Consensus Clinical Guidelines for Inpatient Management of Viral Bronchiolitis

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Northern California Pediatric Hospital Medicine Consortium

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Table of Contents

• Executive Summary (Objectives and Recommendations)
• Consensus Clinical Guidelines
• Definition of Simple / Uncomplicated Viral Bronchiolitis
• Diagnosis
• Hospital Admission / Discharge
• Treatment
• Other Considerations
• FAQ
• Appendix 1: Clinical Pathway for Inpatient Management of Viral Bronchiolitis
• Appendix 2: Clinical Pathway for Initiation and Management of HHFNC
• Appendix 3: High Flow Holiday for Patients with Bronchiolitis on HHFNC
• Appendix 4: Respiratory Scoring Tools
• References

 

Executive summary

Objectives

• Standardize care of pediatric patients with viral bronchiolitis in the acute care and inpatient settings

Recommendations

• Diagnosis

  • Viral testing, other laboratory tests, and CXRs are not routinely indicated for uncomplicated bronchiolitis.

•  Hospital Admission

  • Infection control and isolation should be based on clinical symptoms

  • Pulse oximetry is indicated:

    • First 2-4 hours of admission

    • All patients with an oxygen requirement and 2-4 hours after resolution of O2 requirement

    • Infants < 48 weeks post conceptual age

    • Severe respiratory distress or altered mental status

  • Discharge Criteria: improved work of breathing, maintaining adequate PO hydration, off supplemental oxygen for at least 6hrs, parents able to verbalize anticipated course of recovery.

• Treatment

  • Mainstay of treatment is supportive care with supplemental oxygen, nasal saline, gentle suctioning (no deep suctioning), IV fluids if needed

    • Chest PT, albuterol, hypertonic saline, racemic epinephrine, steroids, or antibiotics are NOT ROUTINELY recommended.

Methods

This guideline was developed through local consensus based on published evidence and expert opinion as part of the UCSF Northern California Pediatric Hospital Medicine Consortium.

Metrics Plan

TBD

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Consensus Clinical Guidelines 

Definition of Simple / Uncomplicated Viral Bronchiolitis

• Typical age: < 2 years

• Classic symptoms: cough, coryza, +/- respiratory distress or work of breathing, +/- fever

• Characteristic clinical exam features (lower airway inflammation/obstruction): symmetric / non-focal findings, rhonchi or coarse crackles, wheeze, prolonged expiratory phase

• First episode of wheeze in child without underlying disease

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Diagnosis

• Clinical diagnosis based on patient’s age, history and typical exam findings of lower airway inflammation/obstruction

• Viral testing:

  • Routine viral testing is NOT indicated – has not been shown to alter clinical management, outcomes, or predict severity of disease

  • Viral testing is indicated IF:

    • Infection control / cohorting for hospital admission (in facilities with shared patient rooms)

    • Unclear diagnosis in infant/child with respiratory symptoms, tachypnea/work of breathing, +/- fever

    • Influenza, COVID, RSV testing in appropriate clinical scenario (e.g. seasonal, consistent symptoms)

  • Other laboratory studies:

    • Routine laboratory testing (e.g. CBC) is NOT indicated – has not been shown to affect management or predict severity of disease

    • Additional testing likely indicated IF:

      • Young infant with fever – follow appropriate guidelines for fever in infant < 90 days

      • Unclear diagnosis in ill-appearing child

  • Radiology

    • CXR is NOT routinely indicated

    • Indicated if suspicion for airway obstruction or ICU admission

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Hospital Admission / Discharge

• Admission criteria (may include):

  • Respiratory distress (based on tachypnea, work of breathing)

  • Hypoxia (consistent O2 sat < 90% on RA, discounting O2 sats during deep sleep)

  • Young age (< 4 weeks old or < 48 weeks post-conceptional age for preterm infants) +/- history of apnea 

  • Dehydration or “ill appearance”

  • Presence of risk factors for severe disease: history of prematurity, hemodynamically significant CHD, chronic lung disease, immunocompromised state

  • Arc of illness may influence decision to admit and guide anticipatory counseling for families

• Infection control / isolation precautions:

