JANUARY 2023 | VOLUME 2 | ISSUE 1

Evidence-Based Urgent Care High-Yield Clinical Education • Practical Application

CLINICAL CHALLENGES:
• Which signs and symptoms can help
differentiate bronchiolitis from other
conditions that cause wheezing in
young children?
• What are the risk factors for apnea
and severe bronchiolitis?
• Which treatments and therapies
are most effective and generally
recommended, and which are not
recommended?

Urgent Care Update Author

Amanda Nedved, MD
Urgent Care Physician; Associate Professor
of Pediatrics, Children's Mercy Kansas City/
University of Missouri–Kansas City School of
Medicine, Kansas City, MO

Peer Reviewer
Danielle Federico, MD, FAAP
Medical Director, PM Pediatrics West Hartford;
Regional Education Coordinator, Connecticut;
West Hartford, CT
Charting & Coding Author
Brad Laymon, PA-C, CPC, CEMC
Certified Physician Assistant, Winston-Salem, NC
Prior to beginning this activity, see
“CME Information” on page 2.
Acute Bronchiolitis: Assessment
and Management in Urgent Care
 Abstract
Acute bronchiolitis is the most common lower respiratory tract
infection in young children that leads to acute care visits and
hospitalizations. Bronchiolitis is a clinical diagnosis, and diagnostic
laboratory and radiographic tests play a limited role in most cases.
Studies have demonstrated a lack of efficacy for bronchodilators
and corticosteroids in most cases of bronchiolitis. Frequent
evaluation of the patient’s clinical status, including respiratory
rate, work of breathing, oxygen saturation, and the ability to take
oral fluids, is important in determining safe disposition. This issue
reviews the literature to provide evidence-based recommendations
for effective evaluation and treatment of pediatric patients with
acute bronchiolitis in the urgent care setting.

This issue is eligible for 4 CME credits. See page 2. EBMEDICINE.NET

 CME Information
Date of Original Release: January 1, 2023. Date of
most recent review: December 10, 2022. Termination
date: January 1, 2026.
Accreditation: EB Medicine is accredited by the
Accreditation Council for Continuing Medical
Education (ACCME) to provide continuing medical
education for physicians.
Credit Designation: EB Medicine designates this
enduring material for a maximum of 4 AMA PRA
Category 1 CreditsTM. Physicians should claim only
the credit commensurate with the extent of their
participation in the activity.
Specialty CME: Included as part of the 4 credits,
this CME activity is eligible for 4 Infectious Disease
CME credits, subject to your state and institutional
approval.
AOA Accreditation: Evidence-Based Urgent Care is
eligible for 4 Category 2-A or 2-B credit hours per issue
by the American Osteopathic Association.
Needs Assessment: The need for this educational
activity was determined by a practice gap analysis;
a survey of medical staff; review of morbidity and
mortality data from the CDC, AHA, NCHS, and ACEP;
and evaluation responses from prior educational
activities for urgent care and emergency medicine
physicians.
Target Audience: This internet enduring material is
designed for physicians, physician assistants, nurse
practitioners, and residents in the urgent care and
family practice settings.
Goals: Upon completion of this activity, you should
be able to: (1) identify areas in practice that require
modification to be consistent with current evidence in
order to improve competence and performance; (2)
develop strategies to accurately diagnose and treat
both common and critical urgent care presentations;
and (3) demonstrate informed medical decision-
making based on the strongest clinical evidence.
CME Objectives: Upon completion of this activity,
you should be able to: (1) diagnose and assess
bronchiolitis severity based on the patient’s history
and physical examination findings; (2) identify risk
factors associated with apnea due to bronchiolitis;
(3) discuss the controversies surrounding the use of
bronchodilators and corticosteroids in patients with
bronchiolitis; and (4) identify criteria for transfer and
hospitalization of patients with bronchiolitis.
JANUARY 2023 • www.ebmedicine.net 2
Discussion of Investigational Information: As part of
the activity, faculty may be presenting investigational
information about pharmaceutical products that is
outside Food and Drug Administration approved
labeling. Information presented as part of this activity
is intended solely as continuing medical education
and is not intended to promote off-label use of any
pharmaceutical product.
Disclosure: It is the policy of EB Medicine to ensure
objectivity, balance, independence, transparency,
and scientific rigor in all CME activities. All individu-
als in a position to control content have disclosed all
financial relationships with ACCME-defined ineligible
companies. EB Medicine has assessed all relation-
ships with ineligible companies disclosed, identified
those financial relationships deemed relevant, and
appropriately mitigated all relevant financial relation-
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disclosure information for this activity below:
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• Keith Pochick, MD (Editor-in-Chief): Nothing to
Disclose
Faculty
• Amanda Nedved, MD (Author): Nothing to
Disclose
• Bradley Laymon, PA-C (Charting & Coding
Author): Nothing to Disclose
• Danielle Federico, MD (Peer Reviewer):
Nothing to Disclose
• Angie Wallace (Content Editor): Nothing to
Disclose
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Urgent Care did not receive any commercial support.
Earning Credit: Go online to https://www.
ebmedicine.net/CME and click on the title of the test
you wish to take. When completed, a CME certificate
will be emailed to you.
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 Points & Pearls
QUICK READ
JANUARY 2023 | VOLUME 2 | ISSUE 1
Points
• Bronchiolitis is the most common lower respira-
tory tract infection in infants and young children
aged <2 years.
• Respiratory syncytial virus (RSV) and human meta-
pneumovirus (HMPV) cause the majority of cases.
• Bronchiolitis is a clinical diagnosis, defined by
the American Academy of Pediatrics (AAP) as
“rhinitis, tachypnea, wheezing, cough, crackles,
use of accessory muscles, and/or nasal flaring in
infants.”
• There can be a variable degree of edema and
narrowing of the small airways, with mucous plug-
ging, atelectasis, air trapping, and hypoxemia.
Changes in these factors account for the variable
clinical presentation of bronchiolitis and the rapid
changes in severity of illness.
• Although wheezing is the prominent finding
in bronchiolitis, other causes of wheezing (eg,
gastroesophageal reflux disease, tracheomalacia,
cardiac disease, cystic fibrosis, vascular ring, al-
lergic reaction, or foreign body aspiration) should
also be considered.
• Distinguishing bronchiolitis from asthma in infants
is challenging. Predictors of asthma include fre-
quent wheezing in the first 3 years of life plus 1 of
2 major criteria (history of a physician diagnosis of
asthma or physician diagnosis of atopic dermati-
tis) or 2 of 3 minor criteria (a diagnosis of allergic
rhinitis in the child, eosinophilia [ie, eosinophil
count ≥4% of the total white blood cells] or
wheezing apart from colds).
• Infants who are premature or those who have
bronchopulmonary dysplasia or congenital heart
disease are at higher risk of developing severe
bronchiolitis.
• The risk of a serious bacterial infection (SBI) in fe-
brile infants aged <28 days with RSV bronchiolitis
is significant. Limited SBI testing (eg, urinalysis)
can be considered in febrile infants with clinical or
laboratory-proven bronchiolitis.
• Oxygen therapy is recommended when the pe-
ripheral capillary oxygen saturation (SpO2) level is
consistently ≤90%.
• Use nasal suction to clear secretions in infants
with respiratory distress or difficulty feeding or
sleeping.
JANUARY 2023 • www.ebmedicine.net
Acute Bronchiolitis: Assessment
and Management in Urgent Care
Pearls
• Most children with bronchiolitis have mild
disease and are discharged home. Table 2 can
help identify patients who are at higher risk of
developing severe bronchiolitis or apnea and
require prolonged monitoring or admission.
• Routine diagnostic testing (chest x-ray, viral
testing, complete blood count, urinalysis) is not
recommended for infants with bronchiolitis.
However, radiographs may be useful if there
is concern for foreign body aspiration, cardiac
disease, or pneumonia.
• Treatment of bronchiolitis remains supportive
(oxygen for SpO2 ≤90%, hydration/nutrition,
nasal suction). The AAP recommends refrain-
ing from administration of bronchodilators,
epinephrine, corticosteroids, anticholinergic
agents, nebulized hypertonic saline, or antibi-
otics in infants with first-time wheeze, as these
agents do not impact hospital admissions or
length of stay. A trial of bronchodilator therapy
in patients with recurrent episodes of wheezing
may be reasonable.
• Because many urgent care clinicians practice in
free-standing locations without emergency care
immediately available, it is important to identify
patients at high risk for respiratory failure and
expedite their transfer to a higher level of care.
• Enteral feeding is preferred over IV hydration when
possible as it provides nutrition in addition to
fluids.
• Bronchodilators produce small, short-term im-
provements but do not affect the rate of hospital-
ization or the length of hospital stay for patients
with first-time wheezing.
• Referral to pulmonology is recommended for
infants with recurrent wheeze or rhinovirus bron-
chiolitis, as these patients may be at higher risk for
developing asthma.
3 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
 Clinical Pathway for Assessment and Management
of Acute Bronchiolitis in Urgent Care

Patient presents to urgent care with suspected bronchiolitis

Perform initial assessment for:

• Overall appearance
• Respiratory effort
• Circulation

Are any of the following present?

• Hemodynamic instability YES Arrange for transfer to higher level of care
• Apnea/respiratory failure
• Severe respiratory distress with persistent hypoxia

NO

• Obtain history, physical examinationa, vital signs, pulse

oximetry reading, respiratory status, hydration status, and
ability to maintain hydration
• Assess risk for severe bronchiolitis and apnea (See Table 2)
• Assess the patient frequently (due to variable disease course)
• Consider nasal suction prior to repeated examinations

Improvement in respiratory status after suctioning? NO

YES

Maintaining hydration? NO Start nasogastric feeds or IV hydration

YES

Meets discharge criteria?b NO

YES
a
Disease severity is assessed based on history and physical
examination. Severe disease (as defined in the 2014 American
Discharge with patient education including supportive care, Academy of Pediatrics guidelines): signs and symptoms associated
follow up instructions, and contingency plan if symptoms worsen with poor feeding; respiratory distress characterized by tachypnea,
or do not improve nasal flaring, and hypoxemia.
b
Discharge criteria:
• Low risk for apnea or severe bronchiolitis
• No nasal flaring, grunting, head bobbing, or other signs of severe
respiratory distress
• Maintaining SpO2 >90%
• Adequate fluid intake to maintain hydration
• Caregiver able to provide appropriate care at home and adequate
follow-up care available
• Patient has access to care if symptoms acutely worsen
Abbreviation: IV, intravenous.

