Last reviewed: March 2026
Contents
MDM Templates
Bronchiolitis — Mild (Discharge)
Infant presents with URI symptoms progressing to cough, wheezing, and tachypnea consistent with bronchiolitis. Well appearing, no hypoxia on room air, tolerating feeds, no apneic episodes.
Wheezing in the setting of URI symptoms in this age group consistent with viral bronchiolitis. Not consistent with asthma, foreign body aspiration, congenital heart disease, vascular ring, or GERD.[1]
Plan: Supportive care education — nasal suctioning, small frequent feeds, humidified air. Discharge with PCP follow-up within 48 hours. Return precautions for increased work of breathing, poor feeding, apnea, color change, or worsening symptoms (typically days 3-5 are the worst).
Bronchiolitis — Moderate (Admit)
Infant presents with bronchiolitis with persistent hypoxia requiring supplemental oxygen, or poor oral intake with signs of dehydration. Does not meet discharge criteria given ongoing oxygen requirement or inability to maintain adequate hydration.
Plan: Admit for supplemental oxygen, nasal suctioning, and hydration support (IV or NG). Respiratory viral panel for cohorting purposes. No routine albuterol, steroids, or antibiotics.[1]
Bronchiolitis — Severe (PICU)
Infant with bronchiolitis and significant respiratory distress with increasing oxygen requirement despite standard nasal cannula. Recurrent apnea or signs of impending respiratory failure.
Plan: HFNC at 1-2 L/kg/min, PICU admission for close respiratory monitoring.[2]
If worsening on HFNC: Consider CPAP/BiPAP. Intubation as last resort — most infants improve with HFNC alone.
Clinical Education
Diagnosis — Clinical, Not Labs
Bronchiolitis is a clinical diagnosis: first episode of wheezing in a child <2 years with a viral URI prodrome. No labs or imaging needed to make the diagnosis. CXR is not routinely indicated — it increases unnecessary antibiotic use without changing outcomes.[1]
Wheezing WITHOUT URI symptoms is NOT bronchiolitis. Consider asthma, foreign body, cardiac disease. The viral prodrome (rhinorrhea, cough, low-grade fever) is essential to the diagnosis.
Viral panel is not routinely needed in the ED — it does not change management. May be useful for cohorting if the patient is being admitted. RSV season is typically November through March.
What Works
The treatment of bronchiolitis is supportive. There is no pharmacologic therapy that shortens the disease course.[1]
| Intervention | Recommendation | Evidence |
| Nasal suctioning | YES — first-line | Improves feeding and breathing. Infants are obligate nasal breathers. |
| HFNC | YES — if hypoxic/severe | Only intervention shown to reduce intubation in severe bronchiolitis.[2] |
| Supplemental O2 | YES — if SpO2 <90% | AAP threshold is 90%. Many institutions still target 94%.[1] |
| IV/NG fluids | YES — if not tolerating PO | Maintain hydration. NG preferred over IV if gut is functional. |
What Doesn’t Work
Most pharmacologic interventions have been studied and shown no benefit in bronchiolitis. Prescribing these wastes resources and gives families false expectations.[3]
| Intervention | Recommendation | Notes |
| Albuterol | NOT recommended routinely | May trial once — if no improvement, stop. Exception: concurrent RAD/asthma suspected.[3] |
| Racemic epinephrine | NOT recommended | Temporary improvement only, no change in outcomes. |
| Hypertonic saline | NOT for ED use | May help admitted patients with repeated doses. No benefit from single ED dose. |
| Corticosteroids | NO | No benefit in bronchiolitis. Do not give unless you are reclassifying as asthma.[4] |
| Antibiotics | NO | Unless bacterial coinfection identified (concurrent UTI, AOM). |
| Chest physiotherapy | NO | No evidence of benefit. |
High-Risk Features
These patients have a lower threshold for admission and observation: age <12 weeks (highest risk for apnea and severe disease), prematurity (<37 weeks GA), congenital heart disease, chronic lung disease/BPD, immunodeficiency, and neuromuscular disease.[1]
Age <12 weeks deserves special attention. Young infants are at highest risk for apnea as a presenting symptom of bronchiolitis, and their small airways are most susceptible to obstruction from inflammation and mucus.
Apnea in Bronchiolitis
Apnea can be the presenting symptom of bronchiolitis — especially in young infants (<2 months) and premature infants. RSV-associated apnea may precede other respiratory symptoms by 24-48 hours.[5]
Any infant with an apneic episode in the setting of bronchiolitis requires admission for cardiorespiratory monitoring. This is not the same as periodic breathing (normal brief pauses <20 seconds without desaturation or color change).
When to Admit
Admission criteria: SpO2 <90% persistently (or <94% depending on institutional practice), unable to maintain oral hydration, moderate-severe work of breathing not improving with suctioning, apnea or history of apnea, age <12 weeks, high-risk comorbidities, unreliable follow-up or caretaker unable to perform suctioning at home.[1]
The AAP guideline says SpO2 ≥90% is acceptable for discharge. This is more permissive than many providers are comfortable with. The guideline acknowledges that transient desaturations are common and do not correlate with disease severity. Continuous pulse oximetry may prolong hospital stays without improving outcomes.
The Bronchiolitis-Asthma Overlap
First wheezing episode + URI + age <2 = bronchiolitis. Recurrent wheezing episodes, atopic history (eczema, food allergies, family history), and older age favor reactive airway disease or asthma.
If in doubt, trial albuterol once. If dramatic improvement, the child may have asthma or RAD rather than pure bronchiolitis — and steroids become appropriate. If no improvement, stop albuterol and treat as bronchiolitis. Do not give steroids for bronchiolitis just because you are uncertain about the diagnosis.[4]
References
- Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502. PubMed
- Franklin D, Babl FE, Schlapbach LJ, et al. A randomized trial of high-flow oxygen therapy in infants with bronchiolitis. N Engl J Med. 2018;378(12):1121-1131. PubMed
- Gadomski AM, Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2014;(6):CD001266. PubMed
- Fernandes RM, Bialy LM, Vandermeer B, et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2013;(6):CD004878. PubMed
- Zorc JJ, Hall CB. Bronchiolitis: recent evidence on diagnosis and management. Pediatrics. 2010;125(2):342-349. PubMed
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