Bronchiolitis Order Set/Pathway
2 years old and under with signs of respiratory illness which may include RR>60, retractions, wheezing, O2 saturation below 93, increased work of breathing, color change, rhinorrhea, or Chest x-ray consistent with Bronchiolitis (hyperinflation or peribronchial cuffing).
Patients with suspected foreign body, history of asthma, severe cardiopulmonary disease, recurrent bronchiolitis/wheezing illness more than 2 times, Rectal T>38.5 and toxic appearing, current PICU admission.
- Height and weight on admission
- Routine V/S
- Daily wt.
- Up ad lib
- Strict I & O
- Weigh diaper
- Encourage fluid intake as tolerated
- Notify MD: Temperature > _______, or < __________
HR > __________
- Assess and Document Bronchiolitis Clinical Score (BCS) on admission, prior to each respiratory treatment, and 30 minutes after treatment
Bronchiolitis Clinical Score
Score 0 1 2 Sign/Symptom Mild Moderate Severe Res. Rate
Work of Breathing None to mild intercostal retractions, or Nasal Flare Moderate intercostal and suprasternal retractions. Grunt, Flare Severe intercostal retractions, flaring, subcostal retractions Breath Sounds/Air Exchange Minimal wheeze/rales
Bilateral air entry
Decreased air entry
Increased exp. phase
Diminished breath sounds with severely impaired air entry O2 Sat (RA) >92% 90%-92% <90% Secretions Rhinorrhea Frequent cough, gag
Inability to cleare secretions
- Notify MD of Bronchiolitis Clinical Score after each assessment
Suction np/op before feeding, PRN, and prior to each inhalation therapy (Document pre- and post-suction Bronchiolitis Clinical Score)
- Respiratory secretion precautions
- Provide parents with Bronchiolitis and RSV Handout
- Educate parents on proper suctioning and airway maintenance techniques
- Educate parents on proper handling of respiratory secretions
IV fluid: (order per usual manner)
D5 1/4 with 20 mEq KCL/L
Apnea monitor if:
- <2 months old (corrected for pre-term infants) and during first 72 hours of current illness
- Current apnea episode
- On apnea monitor at home
BCS on admission, prior to each respiratory treatment, and 30 minutes after treatment
Chest X Ray (consider only if diagnosis of Bronchiolitis is in question)
RSV N/P wash
DFA (may consider)
Consider sepsis work up if less than 1 month old, and rectal temp >38 degrees C.
Per MD judgment: if patient is clinically well may not need nebs, just monitoring and supportive care.
Oxygen by NC or mask if O2 sat (persistently) <93%
1st line treatment:
Racemic Epi via nebulizer, 0.3cc - 0.5 cc of 1:10,000, x2 at 20 min. intervals
- Assess patient using BCS 30 min. after treatment
- If score unchanged or better (lower score), continue Racemic Epi Neb Q2 hr.
- If BCS is worse (higher score), switch to Albuterol nebulizer
Albuterol Neb 2.5 mg /3cc q 2 hours
- Assess patient using BCS 30 min after treatment
- If score is no change or better, continue same or consider weaning treatment interval
- If score is worse: re-evaluate diagnosis of bronchiolitis, increase frequency of treatment, and/or consider transfer to PICU if indicated (if persistent tachycardia > 180 bpm consider l-albuterol 0.63mg/3mL (Xopenex)
Albuterol MDI spacer with mask
(switch from neb to MDI prior to discharge if tolerated. Have parent view MDI video, and RT to teach parent how to administer MDI to patient)
Consider pulmonary consult if child is not responding as expected or has any significant aggravating factors.
- Assess and document BCS prior to and 30 minutes after respiratory treatment
- Notify MD of BCS after each assessment
- Respiratory treatment frequency at q 4 - 6 hr
- Patient able to maintain PO intake
- Respiratory rate <60, baby is comfortable
- Patient is either on RA, or has been on stable oxygen therapy at a level to be considered being able to continue at home effectively
- Parent teaching completed
- Parent is proficient with therapies at home
- When indicated, home care and durable medical supply have been notified and arrangements for visits finalized
- PMD identified, notified, and follow-up appointment has been scheduled
Despite the sometimes inconclusive recommendations for the therapy of Bronchiolitis, there is strong support for developing uniform, evidence based practice guidelines for this illness. There is reduction in rate of admissions, length of stay, medication use and complication rates. We have chosen established guidelines modified to fit our situation. There is obviously much room for individual clinical judgment an assessment.
Inclusion and Exclusion Criteria:
Our purpose is to include toddlers and infants with suspected bronchiolitis (URI sx, wheezing, low grade fevers etc) and exclude those pts who have recurrent wheezing, reactive airway dz or non bronchiolitic wheezing (FB aspiration etc). We also would consider the infant under 1 month of age w. fever or a toxic suspected sepsis pt to require further evaluation and treatment appropriate for their condition.
The reason for these criteria is to not over treat uncomplicated bronchiolitis and not under treat children with reactive airways dz.
- Clinical scores: These are modified from asthma scores and published bronchiolitis scores. The intent is not to depend on specific numbers but to establish trends and to determine success or failure of therapy based on theses trends. These will also allow us to determine frequency of treatments and readiness for discharge. There will be a Bronchiolitis score flow sheet attached to chart to document these trends.
- The Bronchiolitis handout for parents is adapted from established publication available online.
- Apnea Monitor: Based on the evidence we follow, the recommendation is that the highest risk is found in 6-8 week old infants during the initial 72 hours of illness (from onset of URI sx). Exceptions are infants w. h/o apnea, infants w. other underlying illness that could pre dispose for apnea (CNS dz, ex preterm infant, etc), or if infant had apnic/blue spell during this illness. These infants get apnea monitor throughout hospitalization and get home monitor for 3-6 months as determined by PMD and or Pulmonary consultant.
- CXR the use of imaging is up to clinician on case-to-case basis if there are questions of diagnosis etc.
- RSV rapid testing shall be done if hospitalized for cohorting and infection control in the hospital. DFA for Influenza is up to clinician.
- For children under a month with fever with RSV bronchiolitis, we recommend following national guidelines which indicate a full r/o sepsis and IV abx for 48-72 hrs. This does not preclude using this pathway and final decision is always with clinician.
- Racemic Epi: based on the literature, we elected as a group to start w. Racemic Epi. The literature does not support Albuterol in RSV bronchiolitis and there is some evidence for Racemic Epi. Nebs shall be in sequence x 2 times 20 min apart. If clinical condition and scores are same or better we shall continue with Racemic Epi treatments. If pt worsens Albuterol nebs shall be tried.
- Interval for Racemic Epi shall be determined by clinical scores and reassessed frequently to determine course. As patient improves the nebs shall be weaned. When pt is at q4-6 hrs interval nebs shall be stopped and if pt is stable off nebs for 12 hrs or so they may be discharged without nebs.
- 2nd line: Albuterol nebs: as with Racemic Epi frequency shall be determined using clinical scoring. When pt is ready for discharge (q 4-6 hrs interval, on RA etc) an Albuterol MDI and mask shall be attempted. If pt does well with MDI and teaching may go home on MDI. Otherwise Home nebs shall be given.
- If pt fails both Racemic Epi and Albuterol consider transfer to PICU and further w/u. These pt shall be off the pathway.
- Discharge criteria is straightforward and some individual variations are expected per family.
Pediatric Hospitalist Group
Bay Area Pediatric Pulmonology
Andree Hest, R.PH. MScPharm
Bing Tschai, RN, CNS
Oded Herbsman, M.D.
A. Marmor, M.D.
Karen Hardy, M.D.
David Tejeda, M.D.