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2023 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

JANUARY 2023 • www.ebmedicine.net 4 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.

 Case Presentations
A mother brings in her 9-month-old daughter, whom she describes as “gasping for air”...
• The infant has had a runny nose and cough for a few days as well as a low-grade fever, but now she is
breathing rapidly and wheezing, with lower intercostal retractions and nasal flaring.
• The mother states that the infant has had wheezing in the past, and asks if the baby might have asthma
CASE 1

since “it runs in the family.” She also indicates that in the last 12 hours, the baby has not taken her
usual amount of fluids.
• The infant's oxygen saturation level is 89% on room air.
• You begin to think: Should I treat this as reactive airway disease, asthma, or bronchiolitis? Should I give
the patient albuterol, nebulized epinephrine, or oxygen? Does this infant need steroids?
• You also wonder whether this patient should be transferred to a higher level of care and if so, what
mode of transport would be appropriate…

A 6-week-old boy presents with rhinorrhea and poor feeding for the last 2 days…
• The mother states that he is not breastfeeding as well as usual due to his congestion. She says there is
no family history of respiratory problems.
CASE 2

• The boy was born prematurely at 33 weeks' gestation, requiring admission to the NICU for 2 weeks for
respiratory support.
• His oxygen saturation level is 91% to 92% on room air.
• Should you give supplemental oxygen? Should you send respiratory viral panels? Does this infant need
to be admitted to the hospital?

 Introduction
Bronchiolitis is the most common lower respiratory
tract infection (LRTI) in infants and young children
aged <2 years. Each year in the United States, LRTIs
cause >100,000 hospitalizations of children aged <1
year. In particular, respiratory syncytial virus (RSV) is
the leading cause of hospitalization in this age group.
A study published in 2016 that summarized trends
in bronchiolitis hospitalizations in the United States
reported an average cost of $8530 per admission, or
$1.7 billion nationwide.1 Although there was a de-
crease in bronchiolitis hospitalizations between 2000
and 2009 (from 17.9 to 14.9 per thousand, respective-
ly), bronchiolitis remains a major healthcare-related
financial burden.1,2
Despite the high prevalence of bronchiolitis, it is
a clinical diagnosis without a common international
definition. In 2014, the American Academy of Pediat-
rics (AAP) defined bronchiolitis as “rhinitis, tachypnea,
wheezing, cough, crackles, use of accessory muscles,
and/or nasal flaring in infants.”3 Children present-
ing with these symptoms are often given numerous
diagnoses such as reactive airway disease, wheez-
ing, cough, asthma, or pneumonia, as well as bron-
chiolitis.4 A study by Jartti et al suggested that the
diagnosis of bronchiolitis should be restricted either
to children aged <24 months who are having their
first episode of wheezing or to children aged <12
months.5 This issue of Evidence-Based Urgent Care
uses evidence-based medicine to recommend strate-
gies for effective evaluation and treatment of bronchi-
olitis in pediatric patients.
 Pathophysiology
Bronchiolitis is a viral infection of the small airways.
Infection of the bronchial respiratory and ciliated
epithelial cells produces increased mucus secretion,
cell death, and sloughing, followed by a peribron-
chiolar lymphocytic infiltrate and submucosal edema.
This leads to small-airway narrowing and obstruction.
5 Things That Will
Change Your Practice
1. Routine laboratory studies are not necessary
in the diagnosis of acute bronchiolitis in
infants and young children who present
to urgent care with the typical signs and
symptoms of bronchiolitis.
2. Radiographs should be obtained only if
there is suspicion of a different etiology for
the wheezing or respiratory distress, or if the
findings might change management.
3. Routine use of bronchodilators and
corticosteroids in the management of
bronchiolitis is not supported by the current
evidence.
4. Enteral feeding is preferable to intravenous
hydration, if possible.
5. Transfer of high-risk patients to a higher level
of care should be expedited.

JANUARY 2023 • www.ebmedicine.net 5 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.

