Bronchiolitis is a very common condition seen predominantly in children up to 18 months of age. It is characterised by bilateral crepitations and/or wheeze, usually proceeding upper respiratory tract symptoms. It caused by a viral pathogen, most commonly RSV (respiratory syncytial virus). There is no role for bronchodilators, steroids or antibiotics in the management of bronchiolitis.
For the management of acute bronchiolitis, please refer to the Royal Children’s Hospital clinical practice guidelines.
Bronchiolitis is a clinical diagnosis. There is no role for investigations such as blood tests or chest x-ray, except in severe cases in hospital settings. Nasopharyngeal aspirates do not generally assist in the management of bronchiolitis.
Asthma (see asthma pre-referral guideline) is characterised by reversible bronchoconstriction, thus in comparison to bronchiolitis, there is a role for bronchodilator therapy (e.g. salbutamol) in asthma. It is generally diagnosed in children after 12 months of age.
Viral induced wheeze is distinct from bronchiolitis. This is typically seen in children up to five years of age and is characterised by wheeze only during acute illnesses that may or may not be responsive to salbutamol. The child is well between episodes and there is no role for steroid preventers.
Pneumonitis is typically seen in children two years of age and older. It is characterized by bilateral creptitations with hypoxia. There is minimal role for salbutamol and no role for steroids.
Infant wheeze or ‘fat happy wheezers’. This is seen in children less than 12 months of age and is characterized by persistent wheeze even when well, with no response to bronchodilators. There is no role for steroids.
Cardiac failure. Very occasionally young babies may present with cardiac failure due to an undiagnosed congenital cardiac defect (e.g. VSD). Cardiac failure may mimic some of the clinical findings of bronchiolitis: increased work of breathing, tachypnoea, wheeze/crackles. If this is the case, there will be no preceding history of an upper respiratory tract infection and the symptoms will usually have been more gradual than expected with bronchiolitis.
- Bronchiolitis is a clinical diagnosis in children less than 2 year of age.
- The peak of severity is generally 48-72 hours after the onset of lower respiratory tract symptoms and signs.
- There is no role for blood tests or x-ray in most cases of bronchiolitis.
- There is no role for salbutamol, steroids or antibiotics in the management of bronchiolitis.
- Admission is considered for children with bronchiolitis who are hypoxic, dehydrated or apnoeic.
- Beware the ex-premature child with bronchiolitis as they often have a more severe course of illness.
There is no role for salbutamol, steroids or antibiotics in the management of bronchiolitis. Oxygen and fluids are the supportive therapies available for bronchiolitis. Admission is considered for children with bronchiolitis who are hypoxic, dehydrated or apnoeic.
Recurrent bronchiolitis increases the chances of future asthma, although does not require specific management above and beyond the acute episodes.
- Referral to paediatric outpatient services is not appropriate in the management of acute asthma.
- Referral to paediatric outpatient services is generally not required, even for recurrent bronchiolitis.