/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/cpg/,/clinical/cckm-tools/content/cpg/respiratory/,

/clinical/cckm-tools/content/cpg/respiratory/name-97752-en.cckm

201712345

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Respiratory

Diagnosis, Management and Prevention of Bronchiolitis - Pediatric - Emergency Department/Inpatient

Diagnosis, Management and Prevention of Bronchiolitis - Pediatric - Emergency Department/Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Respiratory


1
Diagnosis, Management and Prevention
of Bronchiolitis – Pediatric –
Emergency Department/Inpatient
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ...................................................................................................................................... 4
METHODOLOGY ...................................................................................................................... 4
INTRODUCTION ....................................................................................................................... 5
RECOMMENDATIONS .............................................................................................................. 5
Diagnosis .......................................................................................................................... 5
Treatment .......................................................................................................................... 5
Prevention ........................................................................................................................10
UW HEALTH IMPLEMENTATION ............................................................................................11
APPENDIX A. EVIDENCE GRADING SCHEME(S) .................................................................12
REFERENCES .........................................................................................................................14
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

2
Contact for Content:
Name: Kristin Shadman, MD, FAAP- Pediatrics- Hospitalists
Phone Number: (608) 265-8561
Email Address: kshadman@pediatrics.wisc.edu
Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Guideline Author(s): American Academy of Pediatrics
Coordinating Team Members:
Vanessa Tamas, MD- Pediatric Emergency Medicine
Kirsten Koffarnus, CNS- Pediatric General Medicine/Surgery (P5)
Windy Smith, RN- Pediatric General Medicine/Surgery (P5)
Mary Erschen, RN- Pediatric Emergency Services
Rhonda Yngsdal-Krenz, RT- Respiratory Therapy- AFCH
Josh Vanderloo, PharmD- Drug Policy Program
Scott Guetzlaff- Center for Clinical Knowledge Management (CCKM)
Review Individuals/Bodies:
Teresa Darcy, MD- Pathology- General
Laura Bodine, MS, RD, CNSC, CD- Clinical Nutrition
Amy Hood, MPH, RD, CNSC, CD- Clinical Nutrition
MaryAnn Steiner, PharmD- Pharmacy Benefit Management Program
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 01/28/2016)
ξ Interim revisions (01/26/2017; 12/11/2017)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

3
Executive Summary
Guideline Overview
UW Health has developed an internal guideline based heavily on the 2014 American Academy
of Pediatrics Guideline for the Diagnosis, Management and Prevention of Bronchiolitis.1
Key Revisions (2017 Interim Revisions)
1. Addition of guidance for initiation and management of high flow nasal cannula (HFNC).
Key Practice Recommendations
1. Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history
and physical examination.1 (AAP Evidence quality B, strong recommendation) Radiographic or
laboratory studies should not be routinely obtained.1 (AAP Evidence quality B, moderate
recommendation)
2. The respiratory distress of bronchiolitis in the ED or inpatient setting should be assessed
using the standardized Bronchiolitis Scoring Tool (WARM) (Figure 1).2 (UW Health Very low
quality evidence, weak recommendation)
Figure 1. Bronchiolitis Scoring Tool (WARM)
POINTS 0 1 2 Points
Wheeze None End expiration Entire Expiratory/ Any
Inspiratory
Air Exchange
Assess the following
4 chest areas:
- Left and Right Front
- Left and Right Back
Normal One area decreased More than one area decreased
Respiratory Rate
Age 0-6 mo. > 60
Age 6-18 mo. > 50
Age 18-23 mo. > 45
Normal or below
tachypnea threshold
Above tachypnea threshold N/A
Muscle Use
(Retraction) None Sub-costal/intercostal Any neck or abdominal
3. Do not administer albuterol (or salbutamol), or epinephrine to infants and children with a
diagnosis of bronchiolitis.1 (AAP Evidence quality B, strong recommendation) Routine use of
bronchodilators is not recommended, however a single trial of bronchodilators may be
attempted in select patients (e.g., strong family or personal history of wheezing, other
allergic phenotype) or in patients with a WARM score > 4.3-6 (UW Health Very low quality
evidence, weak recommendation)
4. Interventions should include: positioning (flat head of the bed, sniffing position as needed),
saline drops, and gentle nasal suctioning.7,8 (UW Health Moderate quality evidence, strong
recommendation)
5. Suctioning of the nares with a bulb syringe in conjunction with nasal saline should occur
during the following clinical indications (UW Health Very low quality evidence, weak
recommendation):
ξ Before feedings
ξ As needed for increased work of breathing
ξ Before inhalation therapy
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

4


6. Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin
saturation exceeds 90% in infants or children with bronchiolitis.1,9,10 (AAP Evidence quality D,
weak recommendation)
7. HFNC should be initiated in patients > 28 days and < 2 months of age with a diagnosis of
bronchiolitis and increased WOB, despite standard bronchiolitis therapy. (UW Health Very low
quality evidence, strong recommendation)

Companion Documents
1. Bronchiolitis Algorithm (Inpatient)
2. Bronchiolitis Algorithm (Emergency Department)
3. Bronchiolitis High Flow Nasal Cannula (HFNC) Management on General Care Algorithm
4. Palivizumab – Neonatal/Pediatric – Inpatient/Ambulatory Guideline

Scope
Disease/Condition(s): Bronchiolitis

Clinical Specialty: Pediatric Emergency Medicine, Pediatric Hospital Medicine, Family
Medicine, Respiratory Therapy, Nursing

Intended Users: Physicians, Advanced Practice Providers, Nursing, Respiratory Therapists

Objective(s): To provide an evidence-based approach to the diagnosis, management, and
prevention of bronchiolitis.