Hypoxia can occur due to the ventilation/perfusion
mismatch caused by decreased ventilation of a por-
tion of the lungs. The degree of obstruction may vary
as these areas are cleared, accounting for a rapidly
changing clinical presentation that confounds an ac-
curate assessment of the severity of the illness. This
is the reason examination findings can change from
one minute to the next in a patient with bronchiolitis.
A decrease in lung compliance and an increase in the
end-expiratory lung volume (secondary to air trap-
ping) can result in an increase in the work of breath-
ing. In addition, atelectasis may be accelerated by
the lack of collateral channels, leading to complete
obstruction of the small airways. Smooth-muscle con-
striction seems to have a limited role in bronchiolitis,
perhaps explaining the lack of response to bronchodi-
lators in patients with bronchiolitis.6
Recovery of pulmonary epithelial cells occurs
after 3 to 4 days, but cilia do not regenerate for about
2 weeks, and debris is cleared by macrophages later
on. This explains the median duration of illness of 12
days in children aged <24 months with bronchiolitis;
after 3 weeks, approximately 18% of these patients
will remain ill, and after 4 weeks, 9% will remain ill.7
 Etiology
Understanding of the viruses that cause bronchiolitis
has increased greatly with the availability of sensitive
diagnostic tests that use molecular amplification tech-
niques. RSV continues to account for the majority of
cases (50%-80%).8 However, RSV is a rare pathogen in
older children hospitalized with bronchiolitis because
nearly all people are infected with RSV within the first 2
years of life, and the initial RSV infection is usually the
most severe.9 In the United States, annual epidemics
of RSV typically begin in the late fall and peak between
November and March, but regional seasonality does
exist. Human metapneumovirus (HMPV) accounts for
an additional 3% to 19% of bronchiolitis cases10,11 and
appears to have a clinical course similar to that of RSV,
with most children infected during annual wintertime
epidemics and a subset developing bronchiolitis.12-14
Other causes of bronchiolitis include the parainfluenza
viruses (primarily parainfluenza virus 3), the influenza
viruses, adenoviruses, coronaviruses, rhinoviruses, and
enteroviruses.9-11
The role of rhinoviruses in bronchiolitis is
unclear compared to their well-documented role in
triggering exacerbations of wheezing in patients with
asthma.9,15,16 A study by Jartti et al focused on viral
etiologies in young children with acute asthma and
found that rhinovirus was an important agent (ie, it
was identified in 65% of children aged 1-2 years and
in 82% of children aged ≥3 years).17
Although identification of the specific virus is
not routinely indicated in the urgent care setting,
new molecular diagnostic techniques have made it
JANUARY 2023 • www.ebmedicine.net 6
possible to determine whether young children with
bronchiolitis and other acute respiratory illnesses are
infected with more than one virus. Whether concomi-
tant infections increase the severity of bronchiolitis
remains controversial. One study found that dual
RSV/HMPV infections were associated with a 10-fold
increase in the risk of the need for mechanical ven-
tilation.18 In a study that evaluated the association
between infection with multiple viruses and disease
severity in children aged <2 years, co-infection was
present in 41% of the children. Interestingly, for RSV-
infected children aged <3 months, disease severity
was not associated with the number of detected
viruses. The authors of that study concluded that
disease severity in children with bronchiolitis is not
associated with infection by multiple viruses, and that
other factors (eg, age) contribute to disease severity
to a greater extent.19 Of note, polymerase chain reac-
tion positivity can extend beyond the acute phase of
the viral infection, which has the potential to impact
the results of these studies, depending on the timing
of the testing.
 Differential Diagnosis
Although wheezing is a prominent presentation
of acute bronchiolitis, it is often accompanied by
rhinorrhea, cough, tachypnea and crackles. When
wheezing is present in infants and young children,
other common and critical diseases should be con-
sidered. (See Table 1.) It is important to differentiate
wheezing from stridor, as stridor has an independent
differential diagnostic list, including potential emer-
gent conditions such as epiglottitis. They also differ
in effective treatment options. Stridor is related to
restriction of air flow of the upper airways related to
obstruction or narrowing. It occurs during inspira-
tion. Wheezing is related to restriction of air flow
from the lower airways and can be biphasic.
Clues from the medical history may facilitate the
correct diagnosis. For example, vomiting and wheez-
ing and coughing associated with feeding may indi-
Table 1. Differential Diagnosis for
Wheezing in Infancy
Acute Causes
• Infection: bronchiolitis, pneumonia, chlamydia, pertussis
• Foreign body: aspirated or esophageal
• Cardiac anomaly: congestive heart failure, vascular ring
• Allergic reaction
• Bronchopulmonary dysplasia exacerbation
Nonacute Causes
• Congenital anomaly: tracheoesophageal fistula, bronchogenic cyst,
laryngotracheomalacia
• Gastroesophageal reflux disease
• Mediastinal mass
• Cystic fibrosis
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© 2023 EB MEDICINE. ALL RIGHTS RESERVED.
cate gastroesophageal reflux disease or, if symptoms
are severe, tracheoesophageal fistula, which must be
evaluated by a pediatric specialist.20 When wheez-
ing is associated with positional changes, tracheo-
malacia or anomalies of the great vessels may be
present. If a vascular ring is suspected clinically (eg,
when wheezing is exacerbated by neck flexion and
relieved by neck hyperextension), further investiga-
tion may be warranted. Cystic fibrosis or immuno-
deficiency should be suspected when the child has
a history of multiple respiratory tract illnesses and
a failure to thrive. Further workup by the child’s pri-
mary care provider or a specialist can include ciliary
function testing, immunoglobulin levels, and sweat
chloride testing. Wheezing in the presence of heart
murmurs, cardiomegaly, cyanosis without respiratory
distress, and exertion and sweating associated with
feeding might indicate cardiac diseases. The sud-
den onset of wheezing and choking suggests foreign
body aspiration.
Asthma
It is challenging to distinguish reactive airway dis-
ease and asthma from bronchiolitis in young chil-
dren. To differentiate between the diagnosis of bron-
chiolitis and asthma, some investigators recommend
that the diagnosis of bronchiolitis should apply to
wheezing only in patients aged ≤12 months. In the
past, some investigators have extended the cutoff
for the upper age limit for making the diagnosis of
bronchiolitis from 24 to 36 months. Estimates vary,
but the majority of children diagnosed with asthma
(80%-90%) had symptoms before the age of 6 years,
with 70% of children experiencing asthma-like symp-
toms before the age of 3 years.
Castro-Rodriguez et al developed the modified
Asthma Predictive Index to differentiate between
asthma and recurrent wheezing with bronchiolitis in
younger children. They developed 2 indices for the
prediction of asthma, the stringent index and the
loose index.21
The stringent index requires frequent wheezing
in the first 3 years of life plus 1 of 2 major criteria
(history of a physician diagnosis of asthma or physi-
cian diagnosis of atopic dermatitis) or 2 of 3 minor
criteria (a diagnosis of allergic rhinitis in the child,
eosinophilia [ie, eosinophil count ≥4% of the total
white blood cells] or wheezing apart from colds).
Frequency of wheezing is determined by asking the
parent(s) whether the child’s chest has ever sounded
wheezy or whistling and to rate how often the child
has wheezed (on a scale of 1, “very rarely,” to 5,
“on most days”). Patients are considered “frequent
wheezers” if parents report a value >3 on the scale.
The loose index for the prediction of asthma
requires any wheezing during the first 3 years of life
plus 1 of the major criteria or 2 of the minor criteria.
According to Castro-Rodriguez et al, children with a
JANUARY 2023 • www.ebmedicine.net
positive loose index were up to 5.5 times more likely
between the ages of 6 and 13 years to have active
asthma than children with a negative loose index.
Children with a positive stringent index were up to
9.8 times more likely than children with a negative
stringent index to have asthma later in childhood.21
In one study, children aged <6 months who
were hospitalized for bronchiolitis (caused by vari-
ous viruses) were followed prospectively to evaluate
outcomes, with special focus on asthma at preschool
age (mean age, 6.5 years). Twenty-one children
(12.7%) had asthma at preschool age: 8.2% were
children with a former RSV infection, and 24.7%
were non–RSV-infected patients (P = .01). In adjust-
ed analyses, independently significant early-life risk
factors for asthma were atopic dermatitis, non–RSV
bronchiolitis, and maternal asthma.22
An online tool for calculating the Asthma Predictive
Index is available at: https://www.mdcalc.com/
calc/3381/asthma-predictive-index-api
 Urgent Care Evaluation
Personal Protective Equipment
The safety of healthcare personnel caring for patients
with respiratory illnesses is important. During the
COVID-19 pandemic, the United States Centers for
Disease Control and Prevention (CDC) and the AAP
developed guidance on the use of personal protec-
tive equipment (PPE) when caring for patients with
respiratory illnesses in ambulatory care settings.23,24
Respiratory viral illnesses are often spread via aero-
sols or droplets. Urgent care clinicians should ensure
they protect themselves with appropriate PPE when
caring for patients with bronchiolitis. The CDC recom-
mends National Institute for Occupational Safety &
Health–approved N95 or equivalent or higher-level
respirators be worn for all aerosol-generating pro-
cedures.23 The most common aerosol-generating
procedures performed during the evaluation and
management of patients with bronchiolitis include
nasopharyngeal suctioning and high-flow oxygen
delivery. The AAP recommends increasing the level of
PPE when performing procedures that may produce
aerosolized droplets.24
Initial Assessment
Urgent care clinicians should immediately evaluate
patients with abnormal vital signs identified during
the initial assessment—specifically, abnormal respi-
ratory rate for age or oxygen saturation, as these
patients may be at increased risk of decompensa-
tion. Because of the limited resources available in
the urgent care setting, it is imperative that clinicians
expedite transfer of high-risk patients to a higher
level of care.
7 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
History of Present Illness
For patients who present with symptoms consistent
with bronchiolitis, clinicians should inquire about the
timing of onset of symptoms, progression of symp-
toms, therapies tried prior to presentation, and what
prompted the family to bring their child in for evalua-
tion. Clinicians should also inquire about the patient’s
ability to tolerate feeds and hydration status. Know-
ing the clinical course can help urgent care clinicians
formulate a plan for the evaluation and management
of the patient. Identifying family concerns helps to
address specific concerns and manage expectations.
Past Medical History
Inquiring about prior history of bronchodilator use
and response can help urgent care clinicians deter-
mine if the patient has a component of reactive air-
ways complicating their respiratory status. Clinicians
should also inquire about previous hospitalizations
for respiratory illnesses and family history of asthma.
Additionally, clinicians should assess the patient’s risk
factors for severe bronchiolitis and apnea.
Risk Factors for Severe Bronchiolitis
Several studies have associated premature birth (<35-
37 weeks’ gestation) and younger age (<6-12 weeks)
with an increased risk of severe bronchiolitis.25-27
Other conditions predisposing the patient to severe
disease or mortality include underlying respiratory
illnesses such as bronchopulmonary dysplasia (also
known as chronic lung disease), cystic fibrosis, and
congenital anomalies. Hemodynamically significant
congenital heart disease, an immune deficiency such
as HIV infection or organ or bone marrow transplant,
and congenital immune deficiencies are also risk fac-
tors.28,29 (See Table 2.)
Most studies addressing the risk factors for severe
bronchiolitis and outcomes such as the need for me-
chanical ventilation and intensive care have involved
hospitalized patients, which is a small subset of all
children with bronchiolitis evaluated in the acute care
setting. The infrequent occurrence of these severe
outcomes limits the power of these studies to predict
bronchiolitis severity. In a recent study, multivariable
predictors of escalated care were age <2 months,
oxygen saturation <90%, nasal flaring and/or grunt-
ing, apnea, retractions, dehydration, and poor feed-
ing. Developing a risk score including these variables
may help stratify the risk for patients who need a
higher level of care, which could help with treatment
and disposition decisions.30
Risk Factors for Apnea
Several factors have been identified to predict which
patients with bronchiolitis are at risk for the devel-
opment of apnea in the course of their illness. (See
Table 2.) These factors include young age, prematu-
rity, a history of apnea of prematurity, and presenta-
JANUARY 2023 • www.ebmedicine.net 8
tion with apnea.28,31-34 Of note, these studies have
focused on patients with confirmed bronchiolitis due
to RSV, which could explain the high rates of apnea
(16%-25%) reported in hospitalized patients with
RSV infection.
In a 2006 retrospective study, Willwerth et al
reported the rate of apnea in young infants with
clinically diagnosed bronchiolitis and offered a set
of criteria for identifying high-risk patients. Children
were considered to be at high risk for apnea if: (1)
they were full-term at birth and were younger than
1 month, (2) they were preterm at birth (<37 weeks’
estimated gestation) and were younger than 48
weeks post conception, or (3) the child’s parents or
a clinician had already witnessed an apnea episode
with this illness before admission.35 A small percent-
age of admitted infants with bronchiolitis devel-
oped apnea (2.7%; 19 out 691 infants), and all were
identified as high-risk patients using the high-risk
criteria. Approximately 62% of the patients who did
not develop apnea were classified by these criteria
as being at low risk. Because the study included
only hospitalized patients, this set of criteria may not
apply to all patients with bronchiolitis. The rate of
apnea in this study is lower than the reported apnea
rate of 16% to 25% in the RSV bronchiolitis study,
which could be due to the fact that RSV testing was
performed on disproportionately younger or sicker
Table 2. Risk Factors for Severe
Bronchiolitis and Apnea
Past Medical History
• Risk Factors for Severe Bronchiolitis
◦ Age: <6-12 weeks25-27
◦ Prematurity: <35-37 weeks’ gestation25-27
