Fever < 3 Months Treatment Plan
Confirm Diagnosis of Bronchiolitis in infants <12 months of age
A diagnosis of bronchiolitis requires a history of an upper respiratory tract infection followed by onset of respiratory distress with fever and at least one of the following:
Examination
Assessment of severity of acute bronchiolitis
| Title | Mild | Moderate | Severe |
|---|---|---|---|
| Behaviour | Normal | Some/intermittent irritability | Increasing irritability and/or lethargy/fatigue |
| Respiratory rate | Normal - mild tachypnoea | Increased | Marked increase or decrease |
| Use of accessory muscles | Nil to mild chest wall retraction |
Moderate chest wall retractions Trachael tug Nasal flaring |
Marked chest wall retractions Marked trachael tug Marked nasal flaring |
| Oxygen saturations in room air | Sp02 > 92% | Sp02 90-92% | Sp02 < 90% May not be corrected by 02 |
| Apnoeic episodes | None | May have brief apnoea | May have increasingly frequent or prolonged apnoea |
| Feeding | Normal | May have difficulty with feeding or reduced feeding | Reluctant or unable to feed |
Risk Factors for Severe Disease
Gestational age less than 37 weeks
Chronological age at presentation less than 10 weeks
Chronic lung disease
Congenital heart disease
Chronic neurological conditions
Indigenous ethnicity
Failure to thrive
Trisomy 21
Post-natal exposure to cigarette smoke
Breast fed for less than 2 months
Consider Alternative Diagnosis
Less common causes of respiratory distress in infants
| Alternative Diagnosis | |
|---|---|
| Respiratory | Bacterial pneumonia, including pertussis Aspiration of milk/formula or foreign body Tracheo/bronchomalacia Cystic Fibrosis |
| Other | Congestive cardiac failure Sepsis Intrathoracic mass Allergic reaction |
Seek urgent paediatric critical care advice (onsite or via Retrieval Services Queensland (RSQ) for infants with any of the following:
- Significant o recurrent apnoeas
- Persistent desaturations despite oxygen
- Severe disease who are failing to improve with initial treatment
- Moderate bronchiolitis with congenital heart disease or chronic lung disease
Other Treatments Required in Bronchiolitis
Hydration/Nutrition
- Small frequent feeds are recommended for infants with mild bronchiolitis
- Nasal saline drops may be considered prior to the time of feeding
- Suctioning of the nares may assist feeding in infants with moderate distress
- NGT insertion is highly recommended for infants on HFNC. Advantages include:
- gastric decompression
- ability to feed without interrupting HFNC
- avoid potential for worsening of respiratory symptoms during feeding
- NG or IV hydration is recommended for infants with moderate -severe bronchiolitis who are feeding inadequately (less than 50% over 12 hours)
- If using IV route, isotonic IV fluids (Sodium Chloride 0.9% with glucose, or similar) are recommended
- The volume of fluids required to maintain hydration is unclear
Treatments NOT Recommended
- Beta 2 agonists (e.g. salbutamol) regardless of a personalffamily history of atopy
- Corticosteroids.
- Adrenaline (nebulised, IM, or IV) except in peri-arrest or arrest situation
- Hypertonic saline
- Antibiotics
- Antivirals
- Deep nasal suction
- Chest physiotherapy
Escalation and Advice Outside of ED
Child is critically unwell or rapidly deteriorating Includes children with the following (as a guide)
- Ongoing hypoxia despite oxygen therapy
- Persistent apnoeic events
- Moderate or severe respiratory distress
- Congenital heart disease or chronic lung disease
- Physiological triggers including:
- RR>50
- HR<80or>170
- SBP <65
- SpO2 <83% in oxygen or <85% in air
- GCs=12
Oxygen Therapy Flow Chart for Bronchiolitis
Low Flow Oxygen
| Low flow oxygen for infants with bronchiolitis by method of delivery | |
|---|---|
| Nasal Prongs | Hudson Mask |
| Maximum flow rate of 2 L/min | Commence at a minimum flow rate of 4 L/min to ensure adequate delivery if oxygen requirements is greater than 2 L/min |
Consider HFNC therapy in infants with severe bronchiolitis who are hypoxic (SpO2 <90%) with severe work of breathing and do not respond to standard low flow oxygen.
Oxygen Therapy for Children with Bronchiolitis
Responder to Standard Oxygen Therapy
(within 2 hours since commencement of Oxygen therapy)
- Oxygen saturation can be maintained (Sp02,>90%) with 2 L/min O2
- Heart Rate dropped by 5 beats/min since start of oxygen therapy
- Respiratory rate dropped by 5 breaths/min since start of oxygen therapy
- Work of breathing and recession has reduced since start of oxygen therapy
Indication for Nasal High-Flow in Bronchiolitis
(PARIS 1 criteria)
- Oxygen saturation can’t be maintained Sp02>90% with Standard
- Heart Rate remains unchanged or increased since start of standard oxygen therapy (rule HR > 160/min)
- Respiratory rate remains unchanged or increased since start of standard oxygen therapy (rule RR > 50/min)
- Work of breathing and recession remain unchanged or increased since start of standard oxygen therapy
Consider transfer to higher level of care
once on NHF and if one or more of the following is present:
- Heart rate remains unchanged for longer than 2 hours since start of NHF,
- Respiratory rate remains unchanged for longer than 2 hours since start of NHF
- Oxygen requirement on NHF exceeds FiO, > 40% (dependant on hospital standard policy) to maintain Sp022, 292%
- The Hospital Internal Early Warning Tool (CEWT) calls for medical review
- Increased work of breathing requiring escalation of respiratory support and assessed as severe respiratory failure
- Consider also transfer if local staffing and expertise is inadequate. Relevant communication with RSQ/RFDS and accepting base hospital. The use of Telehealth is encouraged.
Consultation with higher level of service for all NHF patients
Consultation with the level 24 hospital (normally the accepting hospital if transfer is required) will be at 2hrs post commencement of NHF therapy or sooner if required using standard QH video call resources. Communication throughout the tertiary consultations will use the ISBAR technique (standardised within Queensland Health) in conjunction with the Advice/Retrieval Record Paediatrics (MR262) procedures.