severity scoring overview

›Purpose

›Structured severity tracking

›Communication across teams

›Limitations

›Scores do not replace clinical trajectory

›Variable interrater reliability

›Wang bronchiolitis severity score

›Components

›Respiratory rate

›Wheeze

›Retractions

›General condition

›Interpretation

›Higher score correlates with more severe disease

›Respiratory Distress Assessment Instrument

›Components

›Wheeze phase

›Wheeze location

›Retractions sites

›Use case

›Clinical trials

›Serial bedside documentation

›Modified Tal score

›Components

›Respiratory rate

›Wheeze

›Retractions

›SpO2

MRI

›MRI role

›Generally not indicated for bronchiolitis

›Consider only for alternate diagnosis evaluation

›Mediastinal mass

›Vascular ring

›Practical limits

›Sedation risk in infants

›Delay to care

›CT role

›Generally not indicated for typical bronchiolitis

›Consider only for specific alternative diagnoses

›Foreign body with unclear radiographs

›Complicated pneumonia with abscess concern

›Risks

›Ionizing radiation in infants

›Need for sedation in some cases

Ultrasound

›Point of care lung ultrasound

›Potential findings

›B lines

›Subpleural consolidations

›Pleural line abnormalities

›Use case

›Distinguishing atelectasis vs pneumonia in select cases

›Minimizing radiography when expertise available

›Cardiac ultrasound

›Use case

›Suspected congenital heart disease decompensation

›Suspected myocarditis

›Findings supporting heart failure

›Reduced ventricular function

›Volume overload signs

07Disposition/dispo27

Level of care decisions

›Disposition framework

›Mild disease criteria

›SpO2 90% or higher on room air

›Minimal work of breathing

›Adequate oral intake

›Reliable caregivers

›Ward admission criteria

›Need for supplemental oxygen

›Moderate work of breathing

›Poor feeding requiring NG or IV fluids

›High risk comorbidities

›ICU criteria

›Apnea

›Rapidly escalating oxygen or respiratory support

›Persistent hypoxemia despite high flow support

›Hypercapnia with fatigue

›Hemodynamic instability

›Transfer criteria

›Need for pediatric ICU unavailable locally

›Need for intubation or advanced ventilation

›High risk infant with worsening trajectory

Discharge readiness

›Safe discharge elements

›Stable on room air with SpO2 90% or higher

›Feeding adequate for hydration

›Caregiver comfort with nasal suction and feeding plan

›Return precautions understood

›Follow up plan within 24 to 48 hours if higher risk

08Treatment/t76

Supportive care core

›Support bundle

›Nasal suction

›Before feeds and sleep

›Avoid aggressive deep suction if causing trauma

›Oxygen therapy

›Low flow nasal cannula starting point

›Wean to room air when SpO2 stable 90% or higher

›Avoid continuous monitoring in stable improving mild cases

›Hydration and nutrition

›Small frequent feeds

›NG feeds if safe and persistent poor intake

›IV isotonic fluids if unable to tolerate enteral

›Fever control

›Acetaminophen 15 mg per kg PO or PR every 4 to 6 hours

›Maximum 75 mg per kg per day

›Maximum 4000 mg per day

›Ibuprofen 10 mg per kg PO every 6 to 8 hours if age 6 months or older

›Maximum 40 mg per kg per day

›Airway and ventilation escalation

›High flow nasal cannula

›Initiate for persistent moderate to severe distress

›Weight based flow per local protocol

›Titrate flow and FiO2 to SpO2 goal

›Failure signals

›Rising FiO2 requirement

›Worsening retractions

›Rising PaCO2 on blood gas

›CPAP

›Consider for high flow failure with persistent distress

›Monitor for gastric distension

›Intubation and mechanical ventilation

›If apnea or exhaustion with hypercapnia

›Preoxygenation strategy to minimize desaturation

›Post intubation sedation and analgesia plan

Medications and therapies with limited routine role

›Bronchodilators

›Routine use not recommended for classic bronchiolitis

›If trial considered, predefined response criteria

›Improved work of breathing

›Improved aeration

›Improved SpO2 with reduced support

›Albuterol trial dosing

›MDI with spacer 2 to 4 puffs

›Reassess after 10 to 15 minutes

›Nebulized albuterol 2.5 mg for 10 to 15 kg

›Weight adjusted dosing per local protocol

›Stop if no objective response

›Nebulized epinephrine

›Not recommended routinely

›Consider only in select settings per local protocol

›Corticosteroids

›Not recommended routinely

›Consider alternative diagnosis

›Asthma phenotype

›Croup overlap

›Hypertonic saline

›Not for ED routine use

›Consider inpatient pathway in select institutions

›Antibiotics

›Not indicated for uncomplicated bronchiolitis

›Indications

›Confirmed bacterial pneumonia

›Acute otitis media with clear diagnosis

›Sepsis concern

›Example inpatient pneumonia regimen

›Ampicillin IV 50 mg per kg every 6 hours for uncomplicated bacterial pneumonia

›Adjust for local resistance patterns

Evidence and guideline framing

›Guideline alignment

›Supportive care as primary therapy

›Avoid routine bronchodilator use

›Avoid routine corticosteroids

›Avoid routine antibiotics

›Avoid routine chest radiography for typical cases

›Evidence levels mapping

›High certainty recommendations for avoiding routine ineffective therapies

›Conditional trials only with objective response criteria

›Escalation based on respiratory failure physiology rather than virus identification