Target Population: Children with bronchiolitis age 28 days through 23 months without
immunodeficiencies, including HIV infection or recipients of solid organ or hematopoietic stem
cell transplants.

Interventions and Practices Considered:
ξ Nasal suction and WARM assessment
ξ Single administration of albuterol
ξ Palivizumab prophylaxis
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

5



Internally developed recommendations to supplement or support external content were
evaluated by the guideline workgroup using the GRADE grading scheme.

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Introduction
Bronchiolitis is the most common cause of hospitalization among infants during the first 12
months of life. Bronchiolitis is an acute viral infection of the lower respiratory tract, which is
characterized by inflammation, edema, and necrosis of epithelial cells lining small airways,
increased mucus production, and bronchospasm.
Recommendations
Diagnosis
1. Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history
and physical examination.1 (AAP Evidence quality B, strong recommendation) Bronchiolitis is a
clinical diagnosis made by observing the typical signs and symptoms including: rhinitis,
tachypnea, wheezing, cough, crackles, use of accessory muscles, and/or nasal flaring with a
range of severity extending from mild to respiratory failure. Initial assessment should focus
on maintenance of a patient’s airway, cardiopulmonary stability, assessment of respiratory
status, and assuring adequate hydration.
2. It is also important to assess for risk factors of severe disease when making decisions about
evaluation and management.1 (AAP Evidence quality B, moderate recommendation)
Risk factors include:
ξ Age < 12 weeks
ξ History of prematurity < 35 weeks
ξ Underlying cardiopulmonary disease
ξ Immunodeficiency
3. Radiographic or laboratory studies should NOT be routinely obtained including: chest
radiographs, viral studies, cultures of blood, urine or CSF, CBC, BMP (sodium, potassium,
chloride, total carbon dioxide, anion gap, glucose, BUN, creatinine, calcium), and blood
gases.1 (AAP Evidence quality B, moderate recommendation) Laboratory or radiographic studies
may be considered for selected infants if the diagnosis is unclear; when establishing a
definite source of infection would prevent additional unnecessary intervention; if the severity
of disease warrants further investigation; or when the hospitalized child does not improve at
the expected rate. (UW Health Very low quality evidence, weak recommendation)
Treatment
Monitoring
1. Repeated clinical assessment of respiratory status and hydration status is the foundation of
monitoring infants with bronchiolitis.
2. Clinicians may also choose not to use continuous pulse oximetry.1 (AAP Evidence quality D,
weak recommendation) As continuous pulse oximetry has no clear benefit over spot checks,
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

6


spot hemoglobin oxygen saturation (SpO2) checks should occur every 2 hours times two on
admission. Follow up pulse oximetry should occur every 4 hours with vital signs. SpO2
checks should be done for clinical deterioration as needed. Spot checks should also occur
10-15 minutes after oxygen weans. Respiratory rates should be assessed over 1 minute.
3. Consider cardiopulmonary monitoring with continuous pulse oximetry for those patients at
risk for apnea and/or bradycardia. (UW Health Very low quality evidence, weak recommendation)
Risk factors include:
ξ Infants with corrected gestational age (CGA) < 48 weeks
ξ Premature infants with gestational ages less than 35 weeks
ξ Infants with underlying chronic conditions
ξ Infants who are clinically deteriorating.
4. The respiratory distress of bronchiolitis in the ED or inpatient setting should be assessed
using the standardized Bronchiolitis Scoring Tool (WARM) (Figure 1).2 (UW Health Very low
quality evidence, weak recommendation) The WARM is an assessment tool developed by
Cincinnati Children’s Hospital Medical Center.
Figure 2. Bronchiolitis Scoring Tool (WARM)
POINTS 0 1 2 Points
Wheeze None End expiration Entire Expiratory/ Any
Inspiratory

Air Exchange
Assess the following
4 chest areas:
- Left and Right Front
- Left and Right Back
Normal One area decreased More than one area
decreased

Respiratory Rate
Age 0-6 mo. > 60
Age 6-18 mo. > 50
Age 18-23 mo. > 45
Normal or below tachypnea
threshold
Above tachypnea
threshold
N/A
Muscle Use
(Retraction) None Sub-costal/intercostal Any neck or abdominal
TOTAL POINTS

Respiratory Care and Medications
1. Interventions should include: positioning (flat head of the bed, sniffing position as needed),
saline drops, and gentle nasal suctioning.7,8 (UW Health Moderate quality evidence, strong
recommendation) Chest physiotherapy should not be used as there is no evidence to support
routine “deep” suctioning of the lower pharynx or larynx.1 (AAP Evidence quality B, moderate
recommendation) However, suctioning of the nares with a bulb syringe in conjunction with
nasal saline should occur during the following clinical indications (UW Health Very low quality
evidence, weak recommendation):
ξ Before feedings
ξ As needed for increased work of breathing
ξ Before inhalation therapy
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