  • Based on clinical symptoms, NOT viral testing results

    • Droplet precautions for ALL patients

    • +/- Contact precautions (based on institutional guidelines)

  • Patients with RSV or other definitive viral diagnosis may be cohorted in shared rooms

• Pulse oximetry monitoring:

  • Indications for continuous pulse oximetry monitoring

    • First 2-4 hours of any bronchiolitis admission

    • Young age (<4 weeks or <48 weeks post-conceptional age for preterm infants) 

    • Supplemental oxygen requirement + 2-4hrs following discontinuation of supplemental oxygen

    • Severe respiratory distress, “ill appearance”, abnormal mental status (“tired” appearing)

  • Stop continuous pulse oximetry once patient is stable off of oxygen

  • Intermittent oxygen saturation checks q4hrs with vital signs for all other cases

• PICU Consultation / Transfer Considerations:

  • Obtain VBG and CXR if clinically worsening and considering transfer

  • Indications:

    • Persistent, severe respiratory distress despite maximal care

      • severe respiratory distress per validated respiratory scoring tool (see Appendix 4)

      • No improvement in respiratory score in moderate score range > 6 hours

      • Progressive deterioration on two consecutive evaluations in moderate score range

      • Hypercarbia on blood gas

    • Approaching need for escalation of respiratory support beyond capabilities of the pediatric floor at a given institution

• Discharge Planning:

  • Discharge Criteria (must meet all of the following):

    • Improved work of breathing

    • No need for supplemental oxygen for at least 6 hrs

    • Adequate PO hydration

    • Parents able to verbalize anticipated course of recovery

  • Hospital Follow-up

    • Follow-up (PMD, acute care, phone) arranged within 2 days of hospital discharge

    • Direct communication between inpatient & outpatient providers (e.g. discharge summary, phone call, email)

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Treatment

• Supportive care is the preferred treatment for all viral bronchiolitis.

  • Supplemental oxygen:

    • Criteria for starting or restarting supplemental O2

      • O2 sat < 88% awake or asleep on RA for period of 10-20 min

      • O2 sat persistently < 85% at any time

    • Criteria for discontinuing supplemental O2

      • O2 sat consistently > 90%, no or minimal respiratory distress, including during PO feeding

    • Supplemental O2 delivery method depends on institution policies, provider preference, and patient tolerance/comfort (NOTE: blow-by O2 is not a reliable delivery method for supplemental O2 in patients with significant hypoxia)

      • High-flow Nasal Cannula (HFNC)

        • Potential for increased O2 delivery, minimally invasive continuous positive airway pressure

        • Consider if available at institution or for transfer to higher level of care(NOTE: HFNC not available as O2 delivery modality on pediatric ward at some institutions)

        • See Appendix 2 and 3 for guidance on initiation and weaning of HHFNC in bronchiolitis

  • Nasal saline drops/spray:

    • May be used ATC or PRN in patients with symptomatic nasal secretions

  • Nasal suctioning:

    • May be used gently in young infants with symptomatic nasal secretions (NOTE: there is no benefit and potential harm with forceful or deep suctioning)

    • Consider use of mushroom tip catheter

  • Chest PT:

    • NOT indicated

  • Hydration: Evaluate hydration status and ability to take fluids orally

    • Consider IV fluids in patients with significant respiratory distress (risk for aspiration or impending respiratory failure) or clear feeding difficulty / dehydration

    • Consider NG tube for enteral hydration and feeds in babies who have feeding difficulty due to illness

    • HFNC is not necessarily a contraindication to PO or NG feeding; use clinical judgment about trajectory of patient

  • Hypertonic saline (inhaled 3% sodium chloride):

    • NOTE: current variation in practice among institutions

    • Overall mixed evidence that nebulized 3% sodium chloride may decrease length of hospitalization + improve clinical sx / severity of illness in hospitalized patients, but may induce bronchospasm

    • NOT recommended for routine / scheduled use in all bronchiolitis

    • Consider trial of 3% nebulized treatment q8hrs ATC x 24hrs in patients with moderate disease; continue if symptomatic improvement and no adverse effects, and discontinue if no improvement. If child experiences significant adverse effects with initial 3% nebulized sodium chloride dose (e.g., bronchospasm, painful cough), providers can decide to add-on bronchodilator (dosed concurrently) to mitigate side effects with subsequent HTS doses, or discontinue HTS therapy altogether, depending on severity of adverse symptoms.

