MassGeneral Hospital for Children
Clinically-Diagnosed Bronchiolitis in Children 1 month old and above
YES
Meets ANY of these inpatient criteria?
Respiratory
RR >70, dyspnea, SaO2 persistently <90% on RA
Nutrition
Unable to take adequate PO
Social
No means of follow up as outpatient
Risks factors
Age, history of prematurity
Admit
Viral panel for cohorting (contact/droplet)
Chest X-ray not routinely needed
Bulb suctioning prn
Respiratory Assessment Score (RAS)
Respiratory Assessment Score (RAS*)
RAS < 8
Routine management:
Minimize IVF, prefer NGT/PO
Spot check if SaO2 persistently >90%
Wean O2 if SaO2 persistently >90%
Points
0
1
2
3
RR
Normal
≤ 2 mo <60
2-12 mo <50
12-24 mo <40
Mild tachypnea
≤ 2mo 60-69
2-12 mo 50-59
12-24 mo 40-49
Moderate
tachypnea
≤ 2 mo 70-79
2-12 mo 60-69
12-24 mo 50-59
Severe
tachypnea
≤ 2 mo ≥80
2-12 mo ≥70
12-24 mo ≥60
General
Appearance
Asleep, calm,
interactive.
Mildly irritable,
crying but
consolable.
Moderately
irritable,
difficult to
console, less
interactive.
Extremely
irritable,
inconsolable.
Or not
interactive.
Accessory
Muscle Use
(Retractions)
No retractions
Mild
(Abdominal)
Moderate
(some
intercostal,
subcostal)
Severe
(obvious
intercostal,
subcostal,
tracheal, flaring,
seesaw
breathing)
Wheezing
No wheezing or
crackles
Scattered
wheezing with
end expiratory
wheezes and
crackles
Moderate
wheezing
(diffuse
expiratory
wheezing, with
or without
scattered early
inspiratory
wheezing)
Severe
wheezing
(diffuse
inspiratory and
expiratory
wheezing).
Tight/absent
breath sounds.
RAS ≥ 8
Start HFNC 8L/min (infant) or 20L/min (pedi) FiO2 100%
Wean FiO2 to keep SaO2 at 90% to avoid O2 toxicity
NPO for the first 2 hours of HFNC
IV access and start IV fluids, consider NS bolus
Repeat RAS Q 30 minutes x2
Team Huddle (Senior, RT, RN) at 1 hour mark
RAS < 8
RAS ≥ 8
Page PICU Fellow for
transfer to PICU
Space RAS to Q2H
RN can wean FiO2 if SaO2 consistently >90%
Consider switching to PO/NGT feeds if tolerated
RAS ≤ 5 and SaO2 persistently >90 on HFNC 8L/min (infant) or 20L/min (pedi) at 40% FiO2
Discharge Criteria:
• SpO2 ≥ 90%
• Respiratory rate <70 bpm
• Improved work of breathing
• Adequate oral feeding
• Parent education
• Confirmed PCP follow-up
RN pages RT to come assess patient
RT starts weaning HFNC by 1-5L/min Q2-4H until goal of 2L/min is reached
RT may wean quicker if on HFNC 20L/min and wean is being well tolerated
RAS ≤ 5 and SaO2 persistently >90 on HFNC 2L/min 40% FiO2
Switch to standard NC and routine management
CONTACTS: PICU Fellow p21206 Hospitalist on call p21900 Pedi ED attending’s cell (617) 224-2902 RT Ellison 17-18 p24297 RT Pedi ED 24203
2 HFNC sizes: infant size (start at 8L/min) and pediatric size (start at 20L/min).
HFNC wean: RT may wean quicker if clinically indicated and well tolerated by the patient.
(*) Respiratory Assessment Scoring (RAS) system:Adapted from Wang et al. “Observer agreement for respiratory signs and oximetry in infants
hospitalized with lower respiratory tract infections”. Am Rev Respir Dis 1992; 145(1): 106-109.
Protocol adapted from the 2014 AAP Guidelines “The Diagnosis, Management, and Prevention of Bronchiolitis”