7


2. Do not administer albuterol (or salbutamol), or epinephrine to infants and children with a
diagnosis of bronchiolitis.1 (AAP Evidence quality B, strong recommendation) Routine use of
bronchodilators is not recommended, however a single trial of bronchodilators may be
attempted in select patients (e.g., strong family or personal history of wheezing, other
allergic phenotype) or in patients with a WARM score > 4.3-6 (UW Health Very low quality
evidence, weak recommendation) The inhalation therapy should not be repeated if there is not
continued improvement by 2 points in the clinical presentation 15 to 30 minutes after the
trial. Inhaled bronchodilators should only be continued if there is a documented positive
clinical response.11 (UW Health Very low quality evidence, strong recommendation) Initial and
repeat evaluation should be performed by the same individual if possible.
3. Nebulized hypertonic saline should not be administered in the emergency department (AAP
Evidence quality B, moderate recommendation); however it may be administered to hospitalized
patients when a length of stay greater than 4 days is anticipated.1 (AAP Evidence quality B,
weak recommendation)
4. Do not administer systemic corticosteroids to patients with bronchiolitis in any setting.1 (AAP
Evidence quality A, strong recommendation)
5. Antibacterial medications should not be administered unless there is a concomitant bacterial
infection, or a strong suspicion of one.1 (APP Evidence quality B, strong recommendation)
6. The use of supplemental oxygen should be based on SpO2 measurements and the clinical
findings of distress. Clinicians may choose not to administer supplemental oxygen if the
oxyhemoglobin saturation exceeds 90% in infants or children with bronchiolitis.1,9,10 (AAP
Evidence quality D, weak recommendation) Oxygen should be initiated for SpO2 consistently
< 90% and titrated by ¼ L increments to keep oxygen saturation between 91-94%. Spot
SpO2 should be checked within 15 minutes of oxygen titration. Oxygen therapy may also be
considered for increased work of breathing or poor feeding unrelated to hypoxia.
The nasal cannula should be removed when oxygen therapy is discontinued. Increasing
need for oxygen supplementation is a sign of potential deterioration and should prompt
clinical evaluation. Greater than ½ LPM of oxygen is a large flow for a 5-7 kg infant and
should prompt clinical evaluation. Use of high flow nasal cannula is possible in select
patients; refer to the following guideline text and policies below.
7. High flow nasal cannula (HFNC) is a method of providing high-flow, high humidity heated air
or oxygen via nasal cannula used to reduce work of breathing in infants with bronchiolitis.12
Although it is commonly used on general care and intensive care units, specific
recommendations for use have not been established due to lack of any randomized trial.12,13
An exact mechanism of action is unknown14; however, proposed mechanisms include (1)
additional end expiratory pressure aids in lung recruitment15,16, (2) increased flow rate
exceeds peak inspiratory flow to more efficiently deliver oxygen to terminal airways16,17 and
(3) moister secretions improve mucociliary clearance.18 Patients may stabilized or improve
within 1-3 hours of initiating HFNC demonstrated by a clinically appropriate reduction in both
heart rate and respiratory rate.16,19
Use of HFNC has been shown to be well tolerated20, improve work of breathing (WOB)19
and may reduce rates of intubation in patients with bronchiolitis.15,21 HFNC should be
initiated in patients > 28 days and < 2 months of age with a diagnosis of bronchiolitis and
increased WOB, despite standard bronchiolitis therapy. (UW Health Very low quality evidence,
strong recommendation) HFNC may be initiated in the ED or on the general care unit.
General care patients must be admitted or transferred to the Pediatric Hospitalist service.
Impact on length of stay and cost has not been established.23
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

8



HFNC should not be used in patients with impending respiratory failure.22 (UW Health Very
low quality evidence, weak recommendation) The use of HFNC is also not recommended in
patients with a history of cystic fibrosis, neuromuscular disorders, chronic lung disease
requiring oxygen or steroid therapy, hemodynamically significant heart disease which is
uncorrected and/or requires cardiac medication, prematurity < 35 weeks, severe respiratory
distress or respiratory failure requiring intubation/ventilation or intensive care. (AAP Evidence
quality B, moderate recommendation) HFNC may be associated with pneumothorax24, however
pneumothorax is also a known rare complication of bronchiolitis.25

Additionally, patients who meet any of the following criteria should not receive HFNC
(UW Health Very low quality evidence, strong recommendation):
(1) Patients transported from outside facilities by CHETA on HFNC or
(2) Those meeting unstable criteria defined as any of the following:
ξ FiO2 > 50% to keep oxygen saturations > 90%;
ξ Apnea;
ξ Altered mental status (irritability, lethargy);
ξ Poor perfusion (cool extremities, capillary refill >3 seconds);
ξ Bradycardia.

HFNC Initiation: Guidelines for optimum use of HFNC including flow, NPO status, feeding, and
monitoring have not been established13. These guidelines were developed from national and
local expert opinion.26 Procedural instructions for initiation on the general care unit are included
within Appendix B and the HFNC Management on General Care Algorithm. (UW Health Very low
quality evidence, weak recommendation)
Patients who respond to HFNC typically have improvements in respiratory rate, heart rate and
WOB within 60-90 minutes; therefore reassessment with a huddle is recommended within that
time frame.27 (UW Health Very low quality evidence, weak recommendation) Patients who do not
have improvement in heart rate or respiratory rate have been identified as more likely to be
require intubation.28 The following patients should be admitted/transferred to the PICU:
ξ severe respiratory distress concerning for impending respiratory failure,
ξ clinically worsening while on HFNC,
ξ meets unstable criteria.

