Back to Basics: Bronchiolitis

Micro: RSV most common cause, highly contagious via respiratory droplets.


  • Affects children < 2 years old → if wheezing and >2 years old may be reactive airway disease or other conditions that mimic wheezing and bronchiolitis.
  • 1 to 2 days of URI symptoms followed by increased WOB, tachypnea, hypoxia on days 3 to 5 of illness → give good reassurance and return to ER precautions if suspect early.
  • Minute to minute variation of comfortable breathing to respiratory distress

Evaluation → this is a clinical diagnosis

  • CXR only if diagnosis uncertain or suspect co-infection or patient critically ill.
  • Respiratory panel → truly helpful to determine if RSV+ if high risk for apnea.


  • Saline and Nasal suction as children under 2 years are obligate nose breathers.
  • Hydration, anti-pyretics
  • Use WARM score to determine if trial of Albuterol is appropriate
  • If child is sicker, may need high flow nasal cannula (HFNC or vapotherm) or NIPPV and admission
  • Steroids and antibiotics have no role
  • Hypertonic saline without benefit in ED but may have benefit in admitted patients
  • Epinephrine likely with transient effects at best → leads to faster ED discharge rates


  • Discharge if full-term (48 week post conception) + healthy (no cardiac, pulmonary, neuromuscular or metabolic disease) who is euvolemic + not hypoxic + no evidence of increased work of breathing (retractions, tachypnea).
  • If < 12 weeks and RSV+ have low threshold to admit as have apnea risk.

Discharge Instructions:

  • Suction and saline and cool mist humidifier.
  • Slower feeds → decreased volume, increase frequency of meals
  • Elevate head of crib
  • No daycare until afebrile.
  • Return to ER for:
    • Increased work of breathing → show parents a video.
    • Persistent fever, dehydration or poor feeding



Meissner HC. Viral Bronchiolitis in Children. N Engl J Med. 2016 Jan 7;374(1):62-72.

American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006 Oct;118(4):1774-93.