Bronchiolitis

Bronchiolitis is a lower respiratory tract infection predominantly caused by RSV, affecting infants <1 year. It is the most common cause of hospital admission in infants in winter. Treatment is supportive: oxygen, hydration, and monitoring…

NICE NG9 Bronchiolitis Pathway

The pathway

1 · Assess severity

Mild: feeding >75%, no O₂ requirement — safe for home
Moderate: feeding 50–75%, or sats below the oxygen threshold — admit
Severe: apnoeas, severe recession, SpO₂ <90% — PICU referral

2 · Oxygen

Give oxygen if sats are persistently <90% at 6 weeks and over
<92% if under 6 weeks, or any age with an underlying condition
Use low-flow nasal cannulae first
High-flow nasal cannulae (Airvo/Optiflow) for moderate-severe

3 · Hydration

If feeding <50%: NG tube feeds at maintenance rate
IV is the escalation, not an alternative route: only if NG/OG is not tolerated or there is impending respiratory failure
Avoid overhydration (SIADH risk)

4 · Monitoring

Continuous SpO₂ and apnoea monitoring. Heart rate, RR, recession score 4-hourly. Observe during and after feeds.

5 · Do NOT give

Do NOT use salbutamol (no evidence)
Do NOT use steroids (SIGN evidence of harm)
Do NOT use antibiotics unless secondary bacterial infection suspected
Do NOT use chest physio acutely

6 · Discharge criteria

Sats in air for ≥4h including a period of sleep: >90% at 6 weeks and over, >92% if younger or with an underlying condition
Feeding ≥75% usual
Adequate parental understanding
Safety-net for worsening

Drugs

Drug	Dose	Route	Notes
O₂ (low-flow NC)	0.5–2 L/min	Nasal cannulae	Start below 90% at 6 weeks and over; below 92% if under 6 weeks or an underlying condition (NG9, 2021).
High-flow nasal cannula	1–2 L/kg/min	HFNC	Starting flow 1 L/kg/min. Requires HDU/PICU monitoring.
0.9% NaCl + 5% dextrose	Maintenance rate	IV	Holliday-Segar formula. IV only — NG feeding is a different intervention and comes first. Monitor electrolytes daily.

When to escalate

Apnoeas — PICU referral immediately,SpO₂ <90% on high-flow — PICU,Ex-premature (<36 weeks) or CHD — lower threshold for PICU,Worsening work of breathing despite HFNC — intubation and ventilation

Reference: NICE NG9 Bronchiolitis in Children 2015 / SIGN Bronchiolitis 2006

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