◦ Underlying respiratory illness such as bronchopulmonary
dysplasia3
◦ Significant congenital heart disease; immune deficiency including
HIV, organ or bone marrow transplants, or congenital immune
deficiencies28,29
• Risk Factors for Apnea
◦ Full-term birth and <1 month of age30,31
◦ Preterm birth (<37 weeks’ gestation) and age <2 months post
birth25-27,31
◦ History of apnea of prematurity
◦ Apnea witnessed by a caregiver31
Physical Examination Findings
• Risk Factors for Severe Bronchiolitis or Apnea
◦ Altered mental status (impending respiratory failure)
◦ Dehydration due to inability to tolerate oral fluids
◦ Ill appearance26
◦ Oxygen saturation level ≤90%3
◦ Respiratory rate >70 breaths/min or higher than normal rate for
patient age3,26
◦ Increased work of breathing: moderate to severe retractions and/or
accessory muscle use3
◦ Nasal flaring
◦ Grunting
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© 2023 EB MEDICINE. ALL RIGHTS RESERVED.
patients with bronchiolitis, a group naturally at high-
er risk of developing apnea.35 In a study that evalu-
ated risk factors for inpatient apnea among children
hospitalized with bronchiolitis, a similar apnea risk
was found across the major viral pathogens, includ-
ing adenovirus and HMPV.36
Despite the fact that the rate of apnea in hospi-
talized infants with bronchiolitis is low, these clinical
risk criteria can help clinicians in the urgent care
setting make more informed decisions about which
patients require a higher level of care by identifying
infants who may have a higher risk of apnea.
Physical Examination
It is critical for urgent care clinicians to assess the
patient’s risk factors for severe bronchiolitis, which in-
clude persistently increased respiratory effort, apnea,
the inability to tolerate adequate liquids by mouth
to maintain hydration, the need for supplemental
oxygen, or pending respiratory failure that could lead
to the need for positive pressure ventilation or even
mechanical ventilation. (See Table 2, page 8.) It is
difficult to adequately assess a pediatric patient when
they are wrapped under blankets and layers of cloth-
ing. Often, signs of respiratory distress—retractions,
grunting, nasal flaring, etc—do not become obvious
until the patient is undressed.
Serial examination of a patient’s respiratory status
is very important in assessing overall patient status
and reflecting variability in the disease state, from
mucus plugging to progressive respiratory distress
due to lower airway obstruction. Important elements
of the physical examination include respiratory rate,
increased work of breathing as evidenced by acces-
sory muscle use and/or retractions, and auscultation
findings such as wheezes or crackles. The impact of
respiratory symptoms on feeding and hydration, par-
ticularly in young infants, is also critical.
Respiratory Rate
Tachypnea, defined as a respiratory rate >70 breaths/
min in infants, has been associated with increased
risk for severe bronchiolitis in some studies, but not
in others.26,37 Additionally, tachypnea may serve as
a risk factor for development of dehydration with
bronchiolitis, due to difficulty taking oral fluids with
an excessively elevated respiratory rate or associated
vomiting. The respiratory rate in otherwise healthy
children changes considerably over the first year of life,
decreasing from a mean of approximately 50 breaths/
min in full-term newborns to approximately 40 breaths/
min at 6 months and 30 breaths/min at 12 months.38,39
Counting the respiratory rate for 1 minute may be
more accurate than extrapolating measurements from
shorter periods.40 The absence of tachypnea correlates
with the lack of LRTI or pneumonia (viral or bacterial) in
infants.41
JANUARY 2023 • www.ebmedicine.net
The Respiratory Distress Assessment Instrument42
is reliable with respect to scoring but has not been
validated for clinical predictive value in patients with
bronchiolitis. There is no standard clinical score to
assess bronchiolitis, and many treatment trials use dif-
ferent variables to assess a medication’s impact on the
course of bronchiolitis, such as respiratory rate, respira-
tory effort, severity of wheezing, and oxygenation. This
was evident in a report by the Agency for Healthcare
Research and Quality, in which 43 of 52 treatment trials
used different clinical scoring systems, making com-
parison between these studies very difficult.43
Oxygen Saturation
Oxygen saturation, as measured by pulse oximetry,
is among the measures most strongly correlated with
outcomes of patients with bronchiolitis. In a 2008
prospective multicenter study, a pulse oximetry level
of <94% in the emergency department (ED) was as-
sociated with a >5-fold increase in the likelihood of
hospitalization.44 Since pulse oximetry became widely
available, the rate of hospitalization for bronchiolitis
has increased.45
According to the 2014 AAP bronchiolitis guide-
lines, “clinicians may choose not to administer sup-
plemental oxygen if the oxyhemoglobin saturation
exceeds 90% in infants and children with a diagnosis
of bronchiolitis,” but this recommendation was based
on low-level evidence.3 In addition, evidence indicated
that a pulse oximetry reading of 90% tends to overes-
timate the actual oxygen saturation in children (mean
bias 4.2% between 86% and 90% and 1.8% between
91% and 95%).46
 Diagnostic Studies
In the acute care setting, acute bronchiolitis is primar-
ily a clinical diagnosis. Diagnostic testing (eg, chest
radiography, virologic testing, complete blood count,
and urinalysis) is not routinely recommended for
infants with bronchiolitis.
Radiographic Imaging
Although radiographs may be useful to evaluate
alternative diagnoses of foreign body aspiration,
pneumonia, or congestive heart failure based on the
history and physical examinations findings, current
evidence does not support routine use of radiography
in children with bronchiolitis.45 Two studies indicated
that the presence of consolidation and atelectasis on
a chest radiograph was associated with an increased
risk for severe disease;25,26 however, a different study
showed no correlation between chest radiograph
findings and baseline disease severity.47
Obtaining a chest radiograph could, however,
affect the decision to start antibiotics. Numerous pro-
spective studies, including a randomized trial, have
shown that children with a suspected LRTI for whom
9 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
radiographs were obtained were likely to receive anti-
biotics, without any difference in time to recovery.48,49
A subsequent prospective study of 265 children aged
2 to 23 months who presented to the ED with bron-
chiolitis analyzed the use of routine radiography in
patients with a simple form of the disease (defined in
a child as coryza and cough accompanying a first epi-
sode of wheezing, without underlying illness).50 The
authors of that study identified findings inconsistent
with bronchiolitis in only 2 cases, and in neither case
did the findings change short-term management.
Clinicians were more likely to treat patients with an-
tibiotics when ordering radiographs despite the fact
that the radiographic findings did not support such
treatment.50
Viral Testing
Identification of the causative agent of bronchiolitis
has minimal effect on management in the urgent care
setting. In addition, rapid viral antigen testing has
variable sensitivity and specificity, depending on the
test used and its timing in relation to the respiratory
season.51 Clinicians are most likely to obtain viral test-
ing when encountering infants in the first few months
of life who present with fever and typically recognized
signs and symptoms of bronchiolitis. While this is
not recommended in the bronchiolitis guidelines,
the 2016 American College of Emergency Physicians
fever guidelines note that positive viral testing can
impact further workup of fever for a serious bacte-
rial infection (SBI).52 A study of febrile infants aged
<60 days with bronchiolitis and/or an RSV infection
demonstrated that, although the overall risk of SBI in
patients aged <28 days was significant, the risk was
not different between RSV-positive and RSV-negative
groups (10.1% vs 14.2%, respectively). All SBIs in chil-
dren aged between 28 and 60 days with RSV-positive
bronchiolitis were urinary tract infections (UTIs). The
rate of UTIs in the RSV-positive group was signifi-
cantly lower than the rate in the RSV-negative group
(5.5% vs 11.7%, respectively).53 In another study of
2396 infants with RSV bronchiolitis, 69% of the 39 pa-
tients with an SBI had a UTI.54 Therefore, limited SBI
testing can be considered in febrile infants with clini-
cal or laboratory-proven bronchiolitis. A recent review
spanning all age groups found a 0.8% prevalence of
UTI in infants with bronchiolitis.55
 Treatment
Despite the extensive literature on bronchiolitis
and the revised AAP guideline on the assessment
and treatment of bronchiolitis,3 the treatment of
bronchiolitis remains controversial. This is particularly
true for severe bronchiolitis, due to a paucity of
research on the treatment of severe bronchiolitis.
The 2017 Pediatric Emergency Research Networks
study suggests that there has been a decrease
JANUARY 2023 • www.ebmedicine.net 10
in the use of non-recommended interventions.
Nonetheless, >30% of infants hospitalized with
bronchiolitis received supportive therapy that was not
supported by evidence.56 A review of the Pediatric
Health Information Systems Database from June–
December 2020 also indicated a decrease in the
use of nonrecommended interventions in both EDs
and inpatient settings, with a significant decrease
in bronchodilator use.57 A summary of the treatment
recommendations, as supported by various guidelines,
can be found in Table 3 and Table 4, page 11.
Oxygen Supplementation
Pulse oximetry has been adopted into the clinical as-
sessment of children with bronchiolitis on the basis of
data that show that it can reliably detect hypoxemia
that is not detected on physical examination.58 Even
though transient decreases to a peripheral capillary ox-
ygen saturation (SpO2) level <89% do occur in healthy
infants, most have an SpO2 level >95% on room air.59,60
Due to pathological changes in the airway of patients
with bronchiolitis (such as airway edema and slough-
ing of respiratory epithelial cells) mismatching of
ventilation and perfusion and subsequent reductions
in oxygenation can occur. According to the oxygen
dissociation curve, when the SpO2 level is >90%,
large increases in partial pressure of oxygen (PaO2) are
associated with small increases in SpO2. In contrast,
when the SpO2 level is ≤90%, a small decrease in PaO2
is associated with a large decrease in SpO2. Therefore,
in otherwise healthy infants with bronchiolitis who have
Table 3. 2014 AAP Clinical Practice
Guideline Recommendations for
the Diagnosis and Management of
Bronchiolitis3
Strength of Diagnosis/Management
Evidence
Good Do make diagnosis based on history and physical
examination
Do administer intravenous or nasogastric hydration
for patients with poor oral intake
Do not administer albuterol
Do not administer inhaled epinephrine
Do not administer systemic corticosteroids
Do not use chest physiotherapy
Do not administer antibiotics unless there is strong
suspicion of concurrent bacterial infection
Fair  Do not administer nebulized hypertonic saline in the
urgent care setting*
Poor Do administer supplemental oxygen for patients with
oxyhemoglobin saturation ≤90%
Optional use of supplemental oxygen for patients
with oxyhemoglobin saturation >90%
Optional use of intermittent pulse oximetry
*See the section on “Hypertonic Saline” for studies conducted after the
publication of the guideline.
© 2023 EB MEDICINE. ALL RIGHTS RESERVED.
an SpO2 level >90%, increasing PaO2 with supplemen-
tal oxygen will probably provide little benefit, particu-
larly in the absence of respiratory distress and feeding
difficulties.
In addition, the patient’s work of breathing should
be evaluated and considered in the decision of wheth-
er oxygen supplementation is needed. Patients with
risk factors such as prematurity, bronchopulmonary
dysplasia, or hemodynamically significant congenital
heart disease warrant special attention due to the fact
that they are at risk for developing a severe illness.61
These infants often have abnormal baseline oxygen-
ation coupled with an inability to cope with the pul-
monary inflammatory changes associated with bron-
chiolitis. This combination can result in hypoxia that is
more severe and prolonged than that experienced by
otherwise healthy infants, and clinicians should take
this into account when developing strategies for using
and weaning supplemental oxygen.
The AAP recommends that oxygen therapy be
initiated judiciously when SpO2 levels fall consistently
to or below 90%, and that the intensity of monitoring
SpO2 levels be reduced as the infant improves.3 The
2014 AAP guidelines recommend (weak recommen-
dation due to low-level evidence and reasoning) that
“clinicians may choose not to administer supplemental
oxygen if the oxyhemoglobin saturation exceeds 90%
in infants and children with a diagnosis of bronchiol-
itis.”3 This is based on the limited knowledge regard-
ing the poor accuracy of pulse oximetry, especially in
the 76% to 90% range.46 Also, this weak recommenda-
tion is due to the very poor correlation between respi-
ratory distress and oxygen saturation among infants
with LRTIs.62 A study by Schuh et al demonstrated that
clinicians were less likely to admit a patient with mild-
to-moderate bronchiolitis when their reported oxygen
saturation was artificially increased without an increase
in adverse outcomes.63 Additionally, most patients
with bronchiolitis will have transient desaturations that
self-resolve without adverse clinical outcomes.64 For
these reasons, the use of continuous pulse oximetry
is recommended against in the 2014 AAP guidelines,3
the 2013 Choosing Wisely Campaign,65 and the 2020
Best Evidence for Effective Monitoring Practice (BEEP)
guidelines.66
Fluid Administration
Infants with respiratory difficulty who develop nasal
flaring, increased work of breathing, and prolonged
expiratory wheezing may have difficulty maintaining
hydration and adequate nutrition intake. Historically,
clinicians worried that respiratory effort may increase
risk of aspiration.67 However, more recent studies have
demonstrated that aspiration events with enteral feed-
ing in patients with bronchiolitis are rare regardless of
the type of respiratory support provided.68-71 Children
who are at risk for dehydration due to respiratory dis-
tress should be transferred to a higher level of care for
further evaluation. Discussion with the accepting clini-
cian on preferred method of hydration should be dis-
cussed. Because enteral feeds allow patients to receive
nutrition in addition to hydration, nasogastric feeds are
now preferred over intravenous (IV) hydration.3
When using IV fluids for hydration, isotonic fluids
appear to be safer in general than hypotonic solutions.
A 2014 meta-analysis showed that, among hospitalized
children who required maintenance fluids, the use of
hypotonic fluids was associated with significant hypo-
natremia compared to the use of isotonic fluids.72

