Inpatient Clinical Bronchiolitis Pathway

Initial patient assessment: Inclusion criteria:

-Assess O2 sat. Supplemental oxygen for O2 sat < 90% for at least 1 minute: Initiate 0.5L NC for <6months, -Age < 24 months
1Lfor≥ 6months, titrate to maintain O2 sat ≥ 90% -Symptoms of bronchiolitis: cough, nasal
-Max 2 lpm NC O2: if higher rates needed, refer to HFNC pathway. congestion, difficulty breathing
-Assess need for IV/NGT hydration: poor oral intake, poor UOP, RR > 60 -Signs of bronchiolitis: tachypnea, retractions,
wheezing, crackles

Nasal suction and then obtain Respiratory Score

Exclusion criteria:
-Chronic lung disease (BPD, interstitial lung
disease)
-Congenital heart disease AND on medication
MILD MODERATE SEVERE for CHF, pulmonary hypertension, or cyanotic
Respiratory Score 1-4 Respiratory Score 5-8 Respiratory Score 9-12 heart disease
-Anatomic airway defects
-Neuromuscular disease
-Immunodeficiency
-Score q4h -Score q2h -Score q1h -Prior diagnosis of asthma or ≥ 2 wheeze
-Suction q4h prn -Suction q2h -Suction q1h episodes in a year
-q4h pulse ox check -q4h pulse ox check -Continuous pulse ox -Appearing toxic or critically ill
unless on unless on - Consider IVF/NG feeds if
supplemental o2 supplemental o2 RR>60
Weaning Oxygen
-Attempt to wean supplemental O2 with each
respiratory score
Respiratory Score (Frequency according to severity) -Titrate supplemental O2 to maintain O2 sat ≥
90%
-Once off supplemental O2 for ≥4h, change to
intermittent pulse ox checks

Respiratory Score Respiratory Score Respiratory Score

1-4 5-8 9-12 Tests/Treatments NOT ROUTINELY
RECOMMENDED:

Tests:
-Continue as above Consider trial of nebulized
-Viral testing (except for cohorting)
Refer to discharge -Follow guidance normal saline and repeat score
-Chest X-ray
criteria based on score in 30 minutes (If not previously
-Labs- CBC, electrolytes, blood gas
tried)
Treatments:
-Nebulized normal saline
-Albuterol
-Racemic epinephrine
-Corticosteroids
-Antibiotics
Order treatment PRN.

-Anticholinergic medications
-Hypertonic saline
-Continue as above Yes Trial successful?
-Follow guidance
RS improves ≥ 2
based on score

No

Consider trial of nebulized albuterol

and repeat score in 30 minutes (If not
previously tried)
Yes
Floor Discharge Criteria (should meet
ALL of the following):
-O2 sat > 90% for ≥ 12 hours
-RS < 4 for ≥ 12 hours
-Off supplemental O2 ≥ 12 hours
-No wall suction needed ≥ 6hours Yes
-Adequate oral intake Is bronchiolitis the primary Trial successful?
-If apnea occurred, no further apnea for ≥ pathology? (vs. asthma) RS improves ≥ 2
48 hours
-Parent teaching re: bulb suctioning and
signs of respiratory distress completed No

Refer to HFNC pathway

No

Escalation: if not eligible for floor HFNC

Consider Clinical Asthma
pathway, consider PMET to arrange
Pathway
PCCU transfer

Authors: Joanne Nazif MD and Alyssa Silver 9/15