    • Not for use in emergency department

  • Albuterol

    • NOT recommended for routine / scheduled use in all bronchiolitis

    • Trial of albuterol may be indicated if patient is not responding to traditional supportive care; may be continued if beneficial, otherwise should not continue

  • Racemic epinephrine

    • NOT recommended for routine / scheduled use in patients with bronchiolitis

  • Corticosteroids

    • No evidence for benefit

    • NOT recommended for routine use in bronchiolitis

  • Antibiotics

    • NOT recommended for use in bronchiolitis except in children with specific indication of co-existent bacterial infection

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Other Considerations

• Bronchiolitis as a fever source:

  • In well-appearing infants >1mo with fever, clinical diagnosis of bronchiolitis or documented viral infection can generally be considered a source of fever

    • Evidence: occult serious bacterial infection (SBI) or UTI are very rare in well-appearing infants > 1mo

  • Strongly consider urine sample for UA and culture in infants < 3 months or at high risk for UTI

    • Evidence: infants < 3mo or those at high risk for UTI with clinical bronchiolitis have reduced but still significant (~5%) risk of UTI

• Apnea in young infants:

  • Risk factors for apnea with RSV and non-RSV bronchiolitis:

    • Post-conceptional age < 48 weeks (greatest risk = < 42 weeks)

    • Prematurity

    • Tachypnea or respiratory depression

    • Severe hypoxia (< 90% in RA)

    • First 48hrs of illness

  • Consider admission x 24 hours for apnea monitoring in young infants (< 4 weeks old or < 48 weeks post-conceptional age for preterm infants)

    • NOTE: May not be necessary for infants that are >48 hours into symptom course (particularly infants nearing upper limit of age cutoff)

• Prevention of RSV:

  • Maternal RSV immunization, Nirsevimab (Beyfortus), and Palivizumab (Synagis) prophylaxis

  • Refer to current AAP, CDC guidelines

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FAQ

1. What are the new “RSV vaccines” and who is eligible? Should you administer it after RSV infection?

   In order to prevent severe RSV disease in infancy, current CDC recommendations include RSV vaccination of pregnant people at 32-36 weeks gestation with Abrysvo (a bivalent vaccine). This immunization will pass protection to the infant.

   Additionally, there is a new monoclonal antibody, nirsevimab, currently FDA approved for infants 8 months of age or younger born during or entering their first RSV season. It is also approved for infants and toddlers 8-24 months at increased risk of RSV:

   • babies born prematurely with chronic lung disease
   • severely immunocompromised children
   • children with cystic fibrosis and resulting severe disease
   • American Indian and Alaska Native children

   
   In most cases, infants born to mothers who received the RSV vaccine at least 14 days prior to delivery will NOT need nirsevimab.

   If a patient qualifies for nirsevimab, they may still receive it regardless of prior RSV infection or hospitalization secondary to RSV illness. Children who are moderately or severely ill should first recover from the acute illness period prior to receiving nirsevimab.

2. What does “suction” really mean?

   Specifically “deep suctioning” should not be done as studies have shown that it can lead to further irritation and airway trauma, increasing LOS in infants with bronchiolitis.

   Instead “nasal suctioning” with a bulb, olive tip suction catheter, or mouth- operated nasal aspirator (such as Nose Frida or Neil Med Naspira–to be done by parent) can be used to clear the nasal passageways in conjunction with use of nasal saline spray or saline drops to break up mucus.

3. When is it safe to feed by mouth and when should we provide hydration/nutrition via NG or IV?

   NG or IV hydration should be considered when the patient has moderate-severe dehydration or not taking PO fluids/breastfeeding well. NG and IV hydration are both equally effective. The benefit of NG placement over IV is that it may require fewer attempts at placement. NG feeds have not been shown to increase aspiration events. Benefits of IV placement is bolus fluids can be provided if needed but complications such as extravasation may occur. A concern of NG tube placement may be airway obstruction in small infants by occluding the nare. Parents should be included in shared decision making regarding NG vs IV.