Table 4. Key Management Recommendations in Bronchiolitis Guidelines

Guideline Supplemental Supplemental Corticosteroid Corticosteroids: Trial of Alpha Routine Use Routine Use
Oxygen Use Oxygen Use Medications Ventilated or Beta of Alpha of Beta
for Patients for Patients Patients Agonist Agonist Agonist
With an Oxygen With an Oxygen
Saturation <92% Saturation ≤90%
AAP 20143 Not addressed Recommend Not addressed
against
SIGN 200673 Recommend Not addressed Not addressed
SNHS 2010 74 Recommend Not addressed Optionally
recommend
CPS 201475 Not addressed Recommend Not addressed Optionally Recommend Recommend
Recommend
against recommend against against

NICE 201576 Recommend Not addressed Recommend

against
Australasian Recommend for Recommend Recommend
201977 persistent oxygen against against
saturation <92%
Abbreviations: AAP, American Academy of Pediatrics; CPS, Canadian Pediatric Society; NICE, National Institute for Health and Care Excellence; SIGN,
Scottish Intercollegiate Guidelines Network; SNHS, Spanish National Health System.
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JANUARY 2023 • www.ebmedicine.net 11 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.

Nasal Suction
Nasal suction should be used to clear secretions in in-
fants with acute bronchiolitis if they exhibit respiratory
distress or difficulties in feeding or sleeping. This is es-
pecially important in younger infants, who are obliga-
tory nose breathers. One study reported that nasal
aspiration decreased hospital length of stay; however,
routine use of nasopharyngeal suctioning was associat-
ed with longer length of stay for patients admitted with
bronchiolitis. This same study reported longer length
of stays for hospitalized patients when >4 hour lapse
in time occurred between suctioning.78 This seemingly
conflicting data is likely due to the retrospective nature
of the study. Because of the limited studies available,
the 2014 AAP guidelines did not make a recommenda-
tion for or against the use of suctioning.3
A small prospective study comparing nasal aspira-
tion to nasopharyngeal suctioning demonstrated that
nasopharyngeal suctioning resulted in more mucus
removal than nasal aspiration. Nasopharyngeal suc-
tioning had improved lung impedance 30 minutes post
suctioning, which was not seen with nasal aspiration.
This suggests that nasopharyngeal suctioning may be
beneficial in some patients.79
Bronchodilators
Albuterol/Salbutamol able evidence.43 A Cochrane review of 13 studies of
In the revised 2014 AAP guidelines on the diagnosis,
management, and prevention of bronchiolitis, clini-
cians were advised not to administer albuterol (or
salbutamol) to infants and children with the diagnosis
of bronchiolitis.3 This is a strong recommendation that
is supported by studies that show the risk outweighing
the benefit. Two Cochrane reviews found that broncho-
dilators produce small, short-term improvements but
do not affect the rate of hospitalization or the length
of hospital stay.80,81 The 2014 AAP guidelines also
state that “because clinical scores may vary from one
observer to the next and do not correlate with more
objective measures, clinical scores are not validated
measures of the efficacy of bronchodilators.”3 Clini-
cally significant tachycardia and tremors were the most
often reported adverse effects that offset any clinical
scores or improvements, per the guidelines.
The increased respiratory effort in bronchiolitis
is thought to be due to decreased lung compliance
and increased atelectasis rather than smooth-muscle
constriction.6 Therefore, the utility of bronchodilators in
the management of bronchiolitis is limited. However,
the above recommendations are intended for patients
wheezing for the first time. In patients with recurrent
episodes of wheezing with viral illnesses, a trial of
bronchodilators may be warranted, as the patient may
have concomitant reactive airway dysfunction in addi-
tion to acute bronchiolitis.
JANUARY 2023 • www.ebmedicine.net 12
Epinephrine
The 2014 AAP guidelines strongly recommend
against the routine use of epinephrine —systemic or
nebulized—as a treatment for children and infants
with bronchiolitis.3,43,82 The AAP guidelines did state
that there is need for more research to establish the
use of epinephrine as a rescue agent for patients with
severe bronchiolitis. Current data is conflicting. A
meta-analysis indicated that there was a decrease in
clinical symptoms after treatment with nebulized epi-
nephrine as compared to either placebo or albuterol.
A Cochrane review found no reduction in admission
rates in the inhaled epinephrine treatment group,
with some studies demonstrating short-term improve-
ments in clinical scores, oxygen saturation levels, and
respiratory rates.83
Corticosteroids
Although consistent evidence of the efficacy of
corticosteroids in the treatment of bronchiolitis is
lacking,3,43,82 it is estimated that up to 60% of infants
hospitalized with bronchiolitis receive these medica-
tions.58,84-86 Some studies have suggested benefits
with corticosteroid therapy,87-90 but a review of these
studies, including sample size and methodology,
demonstrated the inconclusive nature of the avail-
the use of corticosteroids for bronchiolitis showed
no significant differences in respiratory rates, oxygen
saturation levels, initial admission rates, length of
stay, unscheduled visits to a healthcare provider, or
readmission rates between corticosteroid and pla-
cebo treatment groups.82
A placebo-controlled trial by Schuh et al evaluat-
ed 70 infants with moderate to severe bronchiolitis.91
The authors found significant decreases in respiratory
scores after 4 hours of observation in infants who
received oral dexamethasone 1 mg/kg and 0.6 mg/
kg for an additional 5 days. The admission rate was
significantly lower in the dexamethasone group com-
pared with the placebo group (19% vs 44%, respec-
tively).91 The study was limited by the small sample
size and the larger proportion of positive family
history of atopy (increasing the risk of having asthma)
in infants in the dexamethasone group compared to
those in the placebo group.
A landmark study conducted by the Bronchiolitis
Study Group of the Pediatric Emergency Care Ap-
plied Research Network (PECARN) evaluated the use
of corticosteroids in the treatment of bronchiolitis.
Infants aged 2 to 12 months with first-time wheezing
were enrolled at 20 medical center EDs from 2004
to 2006.92 The infants had “moderate” or “severe”
symptoms as measured by a standard assessment
rubric. Patients received 1 mg/kg of oral dexametha-
sone solution or the same volume of placebo fluid.
Symptom scores and vital signs were assessed at
entry, 1 hour, and 4 hours after receipt of the study
© 2023 EB MEDICINE. ALL RIGHTS RESERVED.
medication or placebo. The local providers could de-
cide on other ED care and laboratory testing at their
discretion. Within 1 week after the ED visits, families
were contacted to obtain information on side effects
and rates of return visits for medical care. In all, 600
patients were randomly assigned to the treatment
groups, and roughly equal numbers in the 2 arms had
complete data. The patients in both groups received
very similar treatment. There was no statistically
significant difference in the percentages admitted
to the hospital (39.7% of patients in the dexametha-
sone group were admitted vs 41% in the placebo
group), even after adjustments for patient age, history
of atopy, and positive RSV test results. The authors
concluded that use of dexamethasone in the ED did
not improve hospitalization rate in first-time wheezers
with bronchiolitis. This study did not address the
question of corticosteroid effectiveness in infants with
bronchiolitis and prior wheezing or in older children
with bronchiolitis.93
Two studies that evaluated the use of inhaled cor-
ticosteroids in the treatment of bronchiolitis showed
no benefit in the course of the acute disease.94,95
Unless there is a clear likelihood of benefit, high-dose
inhaled corticosteroids should not be used in infants
because of safety concerns such as impaired linear
growth. Studies on the safety of inhaled corticoste-
roids for children aged <24 months are scarce.
Supporting the previous study, the 2014 AAP
guidelines strongly recommend refraining from
treatment of bronchiolitis with corticosteroids in any
setting.3 The recommendation is supported by a 2013
Cochrane review of 17 trials with 2596 participants.
Overall, there was no reduction of bronchiolitis admis-
sions or inpatient length of stay with corticosteroid
administration.96
Combination Treatment With Epinephrine
and Corticosteroids
Pediatric Emergency Research Canada conducted
a double-blind, placebo-controlled multicenter trial
at 8 Canadian pediatric EDs involving 800 infants
aged 6 weeks to 12 months with bronchiolitis.86
Patients were randomly assigned to 1 of 4 study
groups: (1) the epinephrine-dexamethasone group
received 2 treatments of nebulized epinephrine (3
mL of epinephrine 1 mg/mL solution per treatment)
and a total of 6 oral doses of dexamethasone (1
mg/kg in the ED and 0.6 mg/kg for an additional 5
days); (2) the epinephrine group received nebulized
epinephrine and an oral placebo; (3) the dexametha-
sone group received nebulized placebo and oral
dexamethasone; and (4) the placebo group received
nebulized placebo and oral placebo. The primary
outcome was hospital admission within 7 days
after the ED visit. The epinephrine-dexamethasone
group had a lower admission rate over 7 days than
the placebo group (17.1% vs 26.4%, respectively).
JANUARY 2023 • www.ebmedicine.net
The study authors did not anticipate this potential
interaction in the design, and after adjustment for
multiple comparisons, the difference did not reach
statistical significance. The synergy between ad-
renergic agents and corticosteroids has been well
described in the asthma literature and has been
observed in other small studies of bronchiolitis.90,97
Of note, the dose of dexamethasone used in the Pe-
diatric Emergency Research Canada and the Schuh
study (1 mg/kg for the first dose and 0.6 mg/kg for
an additional 5 days) is much higher than the typical
dose of dexamethasone used in other respiratory
illnesses such as asthma and croup.91,95 A multicenter
randomized controlled trial that assesses the clinical
and cost-effectiveness of combined adrenaline and
corticosteroids treatment for bronchiolitis is needed.
Anticholinergic Agents
Anticholinergic agents (eg, ipratropium bromide) are
frequently given to children with wheezing because
of their positive effects in the treatment of acute
asthma exacerbation, but their role in the treatment
of bronchiolitis is uncertain. A 2005 Cochrane review
of the role of anticholinergic agents in the treatment
of children aged <2 years with wheezing identified
6 trials, only 2 of which involved patients with first-
time wheezing.98 Compared with a beta-2-agonist
alone, the combination of ipratropium bromide and
a beta-2-agonist was not associated with a differ-
ence in treatment response, respiratory rate, or
oxygen saturation improvement in the ED. There
was no significant difference in the length of hospital
stay between the ipratropium bromide and placebo
groups or between patients receiving ipratropium
bromide and a beta-2-agonist combined and those
receiving a beta-2-agonist alone. At this time, use
of anticholinergic agents—either alone or in combi-
nation with beta-adrenergic agents—is not recom-
mended for viral bronchiolitis.99-101
Hypertonic Saline
Some studies have shown that hypertonic saline
improves mucociliary clearance in pediatric patients
with cystic fibrosis.102 Airway edema and mucus
plugging are the predominant pathologic features
in infants with acute viral bronchiolitis, and several
studies have assessed the ability of nebulized hy-
pertonic saline solution to reduce these pathologic
effects and decrease airway obstruction.
A randomized, double-blind, placebo-controlled
trial was conducted at a single pediatric ED to
determine whether nebulized 3% hypertonic saline