HFNC Weaning: National recommendations for HFNC weaning have not been established.
Therefore, these guidelines are developed from national and local expert opinion.26 Procedural
instructions for weaning on the general care unit are included within Appendix B and the HFNC
Management on General Care Algorithm. (UW Health Very low quality evidence, weak
recommendation)
Weaning should occur quickly in patients who are improving. (UW Health Very low quality evidence,
weak recommendation) FiO2 should be weaned first to keep O2 saturation > 90% until at 30%.
Subsequently, flow should be weaned by 0.5 L every 1-2 hours until < 3 lpm while the patient is
unchanged or clinically improved through assessment of respiratory rate, work of breathing and
WARM score. RT should assess using a WARM score prior to each wean, and not more than
ever 4 hours. WOB and respiratory rate should be assessed within 1 hour of each wean. When
HFNC has been stable at < 3 lpm for 2 hours delivery should transition to standard humidified
nasal cannula. Patients should be transitioned off continuous monitoring to intermittent
monitoring as detailed in standard Bronchiolitis (Inpatient) Algorithm.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

9


Risk of aspiration due to respiratory distress due to bronchiolitis is unknown, although a small
study using tagged video fluoroscopy found no episodes of aspiration or laryngeal penetration in
infants orally feeding.29 Initiation of oral feeds may occur when patient’s respiratory status is
improving and HFNC flow is weaning. (UW Health Very low quality evidence, weak recommendation)
Nurse, physician or speech therapist should observe each feeding while on HFNC for signs of
aspiration (choking, gagging, coughing). Oral feeds should be held if there is concern for
aspiration. (UW Health Very low quality evidence, strong recommendation) Nasogastric feeds may
be considered in patients otherwise improving who have increased work of breathing with oral
feeds. (UW Health Very low quality evidence, weak recommendation)

Nutrition and Hydration
1. Dosing weight should be established based on usual/recent weight and with regard to
hydration status upon admission. Those who are dehydrated on admission should have fluid
replacement. (UW Health Very low quality evidence, strong recommendation)
2. Hydration status should be continually assessed using daily weight measurements and strict
input and output monitoring. (UW Health Very low quality evidence, strong recommendation)
3. Nasogastric or intravenous fluids should be administered in patients who cannot maintain
hydration orally.1 (APP Evidence quality X, strong recommendation) Each patient should be
evaluated for the initiation of enteral nutrition (EN) with regards to risk factors including age,
underlying nutrition status, recent oral intake, stage of illness, and anticipated length of NPO
status. In general for patients who cannot meet nutrition needs through oral intake alone for
more than 2 days, initiate EN support via nasogastric or post-pyloric tube.
4. Exclusive breastfeeding for at least 6 months should be encouraged to decrease the
morbidity of respiratory infection.1 (AAP Evidence quality B, moderate recommendation)

Inpatient Admission
Goals of hospitalization include: careful monitoring of clinical status, maintenance of airway,
treatment of hypoxia, maintenance of adequate hydration, and parental education.

Patients with respiratory symptoms should have contact precautions, in addition to standard
precautions. (UW Health Very low quality evidence, strong recommendation)

Discharge Criteria
Patients should meet the following prior to discharge home (UW Health Very low quality evidence,
weak recommendation):
ξ Respiratory rate less than 70 with an improving clinical status
ξ Near normal work of breathing
ξ SpO2 τ 94% on room air while awake. Lower thresholds while sleeping may be
considered depending upon the phase of the disease
ξ Adequate oral intake to prevent dehydration
ξ Family education including, but not limited to, instruction in use of bulb syringe,
assessing hydration status, and assessing work of breathing
ξ Primary care provider is identified and follow up is scheduled


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

10


Prevention
1. Palivizumab should not be administered to otherwise healthy infants with a gestational age
of 29 weeks, 0 days or greater.1 (AAP Evidence quality B, strong recommendation)
2. Palivizumab should be administered during the first year of life to infants with
hemodynamically significant heart disease or chronic lung disease of prematurity defined as
preterm infants < 32 weeks 0 days’ gestation who require > 21% oxygen for at least the first
28 days of life.1 (AAP Evidence quality B, moderate recommendation)
3. Clinicians should administer a maximum of 5 monthly doses (15 mg/kg/dose) of palivizumab
during the respiratory syncytial virus season to infants who qualify in the first year of life.1
(AAP Evidence quality B, moderate recommendation)
4. All healthcare staff and families should disinfect hands before and after direct contact with
patients, after contact with inanimate objects in the direct vicinity of the patient, and after
removing gloves. Alcohol-based rubs for hand decontamination should be used. If unavailable, soap
and water may be used.1 (AAP Evidence quality B, strong recommendation)
5. Clinicians should inquire about tobacco smoke exposure when assessing the patient for
bronchiolitis.1 (AAP Evidence quality C, moderate recommendation) Counseling should be
provided to caregivers about exposing the patient to environmental tobacco smoke and
smoking cessation.1 (AAP Evidence quality B, strong recommendation)
6. Clinicians and nurses should educate personnel and family members on evidence-based
diagnosis, treatment, and prevention in bronchiolitis.1 (AAP Evidence quality C, moderate
recommendation) Preventive techniques may include any of the following:
ξ Cocooning of the child- avoidance of direct/indirect contact (e.g., avoidance of
kissing, cleaning environmental surfaces)
ξ Limiting interactions with infected patients
ξ Avoiding sharing cups/utensils
ξ Limiting child care and potentially contagious settings (e.g., malls, shopping stores,
etc.)