   Infants with respiratory distress and RR > 60 should be evaluated for safety of a feeding trial. Infants who are choking, gasping, or experiencing worsening tachypnea with feeds and/or on increasing or maximum HFNC settings are at increased risk of aspiration and should be made NPO and started on IV or NG hydration.

4. When should we use:

   1. Albuterol: Studies have not shown albuterol to be helpful in the management of bronchiolitis. A trial of albuterol on presentation could be considered in an older infant or toddler (>12mo), a patient who has had prior wheezing with URI, has been prescribed an inhaler in the past, or has a strong family history of atopy.

   2. Chest x ray considerations for use:

      1. if the clinical course is not progressing as expected with prolonged hospitalization
      2. if the patient develops new or worsening fever after initial improvement
         
         

   3. RVPtesting: May be helpful in some locations for cohorting/type of isolation.

   4. Hypertonic saline: Not endorsed by data from current research, but can be trialed in prolonged hospitalizations (see above “Treatment” section)

5. When to consider bacterial pneumonia/superinfection?

   Consider a bacterial superinfection (such as pneumonia or otitis) in patients who are initially improving and then suddenly worsen clinically or re-present days later to the ED or PCP with worsening symptoms, especially fever or new symptoms.

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Appendix 1: Clinical Pathway for Inpatient Management of Viral Bronchiolitis

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Appendix 2: Clinical Pathway for Initiation and Management of HHFNC

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Appendix 3: High Flow Holiday for Patients with Bronchiolitis on HHFNC

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Appendix 4: Respiratory Scoring Tools

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References

AAP Clinical Practice Guideline. “The Diagnosis, Management, and Prevention of Bronchiolitis”. Pediatrics 134:5. November, 2014.

AAP Clinical Practice Guideline. “Diagnosis and Management of Bronchiolitis”. Pediatrics 118:4. October, 2006.

AAP Committee on Infectious Diseases. “Updated Guidance for Palivizumab prophylaxis among infants and young children at increased risk of hospitalization for RSV infection”. Pediatrics 134:2. August, 2014.

Cochrane Review. “Nebulized hypertonic saline solution for acute bronchiolitis in infants”. July, 2013.

Cochrane Review. “HighHflow nasal cannula therapy for infants with bronchiolitis”. January, 2014.

Zorc and Hall. “Bronchiolitis: Recent Evidence on Diagnosis and Management”. Pediatrics 125:2. February, 2010.

Kirolos A, Manti S et al , A Systematic Review of Clinical Practice Guidelines for the Diagnosis and Management of Bronchiolitis, The Journal of Infectious Diseases, Volume 222, Issue Supplement_7, 1 November 2020, Pages S672–S679, https://doi.org/10.1093/infdis/jiz240

Alyssa H. Silver, Joanne M. Nazif; Bronchiolitis. Pediatr Rev November 2019; 40 (11): 568–576. https://doi.org/10.1542/pir.2018-0260

Srinivasan M, Pruitt C, Casey E, Dhaliwal K, DeSanto C, Markus R, Rosen A. Quality Improvement Initiative to Increase the Use of Nasogastric Hydration in Infants With Bronchiolitis. Hosp Pediatr. 2017 Aug;7(8):436-443. doi: 10.1542/hpeds.2016-0160. Epub 2017 Jul 5. PMID: 28679563; PMCID: PMC5525377.

Gill PJ, Anwar MR, Kornelsen E, Parkin P, Mahood Q, Mahant S. Parenteral versus enteral fluid therapy for children hospitalised with bronchiolitis. Cochrane Database Syst Rev. 2021 Dec 1;12(12):CD013552. doi: 10.1002/14651858.CD013552.pub2. PMID: 34852398; PMCID: PMC8635777.

CDC Website: “ RSV Immunization for Children 19 months and Younger”. https://www.cdc.gov/vaccines/vpd/rsv/public/child.html

UCSF Northern California Pediatric Hospital Medicine Consortium. Originated 5/2014.
Revised 9/2014, 12/2014, 10/2017, 5/2024.
Approved by UCSF P&T Committee: 05.06.2024
Approved by UCSF QIEC Committee: 12.19.17