09Special Populations/sp32

Pregnancy

›Special population notes

›Bronchiolitis definition primarily pediatric

›Adult RSV lower respiratory infection may mimic bronchiolitis pattern

›Pregnancy respiratory physiology

›Reduced functional residual capacity

›Lower tolerance for hypoxemia

›Medication cautions

›Avoid unnecessary medications

›Oxygenation target individualized for maternal fetal status

Geriatric

›Special population notes

›Bronchiolitis uncommon as a diagnostic label in older adults

›RSV lower respiratory infection considerations

›Higher risk of hypoxemia

›Higher risk of decompensation with COPD or CHF

›Disposition sensitivity

›Lower threshold for admission with comorbidity burden

Pediatrics

›Pediatric specific management

›Weight based dosing for all medications

›Feeding safety

›Avoid oral feeds if severe tachypnea with aspiration risk

›NG feeds as preferred over IV when feasible

›Apnea risk

›Highest risk in young infants

›Higher risk with prematurity

›High risk comorbidities

›Chronic lung disease

›Congenital heart disease

›Immunodeficiency

›Social safety factors

›Caregiver ability

›Access to follow up

›Distance to hospital

10Background/b39

Epidemiology

›Population burden

›Most common lower respiratory infection in infants

›Peak incidence in first year of life

›Seasonal clustering in winter months in many regions

›Viral causes

›RSV as leading cause

›Rhinovirus

›Human metapneumovirus

›Parainfluenza

›Influenza

›Risk stratification

›Highest hospitalization rates in young infants

›Prematurity increases severity risk

›Smoke exposure increases severity risk

Pathophysiology

›Airway level mechanisms

›Bronchiolar epithelial infection

›Mucosal edema

›Mucus plugging

›Impaired mucociliary clearance

›Gas exchange consequences

›Ventilation perfusion mismatch

›Air trapping

›Atelectasis

›Increased work of breathing

›Apnea mechanism

›Immature respiratory control in young infants

›Upper airway obstruction and hypoxemia contribution

Therapeutic Considerations

›Why supportive care works

›Disease self limited in most cases

›Interventions target oxygenation and hydration

›Time and secretion management as main modifiers

›Why many medications do not help

›Airway obstruction driven by edema and mucus more than bronchospasm

›Bronchodilator response limited and phenotype dependent

›Steroids do not reliably change edema course in typical bronchiolitis

›Respiratory support physiology

›High flow nasal cannula reduces work of breathing via washout and mild distending pressure

›CPAP recruits atelectatic units and reduces airway collapse

›Mechanical ventilation reserved for failure and apnea

11Patient Discharge Instructions/pdi24

copy discharge instructions

›Home care plan

›Nasal saline drops with gentle suction before feeds and sleep

›Small frequent feeds

›Maintain hydration with usual milk or formula

›Fever comfort care with acetaminophen as directed by weight

›Smoke free environment

›Expected course

›Cough and congestion can last 1 to 2 weeks

›Worst breathing often occurs around days 3 to 5

›Return to ED now

›Trouble breathing

›Fast breathing that is worsening

›Skin pulling in between ribs or under ribs

›Grunting or head bobbing

›Blue lips or face

›Pauses in breathing

›Too sleepy to feed

›Fewer than half normal wet diapers

›Signs of dehydration

›Very dry mouth

›No tears when crying

›Follow up

›Primary care visit in 24 to 48 hours if symptoms not improving

›Earlier follow up for infants under 3 months or high risk conditions

12References/r14

Guidelines and evidence sources

›Clinical guideline set

›American Academy of Pediatrics bronchiolitis guideline

›National Institute for Health and Care Excellence bronchiolitis guideline

›Canadian Paediatric Society bronchiolitis guidance

›Evidence summaries

›Systematic reviews on bronchodilators in bronchiolitis

›Systematic reviews on corticosteroids in bronchiolitis

›Trials and meta analyses on high flow nasal cannula in bronchiolitis

›Coding and terminology references

›ICD-10 bronchiolitis J21.0 RSV bronchiolitis

›ICD-10 bronchiolitis J21.1 human metapneumovirus bronchiolitis

›ICD-10 bronchiolitis J21.8 other specified organisms

›ICD-10 bronchiolitis J21.9 unspecified bronchiolitis

›SNOMED CT bronchiolitis disorder concept mapping for problem list use

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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