with epinephrine is more effective than nebulized
0.9% saline (normal saline) with epinephrine in the
treatment of infants aged <12 months with mild
to moderate bronchiolitis. No improvements were
noted in oxygen saturation levels and Respiratory
Assessment Change scores assessed at baseline and
13 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
at 120 minutes in the hypertonic saline group com-
pared with the normal saline control group. In addi-
tion, the rates of admission and return visits to the
ED were similar between the groups. The authors of
that study concluded that, in the emergency set-
ting, treatment of acute bronchiolitis with hypertonic
saline and epinephrine did not improve clinical out-
comes any more than treatment with normal saline
and epinephrine.103
The 2014 AAP guidelines recommend avoiding
the use of hypertonic saline in the outpatient set-
ting, as it has no effect on admission rates (moder-
ate evidence). However, it recommends using hyper-
tonic saline in children hospitalized for bronchiolitis
(weak evidence).3 This endorsement stems from the
2013 Cochrane review that analyzed 11 trials includ-
ing over 1090 children with bronchiolitis in ED and
inpatient settings. The results indicated that children
treated with hypertonic saline while hospitalized
had a reduction in length of stay when in the hos-
pital for >72 hours. Moreover, hospitalized children
showed “incremental positive effect with each day
posttreatment from day 1 to day 3.” Unfortunately,
use in outpatient settings does not show significant
improvement, as it usually takes 24 hours to demon-
strate clinical improvement.104 A more recent study
published in 2017 demonstrated no reduction in
admission rates or length of stay was demonstrated
when using hypertonic saline compared to normal
saline. In fact, hypertonic saline was shown to have
some minor adverse effects, such as worsening of
cough. As such, hypertonic saline is not commonly
recommended as a treatment modality due to incon-
sistent evidence substantiating its effectiveness.105
 Controversies and Cutting Edge
Leukotriene Receptor Antagonists
Another therapy currently being explored as treatment
for bronchiolitis is the leukotriene receptor antagonist,
montelukast. Benefits in time to resolution of symp-
toms with this therapy are not apparent.106-108
Bronchiolitis and Vitamin D Deficiency
Recent reports have related the increased incidence
of severe bronchiolitis to the increased incidence of
vitamin D deficiency.109 Low levels of vitamin D are
quite common among newborns born in the United
States,110,111 and these low levels have been associated
with an increased incidence of pneumonia and LRTI
requiring hospitalization.112-114
The pathophysiology of these observations may
relate to the role of vitamin D in the activity of the
immune system.115 Camargo et al recently found that
lower maternal intake of vitamin D during pregnancy
had a statistically significant, independent association
with increased risk of recurrent childhood wheeze,116
a finding that was replicated in 5-year-old Scottish
JANUARY 2023 • www.ebmedicine.net 14
children.117 In addition, Camargo et al confirmed this
finding in a separate birth cohort from New Zealand,
in whom low vitamin D levels in cord blood were as-
sociated with increased risks of respiratory infections
at 3 months and wheezing in early childhood.116 In
a 2015 study, among 145 infants aged <1 year and
hospitalized with their first episode of RSV bronchiol-
itis, vitamin D status at the time of bronchiolitis was
not associated with indicators of acute bronchiolitis
severity. Indicators of bronchiolitis severity included
duration of hospitalization, lowest oxygen saturation
measured during hospitalization, and bronchiolitis
severity score.118 Further research is needed to investi-
gate the relationship between bronchiolitis and vitamin
D deficiency and has the potential to help prevent this
common illness.
Bronchiolitis and Asthma
The relationship between bronchiolitis and the devel-
opment of asthma has been studied for years. It has
been estimated that 50% of children with bronchiolitis
have recurrent wheezing or asthma during the fol-
lowing 2 decades of life.6 This is particularly true in
rhinovirus bronchiolitis. In a study that compared the
development of asthma after infections with RSV or rhi-
novirus, 10% of patients in the RSV group had asthma
compared to 60% of patients in the rhinovirus group.119
The results from a small trial of prednisolone use
for 3 days versus placebo in children hospitalized with
their first or second episode of wheezing due to rhi-
novirus bronchiolitis are of particular interest. This trial
demonstrated that children who had rhinovirus bron-
chiolitis and received prednisolone had fewer relapses
during a 2-month period after hospitalization and less
recurrent wheezing at 1 year.120 Further research should
focus on clarifying the potential benefits of identifying
and treating rhinovirus bronchiolitis in order to prevent
the development of asthma.121
Infants and toddlers who have presented with
bronchiolitis have been known to have wheezing,
and this is not uncommon. A frequent question from
parents to clinicians is, “does (or will) my child have
asthma?” Unfortunately, there is no straightforward an-
swer; however, literature shows a correlation between
early childhood bronchiolitis and asthma development.
A prospective cohort study following young children
hospitalized with severe RSV bronchiolitis showed
approximately 50% of the children developed asthma
by the age of 7, with the more severe cases of bronchi-
olitis having the most risk of asthma.122 Formal asthma
testing typically relies on spirometer testing, which
most children could not meaningfully participate in un-
til approximately age 5 years. Referral to pulmonology
for recurrent wheezing evaluation may be worthwhile.
© 2023 EB MEDICINE. ALL RIGHTS RESERVED.
 Disposition
Most children who present to the urgent care with
bronchiolitis have mild disease and are discharged
home.123 Some patients with bronchiolitis will have a
severe course manifested by dehydration, respiratory
distress, respiratory failure, apnea, or death. The most
challenging task for urgent care clinicians is to deter-
mine the appropriate disposition for a young infant, as
the disease course is extremely variable.
Infants with bronchiolitis are frequently
hospitalized because of respiratory distress, hypoxia,
or dehydration due to their inability to take fluids
secondary to the increased work of breathing. (See
Table 5.) In addition, concerns about apnea will affect
the decision to admit the patient. Most guidelines
recommend close observation and hospitalization for
infants with SpO2 levels <90%. A survey of emergency
physicians demonstrated that a reduction in the
patient’s pulse oximetry level from 94% to 92% in a
clinical vignette significantly increased the likelihood
of the physicians to recommend hospitalization.45 The
study stated that most emergency physicians are not
comfortable discharging patients home with an oxygen
saturation of ≤92%.
While it is difficult to predict the clinical course of
patients with borderline oxygen saturations, oxygen
saturation should not be the only factor in determin-
ing disposition. Decisions regarding hospitalization of
infants with SpO2 levels between 90% and 92% should
be supported by a detailed clinical assessment (eg, the
presence of tachypnea, increase in the work of breath-
ing, and the ability to take fluids, etc), consideration of
the phase of the illness, and should take social factors
such as parental comfort and reliability in ensuring
appropriate care and follow-up should be taken into
consideration when disposition decisions are made in
the urgent care setting. As Schuh et al demonstrated,
when oxygen saturations are artificially increased,
clinicians are more likely to discharge patients with
mild-moderate bronchiolitis.63 Additionally, up to 14%
of patients with bronchiolitis hospitalized from the ED
receive no additional interventions and are discharged
in <12 hours.124 A British study revealed that the mean
lag time for SpO2 levels to normalize was 66 hours
after all other problems had resolved.125
Table 5. Criteria for Hospitalization
Patients with bronchiolitis should be considered for admission if
they have any of the following:
• Risk for apnea (See Table 2.)
• Risk for severe bronchiolitis (See Table 2.)
• Respiratory distress, particularly if it interferes with feeding
• Hypoxia (oxygen saturation ≤90%)
• Decreased feeding and/or dehydration
• An unreliable caregiver (ie, unable to ensure patient care and
appropriate 24-hour follow-up)
All patients with severe bronchiolitis should be admitted.
www.ebmedicine.net
JANUARY 2023 • www.ebmedicine.net
A study published in 2016 compared the differ-
ence in the proportion of unscheduled medical visits
within 72 hours of ED discharge in infants with bronchi-
olitis who have oxygen desaturations <90% for at least
1 minute during home oximetry monitoring versus
those without desaturations. Children with and without
desaturations had comparable rates of return for care,
with no difference in unscheduled return medical visits
or delayed hospitalizations. The authors of this study
concluded that stable patients with mild to moderate
bronchiolitis could be observed with intermittent pulse
oximetry in the acute care setting prior to discharge.
However, the results do not apply to infants with chron-
ic respiratory conditions.64
Risk Factors for Unscheduled Return Visits
Norwood et al conducted a prospective cohort study
of patients aged <2 years with bronchiolitis who were
discharged from 30 EDs in 15 states from 2004 to
2006. The Multicenter Airway Research Collaboration
was used to determine predictors of unscheduled visits
within 2 weeks after the ED visit. Of 722 patients who
were eligible for the analysis, 717 (99%) had unsched-
uled visit data; of these, 121 patients (17%, or 1 in 6
children) had unscheduled visits. Independent predic-
tors of unscheduled visits were age <2 months, male
sex, and history of hospitalization. Two-thirds of the
unscheduled visits occurred within 2 days of the ED
visit, with 13% of patients returning to the ED and 6%
being admitted.126
Discharging Children with Bronchiolitis
The admission of well-appearing children with
bronchiolitis who are at high risk for unscheduled visits
is debatable, as the goals of admission are primarily
close observation and supportive therapy. Close
follow-up with the primary care provider and strict
anticipatory guidance instructions could eliminate the
need for hospitalization.
It is important for urgent care clinicians to discuss
details of supportive care at home, including close
monitoring of hydration status and nasal saline
with suctioning 2 to 3 times per day using proper
technique. Families should be instructed on offering
their infant smaller volumes of enteral feedings more
frequently than normal. Clinicians should provide
families with weight-based dosing of antipyretics to
help with fever and/or fussiness. To help manage
expectations, urgent care clinicians should review the
expected clinical course of bronchiolitis including the
anticipated timeline of peak symptoms between days
3 and 5, followed by gradual improvement.
Urgent care clinicians should emphasize signs and
symptoms to watch for that would necessitate reevalu-
ation by a medical professional including increased
work of breathing (retractions, grunting, nasal flaring,
head bobbing), intolerance of enteral feeds, signs of
dehydration (sunken fontanelle, no wet diaper in 12
15 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
 Case Conclusions
For the 9-month-old girl with wheezing, rapid breathing, and nasal flares…
You quickly determined that this patient had severe bronchiolitis, and you knew that aggressive
management was required. Because the patient’s oxygen saturation was <90%, you placed her on pulse
oximetry. Because the infant had wheezed previously, you started a trial of a nebulized bronchodilator
CASE 1

