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

Related Pathway
Bronchiolitis Inpatient
Treatment
Goals and Metrics
SUPPORTIVE CARE
Suction
Hydration, nutrition
Supplemental oxygen
Pulse oximetry
Fever Management
Guidance for Oral or Enteral Feeding in Bronchiolitis Patients
Child with Bronchiolitis
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 months
  • Strong response to albuterol
Triage
History and Physical
Initial Respiratory Assessment
Mild
Moderate
Severe
Consider Suction-bulb

Suction: Bulb

Bronchodilators not recommended for typical bronchiolitis. If used, document reason and response.

  • Suction: Bulb or wall
  • 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/minute
  • 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
  • Base decision on:
    • Repeated assessments
    • Response to therapy
    • Stage of illness
  • Admit if discharge criteria not met:
    • Inpatient: Requires O2 or progression expected
    • EDECU: Mild disease with expected LOS < 24 hours
    • ICU: Apnea, severe distress
              Requires HFNC / CPAP / intubation
  • Infants with these risk factors present early in the illness have higher risk of progression:
    • Gestational age < 34 weeks
    • Respiratory rate ≥ 70
    • Age < 3 months
Posted: September 2005
Revised: September 2011, November 2013, November 2015, February 2016, October 2017, November 2017, March 2018, December 2019, May, 2021
Authors: R. Abaya, MD; K. Crescenzo, RN; E. Delgado, MD; M. Dunn, MD; M. Kerrigan RRT; N. Muthu MD; C. Nelson, MD; A. Reardon CRNP; B. Rodio, RN; N. Strobel CRNP; D. Simpkins RRT; L. Tyler, RRT; J. Zorc, MD