- <2yr old (peak 2-6mo age)
- Respiratory Syncytial Virus (RSV) causes ~70% of cases
- Preemies, neonates, congenital heart disease are at risk for serious disease
- Peaks in winter
- Duration = 7-14d (worst during days 3-5)
- Inflammation, edema, and epithelial necrosis of bronchioles
- Rhinorrhea, cough, irritability, apnea (neonates)
- Assess for dehydration (tachypnea may interfere with feeding)
- Rapid RSV
- Obtain if <1mo old
- If positive then admit
- Not routinely necessary
- May lead to unnecessary use of antibiotics (atelectasis mimics infiltrate)
- Consider if
- Diagnosis unclear
- Critically ill
- Not routinely necessary
Concurrent infection risk
Infants <60 days with RSV bronchiolitis and fever
- Low risk of bacteremia and meningitis in RSV+, still appreciable UTI risk
- Hydration for all infants
- The AAP guidelines also state that it is reasonable to not perform continuous oximetry on infants and children with bronchiolitis
- O2 (maintain SaO2 >90%)
- oxygen saturation alone should not dictate admission
- Nasopharyngeal suctioning may temporarily relieve symptoms
- The use of routine “deep” suctioning may lead to increased length of stay based on one small study 
There is insufficient data to make a recommendation about suctioning.
- AAP recommends as a possible intervention, but 2014 SABRE trial found no change in discharge or adverse events with nebulised HS.
- No decrease in hospital admission using 3% HS in 2017 multi-center, RCT for moderate-severe bronchiolitis, with mild adverse events such as worsening of cough were significantly higher in the HS group
- Only consider administering to infants who require hospitalization (Class B))
- Suction nares / nasal saline drops
- Age <3months
- Preterm (<34wks)
- Underlying heart/lung disease
- Initial SaO2 <90%
- Sa02 alone should not be used as the only factor for admission
- Unable to tolerate PO
- Papadopoulos NG; Moustaki M; Tsolia M; Bossios A; Astra E; Prezerakou A (2002). Am J Respir Crit Care Med.
- Ralston S. et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics 134(5) Nov. 2014. 1474 -e150 doi: 10.1542/peds.2014-2742 PDF
- Schuh S. et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014 Aug 20;312(7):712-8. doi: 10.1001/jama.2014.8637
- Everard ML, Hind D, Ugonna K, et al. SABRE: a multicentre randomised control trial of nebulised hypertonic saline in infants hospitalised with acute bronchiolitis. Thorax. 2014;69(12):1105–1112. doi:10.1136/thoraxjnl-2014-205953.
- Angoulvant F et al. Effect of Nebulized Hypertonic Saline Treatment in Emergency Departments on the Hospitalization Rate for Acute BronchiolitisA Randomized Clinical Trial. June 5, 2017. JAMA Pediatr. Published online June 5, 2017. doi:10.1001/jamapediatrics.2017.1333.
- Bjornson CL. et al. A randomized trial of a single dose of oral dexamethasone for mild croup. NEJM. 2004;351:1306-1313.
- Geelhoed GC. et al. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. BMJ. 1996;313:140-142
- Ralston S. et al. Randomized, placebo-controlled trial of albuterol and epinephrine at equipotent beta-2 agonist doses in acute bronchiolitis. Pediatr Pulmonol. 2005;40:292-299
- Corneli HM, Zorc JJ, Mahajan P, et al; Bronchiolitis Study Group of the Pediatric Emergency Care Applied Research Net- work (PECARN). A multicenter, random- ized, controlled trial of dexamethasone for bronchiolitis [published correction appears in N Engl J Med 2008;359(18): 1972]. N Engl J Med. 2007;357(4):331–339
- Schuh S, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014; 312(7):712-718.
- Ross JD, et al. The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department. J Emerg Med. 1998; 16:535-539.
- Kelley PB, et al. Racemic epinephrine use in croup and disposition. J Emerg Med. 1992; 10:181-183.