with oxygen while closely monitoring her clinical response to treatment. After the treatment, your patient’s
respiratory rate is still in the 70s, with minimal decreases in the work of breathing. Her pulse oximetry level
remained 89% on room air, so you administered supplemental oxygen and called for transport to a higher
level of care. The baby started to cry without tears, and you noticed her dry mucous membranes, so you
administered IV fluids. Despite her elevated respiratory rate, she was able to take a bottle while awaiting
transport.

For the 6-week-old boy with 2 days of rhinorrhea and poor feeding…
The physical examination and history led you to conclude that this patient likely had bronchiolitis. Because
the baby was less than 60 days old, you tested him for RSV; the result was negative. It was apparent to you
CASE 2

that the child was in the high-risk category for multiple reasons, including prematurity, age ≤6 weeks, and
poor feeding. You recalled that each course of bronchiolitis is variable, but that the typical disease process
worsens around day 3 or 4. After some observation, an oral challenge was performed, which the patient
failed. Due to the boy's risk factors and poor feeding despite nasal suctioning, you decided to administer IV
fluids and admit him for additional IV hydration and observation.

hours) and a contingency plan for what to do if symp-
toms do not improve or worsen. Additionally, urgent
care clinicians should counsel families on the increased
risk of secondary bacterial infections like acute otitis
media or pneumonia due to the increased mucus pro-
duction and airway inflammation.
of acute first-time bronchiolitis. Frequent evaluations
of patient clinical status including respiratory rate,
work of breathing, oxygenation, and ability to take
fluid orally after any intervention are very important to
determine safe patient disposition.

 Critical Appraisal of the Literature

 Summary
Acute bronchiolitis is a clinical diagnosis; diagnostic
laboratory and radiographic tests play a limited role in
typical cases. Urgent care clinicians can help decrease
the financial burden of this condition by using history
and physical examination findings and strict criteria
for diagnostic testing to assess and manage bronchi-
olitis in young children. Urgent care clinicians should
assess for high-risk factors for severe bronchiolitis
manifested by respiratory distress, increased work of
breathing that leads to decreased feeding and dehy-
dration, hypoxia, respiratory failure, and apnea and
consider transferring these patients to a higher level
of care. These factors include age <6 to 12 weeks,
prematurity, and underlying comorbidities such as
chronic lung disease, cardiopulmonary disease, and
immunodeficiency. Pulse oximetry drives the use of
healthcare resources. Supplemental oxygen is indi-
cated if the patient’s SpO2 level is consistently ≤90%
or at higher pulse oximetry readings if the patient is in
respiratory distress or has an underlying disease that
causes abnormal baseline oxygenation. Numerous
large trials have demonstrated the lack of efficacy of
bronchodilators and corticosteroids in the treatment
A search of articles published on bronchiolitis from
1970 to 2021 was performed using Ovid MEDLINE®
and PubMed. Terms used in the search included
wheezing, bronchiolitis, lower respiratory tract infec-
tion, RSV, infant respiratory distress, bronchiolitis
guidelines, and steroids. More than 200 articles
were analyzed, providing the background for further
review. In addition, the Cochrane Database of Sys-
tematic Reviews was consulted. Major current interna-
tional guidelines for the diagnosis and management
of bronchiolitis were also reviewed and compared in
relation to recommendations pertinent to the assess-
ment and management of acute bronchiolitis in the
urgent care setting.3,74-78,127
There is significant variation in the bronchiolitis
literature in the definition of bronchiolitis, the clinical
scoring systems, and outcome measures. Additionally,
differing cutoff ages for bronchiolitis, as well as the
lack of a valid clinical scoring system that correlates
with clinically significant improvement and the inclu-
sion of testing for RSV or other viruses in the diagnosis,
complicate a review and comparison of the literature.
Although there are excellent published guidelines to
help clinicians address this common condition, they

JANUARY 2023 • www.ebmedicine.net 16 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.

often exclude the group at high risk for severe bronchi-
olitis (eg, patients who are at risk for serious complica-
tions, such as apnea, and who may need ventilatory
support). The 2014 AAP clinical practice guidelines
provide recommendations on the diagnosis, manage-
ment, and prevention of bronchiolitis.
 References
Evidence-based medicine requires a critical appraisal
of the literature based upon study methodology
and number of subjects. Not all references are
equally robust. The findings of a large, prospective,
randomized, and blinded trial should carry more
weight than a case report.
Risk Management Pitfalls in Urgent Care Management of
Pediatric Bronchiolitis (continued on page 19)
1. “The 4-month-old patient was wheezing, so we
tested him for RSV.” The diagnosis of bronchiol-
itis is based on the history and physical examina-
tion. In most cases, viral testing will not change the
urgent care course. Consider obtaining RSV testing
if a positive RSV test would change their manage-
ment. Another situation in which RSV testing may
be useful is for a patient who has been receiving
monthly palivizumab as prophylaxis. If a break-
through RSV infection is present (based on antigen
detection or another assay), monthly prophylaxis
should be discontinued due to the very low likeli-
hood of another RSV infection in the same year.3
2. “I always transfer first-time wheezing patients
with bronchiolitis if they do not clear in the
urgent care.” One of the main reasons to transfer
patients with bronchiolitis is the concern regarding
the development of apnea. Risk factors for apnea
include young age (<6-12 weeks old), prematu-
rity, a history of apnea of prematurity, presenta-
tion with apnea, or apnea witnessed by a parent
or healthcare provider. In addition, patients with
bronchiolitis may be transferred to a higher level
of care because of respiratory distress, hypoxia, or
dehydration related to the inability to take fluids
secondary to increased work of breathing. Wheez-
ing alone is not a criterion for transfer unless it is
associated with other risk factors for severe disease
or apnea. Social factors such as parental comfort
and reliability in ensuring appropriate care and
follow-up should be taken into consideration when
disposition decisions are made in the urgent care.
JANUARY 2023 • www.ebmedicine.net
To help the reader judge the strength of each
reference, pertinent information about the study
is included in bold type following the reference,
where available. In addition, the most informative
references cited in this paper, as determined by
the authors, are noted by an asterisk (*) next to the
number of the reference.
1. McLaurin KK, Farr AM, Wade SW, et al. Respiratory syncytial
virus hospitalization outcomes and costs of full-term and pre-
term infants. J Perinatol. 2016;36(11):990-996. (Retrospective
multicenter study; 4 million newborns)
2. Hasegawa K, Tsugawa Y, Brown DF, et al. Trends in bronchiolitis
hospitalizations in the United States, 2000-2009. Pediatrics.
2013;132(1):28-36. (Nationwide serial cross-sectional analysis;
544,828 patients aged <2 years)
References continue on page 20
3. “The infant was wheezing, so we sent her
home on steroids.” In contrast to the demon-
strated effectiveness of dexamethasone in treat-
ing asthma and croup, no conclusive evidence
has been shown to date that the use of systemic
dexamethasone improves outcomes in first-time
wheezing patients with bronchiolitis. In addi-
tion, because of safety concerns with the use of
high-dose inhaled corticosteroids in infants, these
medications should be avoided unless there is a
clear likelihood of benefit.
4. “The neonate was wheezing, so I diagnosed
her with bronchiolitis.” Other life-threatening
causes of wheezing should be considered. Clues
from the history and physical examination such as
sweating and exertion with feeding, heart murmur,
and hepatomegaly should be elicited to rule out
congenital heart failure and “cardiac wheezing.”
This determination is important before starting a
trial of nebulized adrenergic treatment.
5. “The 2-month-old born at 30 weeks’ gestation
with chronic lung disease had mild wheezing
and a respiration rate of 60 breaths/min. Pulse
ox reading was 92% on room air on arrival to
the urgent care and did not change after suc-
tioning so I admitted her.” Bronchiolitis presenta-
tion is variable. This patient has 3 risk factors for
severe disease, including young age, prematurity,
and hypoxia. In addition, she has a risk factor for
apnea (ie, <48 weeks post conception). Close
observation is warranted.
17 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
 Charting & Coding: What You Need to Know

S electing an appropriate level of service for bron-

chiolitis and other viral infections can be quite
challenging, even for the experienced coder. The
appropriate evaluation and management codes for
these patient encounters will depend on the level of
service, as guided by the elements of medical deci-
sion making. (See Table 6.) Documentation and the
presenting complaint will be the determining factors
for selecting the correct level of service in encoun-
ters with patients who have bronchiolitis.
First, the clinician must differentiate an acute,
uncomplicated illness from an acute illness with sys-
temic symptoms in order to select the level of ser-
vice in the Problems Addressed category. See Table
7, page 19 for definitions of these terms. Is bronchi-
olitis a “minor illness?” In some patients, perhaps.
Many common pediatric presentations, such as up-
per respiratory infections, otitis media, otitis externa,
urinary tract infections, and nonsystemic rashes meet
the criteria for acute, uncomplicated illness, resulting
in Level 3 (Low) encounters. However, patients with
bronchiolitis may have systemic symptoms (fever,
cough, loss of appetite, wheezing, etc) and a high
risk for morbidity, so the criteria would be met for
an acute illness with systemic symptoms; that would
place these encounters at Level 4 (Moderate) in the
Problems Addressed category.
Complexity of Data is the next category to
consider when selecting a level of service. When
determining the appropriate level of service for this
category, ask yourself these questions:
• How many point-of-care tests and/or outside
laboratory tests did you order?
• Did you review an external note from a previ-
ous visit?
• Did you obtain part or all of the history of pres-
ent illness from an independent historian? In
the case of children, you must document that
you obtained part or all of the history of pres-
ent illness from an independent historian (eg,
the parent) in order to meet the criteria.
• Did you discuss the management of the pa-
tient or a test interpretation with an external
physician or other qualified healthcare profes-
sional? Remember that an external physician
or other qualified healthcare professional must
not be in the same group practice or must be
in a different specialty or subspecialty.

