Clinical Practice Guideline for Bronchiolitis Management: Urgent Care FINAL 10.4.18 1Inclusion Criteria Infants presenting with signs and symptoms of upper respiratory Blue shaded area · Previously healthy infant infection progressing to lower respiratory symptoms1 represents · 1-18 months of age Caregiver Initiated · Suspicion of diagnosis of bronchiolitis: upper respiratory Protocol for symptoms such as rhinitis, coughing; lower respiratory Bronchiolitis signs such as wheezing, crackles, tachypnea, that may 6.04 result in difficulty breathing and/or difficulty feeding Score Suction Rescore Exclusion Criteria: Place in room immediately and notify physician of · Toxic Appearance · CLD (Chronic Lung Disease) O2 sats if less than or equal to 90% · Cardiac disease requiring baseline medications Isolation Standard For · Per CDC/HICPAC Guidelines: Contact Droplet Isolation for temperature the duration of the illness ≥38 C, also refer to 2Risk for Asthma Fever Guideline Patient may be at increased risk for asthma if >12mo old: for appropriate age · with wheeze plus history of atopy OR Severe group Mild Moderate · strong family history of atopy or asthma CRS >7 CRS 0-2 CRS 3-6 Respiratory *Notify physician · Suctioning: Oral, Bulb tip, or NP suctioning as needed; Wean to bulb suctioning · Oxygen PRN to maintain Sats >90% while awake (>88% Consider while asleep ) or If severe respiratory distress One Time Trial 3Feeding/Hydration Albuterol · PO feeding preferred if respiratory rate <60 Continue to evaluate · Intake of 75% maintenance fluid needs is adequate unless At risk for If positive response, dehydrated & suction PRN 2 YES Asthma ? then Off Guideline · D5NS or D5LR are preferred maintenance IV fluids. If Assess hydration3 and Consider giving IVF, avoid hypotonic solution (D5¼ and D5½) due to risk of SIADH induced hyponatremia. Asthma Guideline · NG feedings preferred to IVF unless contraindicated or NO for Further physician order. While NG feedings are not routinely MODERATE SEVERE Management available in Urgent Care, patient may receive in ED or Inpatient. Refer to NG policy: PC 19-02, HS-PC 19-02 4Discharge Criteria Suction PRN Patient must meet all discharge criteria Suction PRN Consider: · Room air sats consistently ≥ 90% while awake or >88% Racemic Epinephrine while asleep · Able to handle secretions or bulb suctioning only · Adequate activity & hydration · Home care needs arranged · Parent verbalizes/demonstrates understanding of: Natural history of the disease, bulb suctioning, and medications if indicated · Parents able to follow-up with PCP within 48 hours or Reevaluate Reevaluate access emergency care if needed 3 3 Assess Hydration Assess Hydration 5Patient/Family Education · Nasal suctioning · Signs/symptoms of respiratory distress · Guidelines for feeding · Review bronchiolitis teaching sheet Meets · No smoking in home & avoidance of other environmental pollutants Discharge NO 6 4 Transfer to Emergency Department Criteria · Persistent Significant work of breathing · O2 requirement to keep sats ≥90%, consistently YES · Unable to handle secretions with bulb suctioning Literature shows the · Poor Feeding following are not beneficial Patient/Family · Consider if history of apneic episode routinely: CBC, CXR, Education5 Consider Air Transport IF: · Multiple episodes of apnea (>1) or any episode requiring RSV labs, antibiotics, bagging serial aerosols, steroids · CRS ≥ 9 and/or chest percussion · FiO2 ≥ 50% Discharge Admit6 · PEWS =7 or score of 3 in any of categories Airway, Circulation, or Disability · Use Air Transport or call 911 as appropriate CRS=Clinical Respiratory Score Developed through the efforts of Children's Healthcare of Atlanta and physicians on Children’s medical staff in the interest of advancing pediatric healthcare. This is a general guideline and does not represent a professional care standard governing providers' obligation to patients. Ultimately the patient’s physician must determine the most appropriate care. © 2018 Children’s Healthcare of Atlanta, Inc.