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

11


UW Health Implementation
Potential Benefits:
ξ Reduction in hospital admissions
ξ Appropriate management of bronchiolitis (e.g., decreased use of albuterol)
ξ Decreased work of breathing following treatment
ξ Reduced rate of intubation (when using HFNC)

Potential Harms:
ξ Overutilization of albuterol

Pertinent UW Health Policies & Procedures
1. UWHC Policy 1.53: Respiratory Care Protocol
2. Respiratory Care Dept. Policy 2.22: High Flow Nasal Cannula
3. Nursing Patient Care Policy 7.21P: High Flow Nasal Cannula for Pediatric Patients

Patient Resources
1. Health Facts For You #7301- Bronchiolitis (English)
2. Health Facts for You #7342- Bronquiolitis (Spanish)
3. Kids Health- Bronchiolitis
4. Healthwise- Bronchiolitis
5. Healthwise- Respiratory Problems, Age 11 and Younger

Guideline Metrics
1. % of patients with bronchiolitis diagnosis and WARM score documented
2. % of patients with a WARM score < 4 who received albuterol

Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline content (such as the following) will be reviewed for consistency and modified as
appropriate.

Delegation Protocols
Respiratory Therapy Treatment for Bronchiolitis – Pediatric – Emergency Department/Inpatient
[136]

Order Sets & Smart Sets
IP – Bronchiolitis – Pediatric – Admission [3902]; ED – Bronchiolitis – Pediatric [5798]

Miscellaneous
RT Flowsheet Rows; Bronchiolitis – Pediatric IPOC

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

12


Appendix A. Evidence Grading Scheme(s)

Figure 3. AAP Grading Scheme






Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

13


Grading of Recommendations Assessment, Development, and Evaluation (GRADE)

Figure 4: GRADE Algorithm

GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations
Strong for using/
Strong against using
The net benefit of the treatment is clear, patient values and circumstances are
unlikely to affect the decision.
Weak for using/
Weak against using The evidence is weak or the balance of positive and negative effects is vague.











Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

14


Appendix B. Procedure for Initiation and Weaning of High Flow Nasal
Cannula (HFNC) in Pediatric Patients with Bronchiolitis

Inclusion Criteria Exclusion Criteria
Age > 28 days and
< 2 months with a
diagnosis of
bronchiolitis and
increased WOB
despite standard
bronchiolitis therapy
ξ History of cystic fibrosis, neuromuscular disorders, chronic lung disease
requiring oxygen or steroid therapy, hemodynamically significant heart disease
which is uncorrected and/or requires cardiac medication
ξ Prematurity < 35 weeks
ξ Severe respiratory distress or respiratory failure requiring intubation/ventilation
or intensive care
ξ Patients transported from outside facilities by CHETA on HFNC
ξ Patients meeting unstable criteria (defined as any of the following):
o FIO2 > 50% to keep saturation >90%,
o apnea,
o altered mental status (irritability, lethargy),
o poor perfusion (cool extremities, capillary refill >3 sec),
o bradycardia.

INITIATION
1) Notify supervising attending physician.
2) Order for HFNC by a resident or attending physician- High Flow Nasal Cannula [RT0071]
3) RT should perform assessment and document WARM score, suction, WARM score, and
reassess for need of HFNC with physician.
4) Make patient NPO, place PIV, and consider normal saline 20 ml/kg bolus.
5) Place patient on continuous cardiopulmonary monitoring with continuous pulse oximetry.
6) HFNC settings:
a) Initiate at 50% FiO2 and titrate to keep oxygen saturation > 90%.
b) Initiate flow settings:
i) 4 lpm 28 days-90 days
ii) 6 lpm 91 days-12 months
iii) 8 lpm 13 months-24 months
7) Reassess patient using a huddle within 60-90 minutes of HFNC initiation.
a) Patients who do not have improvement in heart rate or respiratory rate have been
identified as more likely to be require intubation. The following patients should be
admitted/transferred to the PICU:
i) severe respiratory distress concerning for impending respiratory failure,
ii) clinically worsening while on HFNC,
iii) meets unstable criteria (see exclusions above).

b) ED Huddle
i) If clinically failing, call PICU.
ii) Anticipate floor disposition. RN, RT, EM resident and attending, and accepting floor
resident should huddle post initiation to confirm appropriateness of floor disposition.
Hospitalist attending must accept patient to floor on HFNC and may ask for
additional evaluation by PICU, as needed, to assist with disposition decision-making.

c) Floor Huddle: RN, RT, senior resident should huddle, as well as intern and hospitalist as
available.
i) If clinically failing, call RRT to initiate transfer to PICU.
ii) Hospitalist should be updated after huddle if not available in person.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

