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Bronchiolitis

NICE guideline [NG9] Bronchiolitis in children: diagnosis and management. Last updated: Aug 2021.

Background Information

A LRTI Lower respiratory tract infection- inflammation of the bronchioles in <2 y/o

Note that in those >2 y/o, usually large airways (bronchi) are affected - bronchitis.

Most commonly caused by respiratory syncytial virus (RSV)

Occurs in <2 y/o:
  • More common in <1 y/o
  • Peak incidence at 3-6 months

Typical presentation:
  • Coryzal prodrome lasting 1-3 days
  • Followed by persistent cough

Examination findings:
  • Fever
  • Focal crackles and/or wheeze
  • Poor feeding
  • Respiratory distress features
    • Tachypnoea
    • Chest recession
    • Nasal flaring
    • Grunting
    • Cyanosis
    • Prolonged expiration phase

 

Young infants (esp. <6 weeks) may present atypically with apnoea and no classic signs.

Diagnosis Guidelines

Bronchiolitis should be diagnosed clinically (see above for clinical features).

 

NICE explicitly says NOT to routinely perform a chest X-ray (as X-ray changes may mimic pneumonia). Only consider performing a chest X-ray if intensive care is being proposed.

Management Guidelines

Admission to hospital is indicated if ANY of the following:
  • Apnoea
  • Hypoxia
    • SpO2 <90% in ≥6 weeks old
    • SpO2 <92% in <6 weeks old or those with underlying health conditions
  • Inadequate fluid intake (50-75% of usual volume)
  • Severe respiratory distress (e.g. grunting, marked chest recession, respiratory rate >70 / min)

 

The following risk factors are associated with more severe bronchiolitis (these patients are more likely to require admission):

  • Chronic lung disease
  • Haemodynamically significant congenital heart disease
  • <3 months
  • Premature birth (esp. <32 weeks)
  • Neuromuscular disorders
  • Immunodeficiency

Mainstay of bronchiolitis management is supportive care
  • Respiratory support
    • Oxygen therapy if SpO2 <90% (in ≥6 weeks old) or SpO2 <92% (in <6 weeks old or those with underlying health conditions)
    • Consider CPAPContinuous positive airway pressure in those with impending respiratory failure
 
  • Feeding support
    • Consider nasogastric / orogastric tube or IV isotonic fluids if unable to tolerate oral fluids or insufficient intake
 
  • Consider upper airway suction if 
    • Secretions are causing feeding difficulties or respiratory distress, or
    • Apnoea, even with no upper airway secretions

 

Do not offer the following to treat bronchiolitis:

  • Antibiotics
  • Bronchodilators
  • Corticosteroids
  • Montelukast
  • Hypertonic saline
  • Nebulised adrenaline

References

Author: Adams Lau
Reviewer:
Last edited: 24/08/25