Overview
This is the AHS Pediatric Provincial decision making and treatment summary algorithm for the diagnosis and management for bronchiolitis. It is based on the “Less is Best” philosophy for the investigation and management of bronchiolitis. However the clinician must always be alert to the possibility that the diagnosis may be incorrect, or that there may be underlying co-morbidities.
Certainly by the time of consideration for PICU admission, a CXR is warranted, as by the time a child with bronchiolitis is intubated evidence suggests pulmonary bacterial co-infection rate is >30%. As such, the community acquired pneumonia antibiotic guideline should be followed if the CXR shows undisputed consolidation.
The febrile infant with bronchiolitis should be carefully accessed, with older infants screened for UTI and very young infants (< 28 days) consideration should be given to a full septic work-up, or at least a blood culture.
Generally we do not support the use of bronchodilators (salbutamol, epinephrine) unless, usually in the older child > 8 months, significant airway obstruction (wheeze) is evident. Bronchodilators are only tested in younger children if the child would otherwise be considered for PICU admission for NIV, and only continued if a positive clinical response in noted.
In children in the 8-24 month age range, distinguishing bronchiolitis from bronchodilator responsive asthma can be difficult, and there may be overlap. Our experience is that most often the asthma pathway is overused, and this may make the child appear worse, thus we recommend using careful and repeated clinical assessments and judgement.
At the ACH, for worsening respiratory distress requiring PICU admission, HHHFNC is trialed initially, if the infant would otherwise be deemed to required CPAP/BiPAP.
HHHFNC is judiciously used outside of the PICU under a strict protocol (see Respiratory Therapy section).
In rural centers, HHHFNC can be commenced for significant WOB if supported in that institution. A failure to clinically respond to HHHFNC with 2-6 hours is an indication for PICU referral.