Bronchiolitis Clinical Pathway — Emergency Department | Children's Hospital of Philadelphia

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Related Pathways
Bronchiolitis, Inpatient
Bronchiolitis, Oral/Enteral Feeding, ED and Inpatient

Quality Story
Reducing Albuterol Use in Children with Bronchiolitis

Supportive Care
- Suction
- Hydration, nutrition
- Supplemental oxygen
- Pulse oximetry
- Fever management

Infant With Typical Bronchiolitis

Conserving IVF During Shortage

Additional Treatment Considerations
- Albuterol trial
- Racemic epinephrine
- Antibiotics
- Hypertonic saline
Further Diagnostic Testing

Consider ED Asthma Pathway if:

Recurrent wheezing/prior steroid use
Age > 12 mos
Strong response to albuterol

Triage

History and Physical
Initial Respiratory Assessment

Mild

Moderate

Severe

Consider Suction: Bulb

Consider Suction:
Bulb or NeoSucker

Bronchodilators not recommended for typical bronchiolitis; if used, document reason and response

Consider Suction:
NeoSucker or wall suction catheter
Bronchodilators not recommended for typical bronchiolitis; if used, document reason and response
If no improvement after suctioning, assess with attending at bedside to discuss additional treatment including initiating HFNC oxygen at 1.5 L/kg/min
Guidelines for Initiation of High-flow Nasal Cannula Outside the ICU Job Aid
See Enteral Feeding Guidelines
If required FiO₂ > 0.4 or continued severe distress despite increase to 2 L/kg/min / Max HFNC settings, initiate CPAP at 8 cm/0.4 FiO₂ and consult PICU.

Discharge Criteria

Admission Criteria

Oxygen saturation > 90% awake
Adequate oral intake
Mild/moderate work of breathing
Reliable caretaker
Able to obtain follow-up care
MDI/spacer teaching if response
to albuterol
Observed for 2 hrs if requiring wall catheter suction

Base decision on:
- Repeated assessments
- Response to therapy
- Stage of illness
Admit if discharge criteria not met:
- Inpatient: Requires HFNC, O₂ or progression expected
- EDECU: Mild disease with expected LOS < 24 hrs
- ICU: Apnea, severe distress
  - Requires HFNC above floor maximum, noninvasive or invasive ventilation
Infants with these risk factors present early in the illness have higher risk of progression:
- Gestational age < 34 wks
- Respiratory rate ≥ 70
- Age < 3 mos

Posted: September 2005
Revised: October 2024

Authors:
- R. Abaya, MD;
- K. Crescenzo, RN;
- E. Delgado, MD;
- M. Dunn, MD;
- M. Kerrigan RRT;
- A. Reardon CRNP;
- N. Strobel CRNP;
- D. Simpkins RRT;
- L. Tyler, RRT;
- J. Zorc, MD

Editors: Clinical Pathways Team

Evidence

Educational Media

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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Emergency Department Clinical Pathway for Evaluation/Treatment of Children with Bronchiolitis

Evidence

Educational Media