Value in Inpatient Pediatrics Network

Protocol - Peyton Manning Children's Hospital


Bronchiolitis, in typical presentation, is a self-limited disease characterized by airway edema and not bronchospasm.  The basic management of bronchiolitis is supportive in nature and includes assuring that the patient is well oxygenated and well hydrated.


Patient Population

These are guidelines developed by the Pediatric Hospitalists and the Emergency Room physicians.  These are voluntary and do not represent a hospital wide endeavor.  These guidelines are applicable to the following patients:

1.      Patients less than 1 year

2.      Patients without previous history of wheezing

3.      Patients without significant underlying medical problems, specifically cardiac or pulmonary disease or prematurity


Admission Guidelines (consider admitting patients with the following):

-  Respiratory rate > 70

-  Oxygen saturation < 90% on room air

-  This should generally be measured prior to nebulizer therapy

-  Significant increased work of breathing

-  Inability to take adequate PO intake

-  Care givers unable to provide appropriate care at home

-  Toxic or ill appearing patient

-  The following patients are at high risk for complications

  • Patients < 6 week

-  Apnea may be the initial symptom

  • Underlying cardiac problems
  • Underlying pulmonary problems
  • History of prematurity

These are guidelines for admission and all patients should be considered on a case by case basis


Laboratory and radiologic studies

- Routine nasopharyngeal washing for RSV antigen is not recommended

-  Chest radiographs are not recommended as a routine.

-  Blood gases are recommended only as needed for individual patients.

-  >2 mo. of age bronchiolitis is a cause of fever and routine fever workup isn’t always necessary.  < 2 mo, although the literature supports the workup isn’t warranted, routine fever workup (see the Hospitalist’s or ER’s fever guidelines) is still the national standard till there is more data.

Respiratory care therapies

- A trial of bronchodilator aerosol therapies may be appropriate

·         If, within 60 minutes of a trial inhalation therapy, there is not significant improvement, it is recommended that the therapy not be repeated.

·         Inhalations using epinephrine may be considered in selected patients

- Some studies show this is more beneficial than placebo or beta-agonists

-  Chest physiotherapy is not recommended.

-  Cool mist therapy is not recommended.

-  Supervised cough and suction is not recommended.

-  Aerosol therapy with saline is not recommended

-  Systemic steroids are not recommended

-  Steroid inhalations are not recommended

There is some preliminary evidence suggesting inhaled steroids may decrease long term complications of bronchiolitis but more studies are needed before this can be routinely recommended



- Electronic monitoring as indicated



-  Respiratory/contact isolation per hospital protocol of all patients diagnosed with bronchiolitis



1.      Darville Toni, Yamauchi Terry.  Respiratory Syncytial Virus. Pediatrics in Review. 1998;19:55-61

2.      Flores Glenn, Horwitz Ralph. Efficacy of beta2-Agonists in Bronchiolitis: A Reappraisal and Meta-analysis. Pediatrics. 1997;100:233-239

3.      Kusum Menon, Sutcliffe Teresa, Klassen Terry. A Randomized Trial Comparing the Efficacy of Epinephrine with Salbutamol in the Treatment of Acute Bronchiolitis. Journal of Pediatrics. 1995;126:1004-1007

4.      Dobson Joseph, Stephens-Groff Susan, McMahon Shawn, Stemmler Margaret, Brallier Susan, Bay Curtis. The Use of Albuterol in Hospitalized Infants With Bronchiolitis. Pediatrics. 1998;101:361-368

5.      Perlstein Paul et al. Evaluation of an Evidence-based Guideline for Bronchiolitis.  Pediatrics. 1999;104:1334-1341

6.      Sanchez I, De Koster J et al. Effect of Racemic Epinephrine and Salbutamol on Clinical Score and Pulmonary Mechanics in Infants with Bronchiolitis. Journal of Pediatrics. 1993;122(1):145-151

7.      Diagnosis and Management of Bronchiolitis- A Clinical Practice Guideline.  Subcomittee on Diagnosis and Management of Bronchiolitis.  Pediatrics. Oct. 2006: Vo. 118, pgs 1774-2223