15


WEANING
1) Weaning should occur quickly in patients who are improving. FiO2 should be weaned first to
keep O2 saturation > 90% until at 30%. Subsequently, flow should be weaned by 0.5 L
every 1-2 hours until < 3 lpm while patient is unchanged or clinically improved through
assessment of respiratory rate, work of breathing and WARM score.
2) RT should wean oxygen and flow. Changes in flow should be communicated to the bedside
nurse.
3) RT should assess using a WARM score prior to each wean, and not more than ever 4 hours.
4) RN should assess WOB and respiratory rate within 1 hour of each wean.
5) When HFNC has been stable at < 3 lpm for 2 hours delivery should transition to standard
humidified nasal cannula.
6) Patient should be transitioned off continuous monitoring to intermittent monitoring as
detailed in standard Bronchiolitis (Inpatient) Algorithm.
7) Initiation of oral feeds may occur when patient’s respiratory status is improving and HFNC
flow is weaning. Nurse, physician or speech therapist should observe each feeding while on
HFNC for signs of aspiration (choking, gagging, coughing).
a) Oral feeds should be held if there is concern for aspiration.
b) Nasogastric feeds may be considered in patients otherwise improving who have
increased work of breathing with oral feeds.


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

16


References
1. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis,
management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-1502.
2. Ralston SL, Garber MD, Rice-Conboy E, et al. A Multicenter Collaborative to Reduce
Unnecessary Care in Inpatient Bronchiolitis. Pediatrics. 2016;137(1):1-9.
3. Modl M, Eber E, Malle-Scheid D, Weinhandl E, Zach MS. Does bronchodilator
responsiveness in infants with bronchiolitis depend on age? J Pediatr. 2005;147(5):617-
621.
4. Pinto JM, Schairer JL, Petrova A. Duration of Hospitalization in Association with Type of
Inhalation Therapy Used in the Management of Children with Nonsevere, Acute
Bronchiolitis. Pediatr Neonatol. 2015.
5. Mukherjee S, Rutter K, Watson L, Eisenhut M. Adverse effects of bronchodilators in
infants with bronchiolitis. J Pediatr Pharmacol Ther. 2015;20(1):70-71.
6. Gadomski AM, Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database Syst
Rev. 2014;6:CD001266.
7. Schreiber S, Ronfani L, Ghirardo S, et al. Nasal irrigation with saline solution significantly
improves oxygen saturation in infants with bronchiolitis. Acta Paediatr. 2015.
8. Mussman GM, Parker MW, Statile A, Sucharew H, Brady PW. Suctioning and length of
stay in infants hospitalized with bronchiolitis. JAMA Pediatr. 2013;167(5):414-421.
9. Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in
bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-718.
10. Cunningham S, Rodriguez A, Adams T, et al. Oxygen saturation targets in infants with
bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. Lancet.
2015;386(9998):1041-1048.
11. Lugo RA, Salyer JW, Dean JM. Albuterol in acute bronchiolitis--continued therapy
despite poor response? Pharmacotherapy. 1998;18(1):198-202.
12. Pham TM, O'Malley L, Mayfield S, Martin S, Schibler A. The effect of high flow nasal
cannula therapy on the work of breathing in infants with bronchiolitis. Pediatr Pulmonol.
2015;50(7):713-720.
13. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis,
management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-1502.
14. Milesi C, Boubal M, Jacquot A, et al. High-flow nasal cannula: recommendations for daily
practice in pediatrics. Ann Intensive Care. 2014;4:29.
15. Hough JL, Pham TM, Schibler A. Physiologic effect of high-flow nasal cannula in infants
with bronchiolitis. Pediatr Crit Care Med. 2014;15(5):e214-219.
16. Lee JH, Rehder KJ, Williford L, Cheifetz IM, Turner DA. Use of high flow nasal cannula
in critically ill infants, children, and adults: a critical review of the literature. Intensive
Care Med. 2013;39(2):247-257.
17. Haq I, Gopalakaje S, Fenton AC, McKean MC, C JOB, Brodlie M. The evidence for high
flow nasal cannula devices in infants. Paediatric respiratory reviews. 2014;15(2):124-
134.
18. Hasani A, Chapman TH, McCool D, Smith RE, Dilworth JP, Agnew JE. Domiciliary
humidification improves lung mucociliary clearance in patients with bronchiectasis.
Chron Respir Dis. 2008;5(2):81-86.
19. Bressan S, Balzani M, Krauss B, Pettenazzo A, Zanconato S, Baraldi E. High-flow nasal
cannula oxygen for bronchiolitis in a pediatric ward: a pilot study. Eur J Pediatr.
2013;172(12):1649-1656.
20. Hilliard TN, Archer N, Laura H, et al. Pilot study of vapotherm oxygen delivery in
moderately severe bronchiolitis. Archives of disease in childhood. 2012;97(2):182-183.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

