Beatriz Morillo
Bronchiolitis Next Steps
Once the assessment of the severity is done, the question is whether the child can be safely discharge home or needs hospital admission.
As it has been already mentioned, the therapy is focused in symptomatic relief and supportive measures; however, the management between physicians can differ widely. To assist in the decision making process, several guidelines are released periodically by different organisms (i.e. AAP, NICE, the own Trusts), using the best evidence available at the time although with subtle differences amongst their recommendations.

The routine use of antivirals (i.e. ribavirin) is not recommended, although it could be considered in some specific patients with risk factors. Some other agents have been studied throughout the years based on the pathophysiology of the disease: adrenaline, bronchodilators -salbutamol, montelukast, ipratropium bromide-, systemic or inhaled corticosteroids and hypertonic saline. The current evidence for each of them is:
Adrenaline- large, multicenter, randomized trials have not shown improvement in outcome among these patients.
Bronchodilators- randomized trials have not shown a consistent beneficial effect on disease resolution, need for hospitalization, or length of stay.
Corticosteroids- large, multicenter, randomized trials provide clear evidence of lack of benefit.
Nebulized hypertonic (3%) saline- it may improve symptoms of mild-to moderate bronchiolitis if length of stay is >3 days.
Due to the above results, to date, none of them are routinely recommended, being the only exception the consideration of using nebulized hypertonic saline in hospitalised patients made by the AAP.

Focused in improving the oxygenation and hydration.
• Ensure patient comfort and monitoring- repositioning can decrease the work of breathing. Periodic assessment of vital signs and hydration. Continuous pulse oxymetry is not necessary as there is very poor correlation between respiratory distress and oxygen saturations in these infants. If there are signs of exhaustion, for example listlessness or decreased respiratory effort, recurrent apnoea or failure to maintain adequate oxygen saturation despite oxygen supplementation, a capillary blood gas should be perform and admission to a Paediatric Intensive Care Unit (PICU) must be considered.
• Removal of obstructive secretions- using nasal drops or upper airway suctioning. The latter is not to be routinely used, as it can be distressing; however, as children are obligate nasal breathers, it could be used in those whose upper airway secretions contribute to the respiratory distress or feeding difficulties.
• Physiotherapy-not to be routinely used. It could be considered in those patients with comorbidities who might have difficulty clearing secretions such as those with spinal muscular atrophy or severe tracheomalacia.
• Supplemental oxygen- in those children with persistent hypoxemia. The cut offs differ from the guidelines consulted: SpO2<92% (NICE) or <90% (AAP).
• Continuous positive airway pressure (CPAP)- in cases of impending respiratory failure.
• Supportive fluid management- orogastric or nasogastric feed for those with inadequate oral intake or intravenous fluids for those who cannot tolerate enteral feed or in those with respiratory failure.

• A child who is able to tolerate fluids with orogastric feeds and does not have any signs or symptoms of severity, can be discharged home providing that the caregivers are able to look after the patient:
o Having been given key safety information
o Ensuring appropriate fluid intake
o Recognizing red flag symptoms and seeking urgent professional review if any of them develop
• A child should be admitted to the hospital if any of the following is present:
o Apnoea (observed or reported)
o Persistent oxygen saturation of less than 92% when breathing air
o Inadequate oral fluid intake (50–75% of usual volume, taking account of risk factors and using clinical judgement)
o Persisting severe respiratory distress
In this case, the above non-pharmacological measures should be used, and nebulized hypertonic saline could be considered.

Bronchiolitis Bronchiolitis 02/13/2016
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