1. City and Hackney Bronchiolitis Pathway
Manpreet Sahemey – GP & EM Registrar
Dr Sanjay Wazir – Consultant Paediatrician

2. What is bronchiolitis?
Cough and increased work of breathing – affects a child’s ability to feed
Most commonly seen in the winter months in children aged under 2 years (peaks 3-6 months) caused by RSV
In most cases, symptoms last a few days and the child will improve
1/3 children will develop bronchiolitis in the first year of life
3% of children with bronchiolitis require hospital admission (5-10% for severe bronchiolitis)
The majority of cases can be managed at home

3. Diagnosing Bronchiolitis
A coryzal prodrome lasting 1 to 3 days followed by:
- persistent cough 
- either tachypnoea or chest recession (or both) 
- either wheeze or crackles on chest auscultation (or both)
Infants aged 6 weeks or less may present with apnoeas and no other clinical signs

4. Videos of bronchiolitic children

5. Brochiolitis severity

6. Red flag features
worsening work of breathing e.g. grunting, nasal flaring, marked chest recession
fluid intake is 50-75% of normal
no wet nappy for 12 hours

7. Bronchiolitis management
What can be helpful?
- regular saline nasal drops (available over the counter)
propping up
Humidity e.g wet towel over radiator (evidence base is lacking – Cochrane review 2011)
Do not use the following to treat bronchiolitis:
Antibiotics, salbutamol, montelukast, ipratropium bromide, systemic or inhaled corticosteroids

8. Risk factors for severe bronchiolitis
Chronic lung disease
Congenital heart disease
Age < 3 months
Prematurity <32/40
Neuromuscular disease
Immunodeficiency

9. When to refer to hospital
Signs of exhaustion or increased respiratory effort e.g. grunting, marked chest recession
Apnoea (observed or reported)
Failure to maintain oxygen saturation >92% (where saturation monitoring is available)
RR>60/min
Difficulty feeding or reduced oral fluid intake to 50-75% of usual volume
Clinical dehydration
Decrease in wet nappies
Take into account other factors such as social circumstances, confidence of a carer in looking after the child at home and spotting red flag symptoms

10. NICE guidance

11. The pathway document

12. Traffic light system

13. Management flowchart

14. Case study
9 month old female attended ED with fever and increased WOB, reduced oral intake and wetting nappies slightly less than usual, no rash, no D&V
One of twins – born at 36/40
Thriving, up to date with imms, no regular prescribed meds
Found to be tachypnoeic at 50 bpm, temp 37.9, Sats= 94% (oa), HR=144bpm
Chest left basal crackles
Assessed to be amber -> admitted for a short period of observation and supportive measures, discharged home later once feeding and observations improved

15. Referral options from Primary Care
Contact and speak to the on call Paediatric Registrar via the Homerton Hospital switchboard on bleep 007
For advice contact and speak to the on call Paediatric Consultant via the Paediatric advice hotline on The hotline is open every weekday 9am to 5pm.

16. Bronchiolitis at HUH
 We did an audit regarding bronchiolitis referrals and admission last year
There were about 400 A&E presentations
20% were admitted which includes admissions as well as observations.

17. References
Bronchiolitis in children: diagnosis and management. NICE guideline [NG9] Published June 2015
Schuh et al. Efficacy of oral dexamethasone in outpateints with acute bronchiolitis. J Pediatr 2002; 140(1):27-32
Patel H et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev 2004;(3): CD004878
Corneli HM et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med Jul 26;357(4):331-9

18. Q&A

19. Reminder Paediatric hotline – 07795390715
Paediatric advice and guidance – through the electronic referral system (e-RS)
Urgent clinic – refer through the e-RS system