17


21. Schibler A, Pham TM, Dunster KR, et al. Reduced intubation rates for infants after
introduction of high-flow nasal prong oxygen delivery. Intensive Care Med.
2011;37(5):847-852.
22. Kelly GS, Simon HK, Sturm JJ. High-flow nasal cannula use in children with respiratory
distress in the emergency department: predicting the need for subsequent intubation.
Pediatric emergency care. 2013;29(8):888-892.
23. Franklin D, Dalziel S, Schlapbach LJ, et al. Early high flow nasal cannula therapy in
bronchiolitis, a prospective randomised control trial (protocol): A Paediatric Acute
Respiratory Intervention Study (PARIS). BMC pediatrics. 2015;15:183.
24. Hegde S, Prodhan P. Serious air leak syndrome complicating high-flow nasal cannula
therapy: a report of 3 cases. Pediatrics. 2013;131(3):e939-944.
25. Silva C, Almeida AF, Ferraz C, Nunes T, Guedes Vaz L. Spontaneous Pneumothorax
With Subcutaneous Emphysema: A Rare Complication of Respiratory Syncytial Virus
Infection. J Clin Med Res. 2016;8(3):260-262.
26. Seattle Children’s Hospital WL, Beardsley E, Chen T, Crotwell D, Ford R, Foti J, Leu M,
Magin J, Ringer C, Roberts J, Slater A Bronchiolitis Pathway. Bronchiolitis Pathway.
2015 November.
27. Mayfield S, Bogossian F, O'Malley L, Schibler A. High-flow nasal cannula oxygen
therapy for infants with bronchiolitis: pilot study. J Paediatr Child Health. 2014;50(5):373-
378.
28. McKiernan C, Chua LC, Visintainer PF, Allen H. High flow nasal cannulae therapy in
infants with bronchiolitis. J Pediatr. 2010;156(4):634-638.
29. Maffey A, Moviglia T, Mirabello C, et al. Swallowing and respiratory distress in
hospitalized patients with bronchiolitis. Dysphagia. 2013;28(4):582-587.


Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Respiratory Care Protocol - Bronchiolitis
NON-Pharmacological Management
Obtain history and
perform physical exam
Meets
criteria?
Inclusion Criteria
ξ Age 28 days to < 24 months
Exclusion Criteria
ξ Intubation or ventilator
ξ Cystic fibrosis, bronchopulmonary
dysplasia (BPD), spinal muscular
atrophy (SMA)
ξ Immunodeficiencies
ξ Chronic Lung Disease
ξ Hemodynamically significant heart
disease
ξ Prematurity with gestational < 35 weeks
ξ Pediatric Intensive Care Unit (PICU)
ξ Severe respiratory distress
Pediatric Emergency Dept. Bronchiolitis Treatment Algorithm
Outside scope.
- Consider PICU consult or
High Flow Nasal Canula
MD activates “Respiratory Care Protocol - Bronchiolitis”
*ED – Bronchiolitis – Pediatric [5798]
ξ RT performs initial assessment including use of Bronchiolitis
Scoring Tool (WARM)
ξ RT suctions nasal passages
ξ RT reassesses when patient calm using WARM tool
WARM
score > 4?
RT order and give single trial of albuterol (2.5 mg, once) via nebulizer.
RT reassess using WARM tool 30 minutes post-
treatment
WARM score
improved by
> 2 points?
Management without inhaled medications:
A)

RN assess and record using WARM tool with Intermittent vitals
B) Perform nasal suction
C) RN reassess and record using WARM tool when patient calm
WARM
score > 4?
Did patient
receive trial
albuterol
dose?
Yes
Yes
Yes
Contact Attending
Yes
No
1. RT notify Resident
2. RT to do the following every 4 hours:
A)

assess using WARM tool
B) nasal suction
C) order and give albuterol via nebulizer (2.5 mg, PRN –
Bronchiolitis Score (WARM) > 4
)
D) reassess (WARM) 30 minutes post treatment*
*If score is < 3, patient to be managed via “NON-pharmacological
Management.” RT to notify Resident/Attending.
No
ξ RN performs initial assessment using Bronchiolitis
Scoring Tool (WARM)
ξ RN perform nasal suction

ξ RN reassess when patient calm using WARM tool
WARM
score > 4?
Proceed to
NON-
Pharmacological
Management
No
Yes
No
No
Proceed to
Respiratory
Care Protocol
- Bronchiolitis
No
Yes
Bronchiolitis – Pediatric – ED/Inpatient Clinical Practice Guideline | Last revised: 01/2016 | Contact CCKM for revisions.
01/2016
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Respiratory Care Protocol - Bronchiolitis
NON-Pharmacological Management
Obtain history and
perform physical exam
Meets
criteria?
AFCH Bronchiolitis Inpatient Treatment Algorithm
Outside scope.
Consider contacting Rapid
Response Team if in severe
respiratory distress.
MD activates “Respiratory Care Protocol - Bronchiolitis”
*IP – Bronchiolitis – Pediatric – Admission [3902]
ξ RT performs initial assessment including use of Bronchiolitis
Scoring Tool (WARM)
ξ RT suctions nasal passages
ξ RT reassesses when patient calm using WARM tool
WARM
score > 4?
RT order and give single trial of albuterol (2.5 mg, once) via
nebulizer.
RT reassess using WARM tool 30 minutes post-
treatment
WARM score
improved by
> 2 points?
RN management without inhaled medications:
A)