Table 6. Simplified Elements of Medical Decision Making128

MDM Levela Problems Addressed Complexity of Data Risk of Complications E/M Service
Codes

Level 2: • Minor/self-limited • Minimal/none • Minimal risk • 99202

Straightforward • 99212

Level 3: Low • 1 stable chronic illness
• 1 acute, uncomplicated illness
• 1 acute, uncomplicated injury
Level 4: Moderate • 1 or more chronic illnesses
with exacerbation
• 2 stable chronic illnesses
• 1 undiagnosed new problem
• 1 acute illness with systemic
symptoms
Level 5: High • Severe illness with
exacerbation
• Threat to life or bodily function
At least 1 of these: • OTC medication • 99203
• 2 data sources (eg, ordering or management • 99213
reviewing tests)
• Independent historian
At least 1 of these: • Prescription drug • 99204
• 3 data sources (eg, ordering management • 99214
or reviewing tests); can include • Significant social
independent historian determinants of health
• Independent interpretation of
test results
• Discussion of management or
test interpretation
At least 2 of these: • Severe without • 99205
• 3 data sources (eg, ordering emergent treatment • 99215
or reviewing tests); can include
independent historian
• Independent interpretation of
test results
• Discussion of management or
test interpretation

a
Level is based on meeting 2 out of 3 elements of medical decision making.
Abbreviations: E/M, evaluation and management; MDM, medical decision making; OTC, over the counter.

JANUARY 2023 • www.ebmedicine.net 18 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.

 Charting & Coding: What You Need to Know
An independent historian alone would make the en-
counter Level 3 (Low) in the Complexity of Data cat-
egory, while an independent historian and 2 point-
of-care tests would meet the criteria for Level 4.
Risk of Complications is the final category to
consider when determining the correct level of ser-
vice. In the case of pediatric patients who have bron-
chiolitis, if the patient is severely ill or is transferred
to the ED, the encounter will meet the criteria for at
least Level 4 (Moderate). Level 4 criteria are also met
if prescription medication is given (eg, an antibiotic
or intramuscular injection in the clinic).
In summary, many pediatric patients who
present with bronchiolitis will meet the criteria for
at least a Level 4 office visit, particularly children
who are very ill or who require transfer to the ED.
Documentation and the Problems Addressed are
the most important aspects when determining the
correct level of service for these patient encounters.
Risk Management Pitfalls in Urgent Care Management of
Pediatric Bronchiolitis (continued from page 17)
6. “The ‘happy wheezer’s’ pulse oximetry reading
was 92% on room air, so I immediately admin-
istered supplemental oxygen.” In a wheezing
patient who has no respiratory distress but has
low SpO2, the first priority is to ensure that pulse
oximetry probes are placed appropriately, par-
ticularly in the active infant/child. Poorly placed
probes and motion artifacts will lead to inac-
curate measurements and false alarms. Before
instituting oxygen therapy, the initial reading
should be verified by repositioning the probe
and repeating the measurement. The infant’s
nose should also be suctioned. If the SpO2 level
remains ≤90%, oxygen should be administered.
The infant’s clinical work of breathing should also
be assessed and may be a factor in the decision
to use oxygen supplementation.
7. “I ordered a radiograph because the wheezing
patient had a fever.” Radiographs should not be
obtained routinely for diagnosis of bronchiolitis
because no evidence supports the practice. If
another diagnosis such as foreign body aspiration,
pneumonia, or congenital heart failure is suspect-
ed on the basis of the history and physical exami-
nation findings, radiographs may be useful.
JANUARY 2023 • www.ebmedicine.net
Table 7. Definitions for Determining
Problems Addressed128
Acute, uncomplicated illness or injury
• New or recent short-term problem
• Little to no risk of mortality with treatment
• Low risk of morbidity
• Full recovery expected, without functional impairment
• Problem would usually be self-limited or minor, but is not
resolving as expected with definite and prescribed course of
treatment
• Examples: cystitis, allergic rhinitis, simple sprain
Acute illness with systemic symptom
• Illness causing systemic symptoms
• Excludes systemic general symptoms but may be single systemª
• High risk of morbidity without treatment
• Examples: pyelonephritis, pneumonitis, colitis
Systemic general symptoms (eg, fever, body aches, fatigue) that
a
occur in minor illness and can be treated fall within the definition
of “acute, uncomplicated illness or injury“ or “self-limited or minor
problem.“
8. “The mother stated that her 1-month-old baby
had a runny nose and cough for 2 days. The
nurse called because the baby turned blue for a
brief period. Upon reassessment, his breathing
rate was 60 breaths/min, and his pulse oxim-
etry reading was 96% on room air, so I sent him
home.” Young age (<1 month old) and witnessed
apnea by a healthcare provider are major risk
factors for developing another apneic episode or
persistent apnea. Admission of this neonate to a
monitored bed (with apnea monitor) is indicated.
9. “The infant was stable but having trouble clear-
ing mucus in the urgent care. He already had
nasal suctioning, so we trialed nebulized hyper-
tonic saline for symptomatic relief and sent him
home.” Nebulized hypertonic saline has shown
benefit in some studies in reducing hospitalization
length of stay when used for >3 days; however, it
has not been shown to have much benefit when
used in the outpatient setting or in brief time
frames. The AAP moderately recommends not giv-
ing hypertonic saline in the outpatient setting.
19 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
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the diagnostic labeling of nonbacterial lower respiratory tract
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emergency department. Pediatrics. 2009;123(4):e573-e581.
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DOI: 10.1542/peds.2008-1675
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Acknowledgments
Portions of this content were previously published
in: Joseph MM, Edwards A. Acute bronchiolitis:
assessment and management in the emergency
department. Pediatr Emerg Med Pract.
2019;16(10):1-24. Used with permission of EB
Medicine.
23 © 2023 EB MEDICINE. ALL RIGHTS RESERVED.
 CME Questions
Current Evidence-Based Urgent Care
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1. Which of the following is responsible for
bronchiolitis recovery lasting >12 days?
a. Smooth muscle constriction
b. Normal regeneration of ciliated epithelial
cells
c. Increase in lung compliance creating
secondary air trapping
d. Defective macrophage response
2. Which of the following symptoms is NOT
consistent with the clinical definition of
bronchiolitis?
a. Tachypnea
b. Wheezing
c. Stridor
d. Use of accessory muscles
3. Which of the following disorders should be
considered in the differential diagnosis of
bronchiolitis?
a. Pneumonia
b. Congestive heart failure
c. Asthma
d. All of the above
4. Which of the following historical findings is
NOT a risk factor for severe bronchiolitis?
a. History of wheezing
b. Age <12 weeks
c. Prematurity (<34-35 weeks’ gestation)
d. Significant congenital heart disease and an
immune deficiency
JANUARY 2023 • www.ebmedicine.net 24
5. Which of the following findings is NOT
considered a risk factor for apnea with
bronchiolitis?
a. Full-term birth and <1 month of age
b. Apnea witnessed by a caregiver
c. High fever
d. Preterm birth (<36 weeks’ gestation) and <2
months post birth
6. Which of the following physical examination
findings is NOT a risk factor for severe
bronchiolitis?
a. Oxygen saturation level ≤90% on room air
b. Severe nasal congestion
c. Respiratory rate >70 breaths/min
d. Increased work of breathing (ie, moderate to
severe retractions and/or accessory muscle
use).
7. In a well-appearing young infant with high
fever and bronchiolitis, which of the following
is the most common serious bacterial infection
that a patient should be evaluated for?
a. Pneumonia
b. Urinary tract infection
c. Bacteremia
d. Meningitis
8. Of the children with bronchiolitis listed below,
which of the following does NOT meet criteria
for hospitalization?
a. A 6-month-old with a pulse oximetry of 89%
b. An 11-month-old with decreased oral intake
and dry mucous membranes
c. An 8-month-old with nasal flaring and
grunting that does not improve with
suctioning.
d. A 5-month-old with a pulse oximetry of 93%
and a pediatrician appointment in 1 to 2 days
© 2023 EB MEDICINE. ALL RIGHTS RESERVED.
Evidence-Based Urgent Care Editorial Board

EDITOR-IN-CHIEF Emily Montgomery, MD Claude E. Shackelford, MD Joseph Toscano, MD

Keith Pochick, MD
Attending Physician, Urgent
Care, Charlotte, NC
EDITORIAL BOARD
Margaret Carman, DNP, RN,
ACNP-BC, ENP-BC, FAEN
Clinical Associate Professor,
School of Nursing, University
of North Carolina Chapel Hill,
Chapel Hill, NC
Chrysa Charno, PA-C, MBA,
FCUCM
Chief Executive Officer
and Clinical Director, Acute
Kids Pediatric Urgent Care,
Rochester, NY
Tracey Quail Davidoff, MD,
FCUCM
Urgent Care Physician,
Orlando, FL
Melinda Johnson, DNP,
APRN, FNP-BC, AGACNP-
BC, ENP-C
Assistant Professor, Emergency
Nurse Practitioner Program,
Vanderbilt University School of
Nursing, Nashville, TN
Director of Education, Division
of Urgent Care, Children's
Mercy Kansas City, Kansas
City, MO; Clinical Assistant
Professor, University of
Missouri-Kansas City School
of Medicine, Kansas City, MO;
Clinical Assistant Professor,
University of Kansas School of
Medicine, Kansas City, KS
Cesar Mora Jaramillo, MD,
FAAFP, FCUCM
Associate Medical Director,
Express at Providence
Community Health Centers;
Clinical Assistant Professor,
Department of Family
Medicine, Warren Alpert
Medical School, Brown
University, Providence, RI
Patrick O'Malley, MD
Attending Physician,
Emergency Department,
Newberry County Memorial
Hospital, Newberry, SC
Assistant Professor of Urgent Care Physician, John
Clinical Medicine, Vanderbilt Muir Urgent Care, East San
University Medical Center; Francisco Bay Area, CA;
Assistant Medical Director, Physician and Clinical Chief,
Walk-In Clinics, Vanderbilt Emergency Medicine, San
University Medical Center, Ramon Regional Medical
Nashville, TN Center, San Ramon, CA
James B. Short, MD, FAAFP,
BCUCM
Director, Piedmont Urgent
Care, Atlanta, GA
Benjamin Silverberg, MD,
MSc, FAAFP, FCUCM
Associate Professor,
Department of Emergency
Medicine; Medical Director,
Division of Physician Assistant
Studies, Department of
Human Performance, West
Virginia University School of
Medicine, Morgantown, WV

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