Rapid Patient Assessment
This section allows for a comprehensive initial assessment. Use diagnostic criteria, identify risk factors, and estimate clinical severity to guide your initial management decisions.
Key Diagnostic Criteria
The diagnosis is clinical. Consider bronchiolitis in children < 2 years with the following presentation:
- ✓ Catarrhal prodrome: 1-3 days of rhinorrhea, cough and/or low-grade fever.
- ✓ Inferior pathway involvement: Appearance of tachypnea or thoracic retractions.
- ✓ Auscultation: Presence of wheezing and/or crackles.
- ✓ First episode: It is generally reserved for the debut of the painting.
Risk Factors for Serious Illness
Check the factors present in your patient to evaluate their vulnerability.
Gravity Calculator (Modified Tal)
Estimate clinical severity. This is a tool to support clinical judgment.
Therapeutic Management
The treatment of bronchiolitis is fundamentally supportive. Pharmacological therapies are not routinely recommended. Explore the key recommendations below.
Essential Support Measures
They are the pillar of treatment.
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1Hydration and Nutrition: Offer small, frequent feedings. Consider NGT or IV fluids if intake is <50-75% of usual or there is marked respiratory distress.
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2Secretion Management: Nasal washes with saline solution and gentle aspiration, especially before feedings. Avoid deep or routine aspiration.
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3Oxygen therapy: Start if persistent SatO₂ <90% (or <92% in at-risk patients). Goal: maintain SatO₂ >90% (or >92%).
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4Advanced Support (HFNC/NIV): Consider in cases of moderate-severe respiratory distress that do not respond to low-flow O₂. Its use must be protocolized and monitored.
Pharmacological Guide (Traffic Light System)
Click on each card to see the details and nuances of the recommendation.
Bronchodilators (Salbutamol, Adrenaline)
NOT ROUTINELY RECOMMENDED. They have not been shown to improve SatO₂, reduce hospital stay or resolve the disease.
Reason for Recommendation/Key Evidence: International guidelines (AAP, NICE, GFRUP) advise against its routine use due to lack of evidence of significant clinical benefit in most cases. A single therapeutic trial could be considered in very specific subgroups (with previous wheezing or history of atopy/asthma) but if there is no clear response, it should be suspended.
Corticosteroids (Systemic/Inhaled)
NOT ROUTINELY RECOMMENDED. No benefit has been demonstrated in acute bronchiolitis.
Reason for Recommendation/Key Evidence: Clinical trials have consistently demonstrated no benefit in reducing hospitalizations or improving outcomes. They might play a role in recurrent episodes of wheezing with a family history of asthma, but not in the first episode of bronchiolitis.
Antibiotics
DO NOT USE. Bronchiolitis is viral.
Reason for Recommendation/Key Evidence: The etiology is viral; The indiscriminate use of antibiotics offers no clinical benefit and contributes to antimicrobial resistance. Reserve only for cases with clear evidence of concomitant bacterial superinfection or suspicion of sepsis.
Hypertonic Saline Solution (3%)
CONSIDER WITH NUANCES. Some guidelines (AAP) allow its use in hospitalized patients. The evidence is of low quality.
Reason for Recommendation/Key Evidence: The evidence suggests a possible slight reduction in hospital stay and improvement in severity scores, but it is not universally recommended nor is it used on an outpatient basis. Its use must be cautious and under supervision.
Clinical Management Criteria
Use this guide as a quick reference to make decisions about hospitalization, PICU admission, and discharge, ensuring standardized and safe patient management.
Hospitalization Criteria
- Apnea (observed or reported)
- Persistent hypoxemia (SatO₂ <90-92%)
- Severe respiratory distress (RR>70, marked retractions, moaning, fatigue)
- Inadequate oral intake (<50-75% usual) with signs of dehydration
- Toxic appearance, cyanosis or lethargy
- Age < 4 weeks
- Presence of important risk factors
- Unfavorable social environment
PICU Admission Criteria
- Severe respiratory failure that does not improve or worsens quickly
- Recurrent apneas with desaturation
- Confirmed hypercapnia
- Need for advanced ventilatory support (NIV/invasive)
- Complex comorbidities requiring intensive monitoring
Hospital Discharge Criteria
- Clinical and respiratory stability
- SatO₂ ≥90-92% in ambient air maintained (incl. sleep) for at least 4-6h
- Adequate oral intake to maintain hydration
- Parents/caregivers confident and trained to manage at home
- Possibility of medical follow-up assured in 24-48 hours
Prevention of RSV Infection
Immunoprophylaxis has revolutionized the prevention of RSV, the main cause of bronchiolitis. Learn about current strategies, including new monoclonal antibodies and maternal vaccination.
Immunoprophylaxis strategies
Nirsevimab: The New Preferred Recommendation
Long-acting monoclonal antibody that offers protection throughout the RSV season with a single intramuscular dose. Recommended for all infants starting their first RSV season, unless they are already protected by maternal vaccination. Prioritization focuses on the highest risk groups, but the goal is universal immunization.
In-depth information
Explore the etiology, epidemiology, and long-term sequelae of bronchiolitis for a more complete understanding of the pathology and its future implications.
Etiology of Bronchiolitis
Respiratory Syncytial Virus (RSV) is the predominant causal agent. Other viruses may be involved, but to a lesser extent.
Long-Term Prognosis and Aftermath
Although bronchiolitis is usually self-limiting, there is a strong association with the subsequent development of recurrent wheezing and asthma. This connection underscores the importance of respiratory monitoring in these patients.
Note: Data in the graph is representative to illustrate the association.