Perform nasal suction as needed and before feedings.
*If patient increasing in distress contact RT.
**If patient is in severe respiratory distress contact Resident on Call/Attending
and consider contacting Rapid Response Team.
Yes
No
No
Proceed to
NON-
Pharmacological
Management
1. RT notify Resident
2. RT to do the following every 4 hours:
A) assess using WARM tool
B) nasal suction
C) order and give albuterol via nebulizer (2.5 mg, PRN –
Bronchiolitis Score (WARM) > 4)
D) reassess (WARM) 30 minutes post treatment*
*If score is < 3, patient to be managed via “NON-pharmacological
Management.” RT to notify Resident on call/Attending.
Inclusion Criteria
ξ

Age 28 days to < 24 months
Exclusion Criteria
ξ Intubation or ventilator
ξ Cystic fibrosis, bronchopulmonary dysplasia (BPD),
spinal muscular atrophy (SMA)
ξ Immunodeficiencies
ξ Chronic Lung Disease
ξ Hemodynamically significant heart disease
ξ Prematurity with gestational < 35 weeks
ξ Pediatric Intensive Care Unit (PICU)
ξ Severe respiratory distress
Yes
Contact Resident on
Call/Attending
Yes
Yes
No
Did patient
receive trial
albuterol
dose?
No
Bronchiolitis – Pediatric – ED/Inpatient Clinical Practice Guideline | Last revised: 04/2016
Contact CCKM for revisions.
04/2016
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Bronchiolitis High Flow Nasal Cannula (HFNC) Management on Emergency and General Care Units
Prior to HFNC Initiation:
MD to order (using bronchiolitis order set)
Resident to notify Attending
MD to consider:
ξ Place PIV (consider normal saline bolus)
ξ NPO
In ED:
ξ if unchanged: call PICU
ξ If improving: call pediatric hospitalist attending for
admission. Suction and VS q I hour while waiting to admit
On Floor:
ξ Suction at least q 2 hrs. until off HFNC, with VS q 2 hrs. x 6
hrs., then q 4 hrs unless clinical need for Ĺ frequency
Weaning HFNC on general care unit:
FiO2 should be titrated by RT to maintain saturations>90% q1-
2 hr until 30%
HFNC flow rate should be weaned quickly in improving
patients, including at night. Wean flow by .5 q 1-2 hr until
”3lpm as long as patient is:
ξ Clinically improving
ξ Requiring less than 30% FiO2
ξ WARM score is stable or improving
RT to assess using WARM Score prior to each wean and/or at
least q4 hour
RT to notify RN of any wean in flow
RN assess WOB and RR within 1 hour of wean in flow
When HF1C is stable at ” 3lpm for 2 hours, change to
humidified nasal cannula
ξ In ED: Call PICU if need > flow range
ξ On Floor: Call RRT if need > flow range
ξ Transfer patient to ICU if • Max Flow of:
28 day-3 mo 12 Lpm
3 mo-12 mo 15 Lpm
13 mo-24 mo 20 Lpm
ξ Increase respiratory support with HFNC or other therapies
while awaiting transfer
Sign of clinical improvement (at least one):
ξ Improving WARM Score
ξ Lower respiratory rate (not inappropriately low for age)
ξ Lower heart rate
HFNC Inclusion Criteria
ξ On Pediatric Hospitalist Service
ξ Attending Hospitalist Notified
ξ On bronchiolitis protocol
ξ Age 28 days to < 24 months
HFNC Exclusion Criteria
One of the following:
ξ Patients excluded from bronchiolitis protocol
ξ Transported by CHETA on HFNC
ξ Exceeds Max general care unit flow/age
Meets Unstable Criteria
ξ FIO2 >50% to keep sats >90%
ξ Apnea
ξ Altered mental status (irritability, lethargy)
ξ Poor perfusion (cool extremities, capillary refill >
3 seconds)
ξ Bradycardia
ξ Concern for impending respiratory failure
Initiate HFNC in ED or general floor unit
FiO2 to maintain/titrate sats of > 90%
Age Flow
28 day-3 mo 4 Lpm
3 mo-12 mo 6 Lpm
13 mo-24 mo 8 Lpm
Huddle 60 minutes
post HFNC initiation/change.
In ED: RN, RT, EM resident/
attending and accepting floor
resident
On Floor: RN, CTL, RT,
senior resident
Clinically worsening despite support increase or other clinical
concerns
Clinically unchanged or improving
Criteria for transfer to the ICU:
ξ Clinical worsening on HFNC trial
ξ Meets unstable criteria
ξ Meets General Care Max Flow/age
Criteria for transfer from the ICU to floor:
ξ Meets inclusion criteria, stable on flow rate at or
below the floor maximum for 8-12 hours
ξ If does not meet bronchiolitis HFNC management
on general care units, see HFNC policy
ĹW2B despite standard bronchiolitis care
Is patient
worsening?
Bronchiolitis HFNC algorithm; Dr. Shadman. $dapted from Seattle Children’s
Hospital, Wilson L, etal. Revised 10-17.
No
Yes
ξ Ĺflow for ĹWOB
ξ Ĺ O2 for Ļ% saturations
ξ FYI Care team
In ED: Call PICU if needs Ĺ flow rates
On Floor: Titrate flow to improve/
maintain WOB:
Age FlowRange
28 day-3 mo 4-8 Lpm
3 mo-12 mo 6-12 Lpm
13 mo-24 mo 8-15 Lpm
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org