Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

confirmed bronchiolitis

1st line – supportive care

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ACUTE
|
confirmed bronchiolitis
1st line – 

supportive care

The main goal of treatment is to correct abnormalities in oxygenation and hydration.[43][52][54]

The majority of infants can be managed as outpatients. Indications for hospitalisation include persistent hypoxaemia, tachypnoea so severe that it impedes oral feeding or hydration, apnoea, and clinical concern for impending respiratory failure.

Infants with bronchiolitis may have difficulty feeding, due to tachypnoea and nasal secretions.[43] Respiratory compromise can also increase risk of aspiration.[68] Approximately 30% of hospitalised infants require intravenous or nasogastric fluids.

One randomised controlled trial found that intravenous hydration and nasogastric hydration were both appropriate for infants with bronchiolitis. There was no significant difference between the groups in intensive care admission, need for ventilatory support, and adverse events. Nasogastric tube insertion may have a higher success rate and require fewer attempts than intravenous access.[69]

Whichever method is used, hydration therapy should be administered judiciously, so as to avoid over-hydration, which can contribute to increased airway obstruction. If intravenous therapy is required, isotonic solutions should be used, as hypotonic solutions can contribute to the risk of hyponatraemia in infants with bronchiolitis.[70] There is a paucity of data upon which to base nutrient intake guidelines for sick infants with bronchiolitis, with some studies showing that infants are hypermetabolic while others show them to be hypometabolic.[70]

Consider – respiratory support

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ACUTE
|
confirmed bronchiolitis
Consider – 

respiratory support

Additional treatment recommended for SOME patients in selected patient group

Supplemental oxygen should be administered to hypoxaemic children.

Initially treatment is standard oxygen therapy (SOT), administered by nasal cannulae or head box.

The American Academy of Pediatrics recommends a target oxyhaemoglobin saturation (SpO₂) ≥90%.[43]

Because fever and acidosis shift the oxyhaemoglobin desaturation curve to the right, a higher SpO₂ goal may be more appropriate with those conditions: for example, some guidelines recommend >92%.[54][55]

Other signs of impaired respiratory function, such as increased work of breathing or retractions, can be used as factors in deciding on supplemental oxygen therapy.

Infants with underlying cardiac or pulmonary disease may have baseline abnormalities in oxygenation. In these patients, the threshold for using supplemental oxygen may be higher.

High-flow nasal cannula therapy (HFNC) delivers a humidified, heated air and oxygen mixture at high flow through a nasal cannula.[62] HFNC is used as a rescue therapy for hypoxaemic children who have not responded to SOT.[63][64] One randomised controlled trial found that 61% of children who did not respond adequately to SOT did respond to HFNC, avoiding the need for intensive care admission.[65] HFNC is superior to SOT in preventing treatment failure (need for escalation of care).[62]

Nasal continuous positive airways pressure (CPAP) may be considered for children with severe disease, particularly those who have not responded to HFNC, or who have signs of impending respiratory failure.[54][55]

Signs of impending respiratory failure include: exhaustion (listlessness or decreased respiratory effort), recurrent apnoea, and failure to maintain adequate oxygen saturation despite supplemental oxygen.[55] CPAP prevents the collapse of peripheral airways during expiration, and permits deflation of over-distended lung regions.[66] There is insufficient evidence to determine if CPAP decreases the need for subsequent intubation and mechanical ventilation; larger, adequately powered trials are needed.[66]

Intubation and mechanical ventilation may be necessary for children who remain unstable despite supplemental oxygen and non-invasive ventilation support.

One systematic review involving the use of CPAP or bi-level positive airway pressure in children under 2 years of age with viral bronchiolitis identified predictors of failure of non-invasive ventilation, including persistent apnoea, persistently elevated partial pressure of carbon dioxide (pCO₂) after 2 hours of therapy, lower age and weight, and lower initial heart rate with less of a decrease in heart rate following initiation of therapy.[67]

Consider – ribavirin

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ACUTE
|
confirmed bronchiolitis
Consider – 

ribavirin

Additional treatment recommended for SOME patients in selected patient group

Use of ribavirin may be considered in infants with severe disease or those who have severe risk factors (e.g., severe chronic lung disease or immunodeficiency).[71] Routine use is not recommended.

Administered by inhalation via a small particle aerosol generator (SPAG).

Requires special aerosol protection for healthcare workers.

Very high doses have been shown to be potentially mutagenic in animals, but not in humans. This has resulted in recommendations that pregnant healthcare workers should not be exposed to ribavirin.

No effect on long-term pulmonary function or on incidence of recurrent wheezing has been demonstrated in patients receiving ribavirin. Large randomised controlled trials are needed to determine effects on length of stay and reduction in duration of mechanical ventilation in high-risk patients.

Primary options

ribavirin: consult specialist for guidance on dose

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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