Bronchiolitis Pathway v12.0: Table of Contents Inpatient & ED Inclusion Criteria · Age <2 years · Prematurity and/or age <12 weeks may be included, but expect a more severe course of illness Stop and · Viral upper respiratory symptoms & lower respiratory symptoms Review that may include: increased work of breathing, cough, feeding difficulty, tachypnea, wheeze, fever Inpatient & ED Exclusion Criteria · Cardiac disease requiring baseline medication · Anatomic airway defects · Neuromuscular disease · Immunodeficiency · Chronic lung disease HFNC Inclusion Criteria · Primary diagnosis of bronchiolitis · Age 44 weeks PMA to <2 years · ONE of the following: Stop and 1) Severe respiratory distress (deep retractions in multiple areas, Review grunting, head bobbing), or 2) Significant hypoxia (need for >1 lpm NCO2 if 30-90 days, >1.5 lpm for 91 days – 6 months, >2 lpm for 6 months – 2 years) HFNC Exclusion Criteria · Concern for impending respiratory failure (lethargy, poor perfusion, apnea) · Primary diagnosis of pneumonia, asthma, or croup · Born prematurely <34 weeks (if <6 mo) · History of intubation for respiratory failure · Cardiac disease requiring baseline medication · Anatomic airway defects · Neuromuscular disease · Immunodeficiency · Chronic lung disease Bronchiolitis Care Criteria & Respiratory Score ED Management Inpatient Phase HFNC Phase Appendix Version Changes Approval & Citation Evidence Ratings Bibliography For questions concerning this pathway, contact: Last Updated: December 2020 [email protected] Next Expected Review: December 2025 If you are a patient with questions contact your medical provider, Medical Disclaimer © 2020 Seattle Children’s Hospital, all rights reserved Bronchiolitis Pathway v12.0: Criteria and Respiratory Score Inclusion Criteria · Age <2 years · Prematurity and/or age <12 weeks may be included, but expect a more severe course of illness Stop and · Viral upper respiratory symptoms & lower respiratory symptoms Review that may include: increased work of breathing, cough, feeding difficulty, tachypnea, wheeze, fever Exclusion Criteria · Cardiac disease requiring baseline medication · Anatomic airway defects · Neuromuscular disease · Immunodeficiency · Chronic lung disease RESPIRATORY SCORE (RS) Variable 0 points 1 point 2 points 3 points RR <2 mo ≤60 61-69 ≥70 2-12 mo ≤50 51-59 ≥60 1-2 yr ≤40 41-44 ≥45 Retractions None Subcostal or intercostal 2 of the following: 3 of the following: subcostal, subcostal, intercostal, intercostal, substernal, substernal, OR nasal suprasternal, supraclavicular OR flaring (infant) nasal flaring / head bobbing (infant) Dyspnea 0-2 years Normal feeding, 1 of the following: difficulty 2 of the following: difficulty Stops feeding, no vocalization or vocalizations and activity feeding, decreased feeding, decreased drowsy and confused vocalization or agitated vocalization or agitated Auscultation Normal breathing, no End-expiratory wheeze only Expiratory wheeze only Inspiratory and expiratory wheezing present (greater than end- wheeze OR diminished breath expiratory wheeze) sounds OR both For questions concerning this pathway, contact: Last Updated: December 2020 [email protected] Next Expected Review: December 2025 If you are a patient with questions contact your medical provider, Medical Disclaimer © 2020 Seattle Children’s Hospital, all rights reserved Bronchiolitis Pathway v12.0: ED Management Inclusion Criteria · Age <2 years Therapies NOT · Prematurity and/or age <12 weeks may be included, but expect a more severe course of illness routinely Stop and · Viral upper respiratory symptoms & lower respiratory symptoms recommended Review that may include: increased work of breathing, cough, feeding difficulty, tachypnea, wheeze, fever · Albuterol · Racemic Exclusion Criteria Epinepherine · Cardiac disease requiring baseline medication · Corticosteroids · Anatomic airway defects · Chest Physiotheraphy · Neuromuscular disease · Montelukast · Immunodeficiency · Antibotics · Chronic lung disease · Hypertonic Saline Urgent Care Transfer Criteria · Severe respiratory distress after suction and reevaluation · Inadequate oral hydration ! ! · Hypoxemia · Apnea Routine testing Chest X-rays · Signs of clinical deterioration for viral pathogens NOT routinely NOT recommended recommended *Transport via ALS unless for cohorting Initial assessment Considerations for severely ill patients · SCORE, SUCTION, SCORE: nasal suction; follow with NP · May consider ONE-TIME albuterol MDI trial if: suction if needed · Severe respiratory distress OR · Provide supplemental O2 to keep saturation >90% (>88% · Worsening respiratory distress PLUS increased risk for asleep). Start at ½ L and titrate as needed. asthma (>12 months old, wheeze, and one of the following: