Key priorities for implementation

Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

  • Diagnose bronchiolitis if the child has a coryzal prodrome lasting 1 to 3 days, followed by:

    • persistent cough and

    • either tachypnoea or chest recession (or both) and

    • either wheeze or crackles on chest auscultation (or both).

  • When diagnosing bronchiolitis, take into account that young infants with this disease (in particular those under 6 weeks of age) may present with apnoea without other clinical signs.

  • Immediately refer children with bronchiolitis for emergency hospital care (usually by 999 ambulance) if they have any of the following:

    • apnoea (observed or reported)

    • child looks seriously unwell to a healthcare professional

    • severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute

    • central cyanosis

    • persistent oxygen saturation of less than 92% when breathing air.

  • Consider referring children with bronchiolitis to hospital if they have any of the following:

    • a respiratory rate of over 60 breaths/minute

    • difficulty with breastfeeding or inadequate oral fluid intake (50–75% of usual volume, taking account of risk factors [see recommendation 1.3.3] and using clinical judgement)

    • clinical dehydration.

  • When assessing a child in a secondary care setting, admit them to hospital if they have any of the following:

    • apnoea (observed or reported)

    • persistent oxygen saturation of less than 92% when breathing air

    • inadequate oral fluid intake (50–75% of usual volume, taking account of risk factors [see recommendation 1.3.3] and using clinical judgement)

    • persisting severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute.

  • Do not routinely perform a chest X‑ray in children with bronchiolitis, because changes on X‑ray may mimic pneumonia and should not be used to determine the need for antibiotics.

  • Do not use any of the following to treat bronchiolitis in children:

    • antibiotics

    • hypertonic saline

    • adrenaline (nebulised)

    • salbutamol

    • montelukast

    • ipratropium bromide

    • systemic or inhaled corticosteroids

    • a combination of systemic corticosteroids and nebulised adrenaline.

  • Give oxygen supplementation to children with bronchiolitis if their oxygen saturation is persistently less than 92%.

  • Give fluids by nasogastric or orogastric tube in children with bronchiolitis if they cannot take enough fluid by mouth.

  • Provide key safety information for parents to take away for reference for children who will be looked after at home. This should cover:

    • how to recognise developing 'red flag' symptoms:

      • worsening work of breathing (for example grunting, nasal flaring, marked chest recession)

      • fluid intake is 50–75% of normal or no wet nappy for 12 hours

      • apnoea or cyanosis

      • exhaustion (for example, not responding normally to social cues, wakes only with prolonged stimulation)

    • that people should not smoke in the child's home because it increases the risk of more severe symptoms in bronchiolitis

    • how to get immediate help from an appropriate professional if any red flag symptoms develop

    • arrangements for follow‑up if necessary.

  • National Institute for Health and Care Excellence (NICE)