personal history of atopy or recurrent wheezing OR strong family history of atopy or asthma) Rehydration · Continue albuterol PRN ONLY if improves work of breathing · Give supplemental NG or IV fluids if moderately to · Consider HFNC for significant hypoxia OR severe respiratory severely dehydrated; NPO and IV fluids if severe distress not improving with rigorous supportive care (suction, respiratory distress hydration, antipyretics, standard NC) · Encourage NG over IV fluids, esp. if <1 year old · If safe for PO feeds and mildly to moderately dehydrated, attempt oral feeding Go to HFNC Phase Family teaching · Viral illness, treated by hydration and suction · Signs of respiratory distress · When and how to suction · Frequent feeds and watch hydration status · Cough may last 2-4 weeks, do not use OTC cough and cold medications, avoid tobacco smoke Suction and reevaluation · Respiratory score (SCORE, SUCTION, SCORE) Q 1 hour + prn if mild to moderate distress Discharge Decision to Admit or Able to · Respiratory score and suction q30 minutes + prn if severe Recommend follow Discharge discharge respiratory distress up in 24-48 hours · For patients with prolonged ED stays, may space suctioning per MD discretion Medical Unit Admit Criteria ICU Admit Criteria (any of the following) (any of the following) · Sustained hypoxemia (SpO2 <90% awake, · Clinical worsening despite floor max HFNC 88% asleep) support · Apnea · Desaturations below 90% despite 50% FiO2 · Dehydration/impaired oral hydration requiring · Other late findings of respiratory failure: ongoing IV or NG fluids · Inappropriately low respiratory rate with · HFNC trial initiated, clinically improved or worsening obstruction unchanged · Lethargy despite noxious stimuli · Moderate to severe respiratory distress AND · Poor perfusion one of the above criteria · Apnea >20 seconds with associated bradycardia/desaturation requiring intervention For questions concerning this pathway, contact: Last Updated: December 2020 [email protected] Next Expected Review: December 2025 If you are a patient with questions contact your medical provider, Medical Disclaimer © 2020 Seattle Children’s Hospital, all rights reserved Bronchiolitis Pathway v12.0: Inpatient Management Inclusion Criteria · Age <2 years Therapies NOT · Prematurity and/or age <12 weeks may be included, but expect a more severe course of illness routinely Stop and · Viral upper respiratory symptoms & lower respiratory symptoms recommended Review that may include: increased work of breathing, cough, feeding difficulty, tachypnea, wheeze, fever · Albuterol · Racemic Exclusion Criteria Epinepherine · Cardiac disease requiring baseline medication · Corticosteroids · Anatomic airway defects · Chest Physiotheraphy · Neuromuscular disease · Montelukast · Immunodeficiency · Antibotics · Chronic lung disease · Hypertonic Saline Patient admitted ! Signs of clinical Begin family teaching deterioration: · Signs of respiratory distress · How to suction · When to suction Lethargy despite noxious stimuli, inappropriately low respiratory rate with worsening · Assess patient obstruction, apnea, poor perfusion; · Calculate respiratory score Deterioration does not correlate with day of illness · Place CR monitors · Notify MD · Call Rapid Response Team Pre-suction score is LOW (1-4) Pre-suction score is MODERATE (5-8) Pre-suction score is HIGH (9-12) · Score, Suction, Score minimum · Score minimum q 2 hours · Score minimum q 1 hours q4 hours, prior to feeds or if · Suction minimum q2-4 hours. Score after · Suction minimum q2-4 hours. Score more distressed suctioning. after suctioning. · Nasal suction · Nasal suction · Nasal suction · No continuous pulse oximetry · NP suction if clinically indicated for work of · NP suction if clinically indicated for work · If on NG/IV fluids, discontinue breathing after nasal suctioning of breathing after nasal suctioning fluids and restart oral feeds · Spot SpO2 checks; continuous pulse · Continuous pulse oximetry oximetry if on supplemental O2 or per care · Consider albuterol trial and HFNC trial team request due to clinical concerns (see below) · Rescore at interval specified above (either 1, 2, or 4 hours) · Recategorize based on pre-suction score Ready for discharge? Inadequate PO Intake Discharge Criteria Escalation for worsening patients · Encourage NG over IV fluids, · May consider ONE-TIME albuterol especially if <1 year old Patients should be meet ALL of the trial (only if not previously trialed) if: · NPO and IV fluids if severe following criteria: · Severe respiratory distress OR respiratory distress · Respiratory score <5 for at least 8 hours · Worsening respiratory distress · No need for NP suctioning for 4 hours PLUS increased risk for asthma · Off supplemental