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Bronchiolitis
It's a supportive-care illness — your job is to know who needs that support in hospital. Recognise the coryzal infant with cough, fast breathing and crackles or wheeze. Decide on admission using the NICE thresholds, support oxygen and feeding, and avoid the treatments that don't work. Built for revision, not live patient decisions.
Settle them, and check the basics
admit or home?Red flags — what each should make you think
Bronchiolitis usually gets worse before it gets better, peaking around days 3–5. A baby who looks fine on day 2 may need admission on day 4, so safety-netting has to be specific about what to watch for.
Supportive care
- O₂Oxygen if needed
- 🍼Feeding support
- 👃Nasal suction
- CPAPCPAP
- 🩸Capillary gas
- ☎Senior / PICU
Understand the infant
diagnose · assessDiagnosis (NICE NG9)
- Under 2 years (peak 3–6 months), in winter
- 1–3 days of coryza, then persistent cough plus tachypnoea or recession, and wheeze or crackles
- Fever is usually under 39°C — a high fever should make you look for another cause (pneumonia)
Don't give
- Salbutamol, ipratropium, adrenaline (nebulised)
- Steroids, montelukast
- Hypertonic saline
- Antibiotics (unless secondary bacterial infection suspected)
- Chest physiotherapy (unless relevant comorbidity)
Risk factors for severe disease
- Chronic lung disease (including bronchopulmonary dysplasia)
- Haemodynamically significant congenital heart disease
- Age under 3 months
- Prematurity (especially under 32 weeks)
- Neuromuscular disorders, immunodeficiency
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Pauses in breathing, especially in under 6–8 weeks and premature babies, sometimes before other signs.
Observation, apnoea monitoring.
Admit, monitor; stimulation, oxygen, CPAP/PICU if recurrent.
Grunting, severe recession, falling RR from exhaustion, rising CO₂, reduced consciousness.
Capillary/venous gas.
CPAP/high flow, PICU review.
Poor feeding, sweating, tachypnoea, murmur, large liver, poor weight gain.
CXR, ECG, echo.
Cardiology.
Paroxysmal cough with whoop/apnoea (pertussis); fever, mottling, lethargy (sepsis).
PCR, septic screen.
Treat accordingly; notify pertussis.
Investigate — what to order, when, and what it tells you
test with a question in mindUsually none
Capillary gas
Others
How the plan comes together
disposition · handoverhome
Feeding adequately, SpO₂ above thresholds, no apnoea, mild distress, parents able to cope.
Safety-net: worsening breathing (grunting, recession), pauses in breathing, blue lips, feeding under half usual, no wet nappy for 12 h, exhaustion.
admit
Apnoea, persistent low SpO₂, inadequate feeding, severe distress; lower threshold for high-risk infants or social concerns.
Hand over: day of illness, feeds, oxygen requirement, apnoeas, risk factors.
Supportive care only: oxygen if below the thresholds, feeding support, suction if needed, and no nebulisers or steroids. Safety-net properly, because it peaks around day 3–5. Nicely done getting here.
Clerking template
copy or downloadBronchiolitis — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 10 knownFrequently asked questions
quick answersWhat are the red flags for bronchiolitis?
- Apnoea (seen or reported) — think admit — high risk
- SpO₂ persistently below 90% (or 92% if under 6 weeks/high risk) — think admit for oxygen
- Feeding below 50–75% of usual — think admit for feeding support
- Grunting, severe recession, RR above 70 — think severe — consider CPAP
- Under 3 months, born before 32 weeks — think high risk
- Exhausted, rising CO₂ — think impending respiratory failure
What is the initial management of bronchiolitis?
- Oxygen if needed — if SpO₂ persistently below 90% (age 6 weeks+) or below 92% (under 6 weeks or underlying conditions)
- Feeding support — NG or OG feeds if oral intake inadequate; IV fluids if NG not tolerated or impending respiratory failure
- Nasal suction — only if secretions are causing distress or feeding difficulty
- CPAP — if impending respiratory failure
- Capillary gas — if severe respiratory distress or worsening
- Senior / PICU — if CPAP or exhaustion
Always alongside senior support and your local guideline.
What diagnoses must you not miss in bronchiolitis?
- Apnoea — young infants
- Respiratory failure — exhaustion
- Heart failure / congenital heart disease (mimic) — murmur · hepatomegaly
- Pertussis / sepsis (mimics) — paroxysms · unwell
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for bronchiolitis?
- Usually none — Clinical diagnosis.
- Capillary gas — Severe distress, worsening, possible respiratory failure.
- Others — Infection control (cohorting).
Admit or discharge: how is the plan decided for bronchiolitis?
- Home — Feeding adequately, SpO₂ above thresholds, no apnoea, mild distress, parents able to cope.
- Admit — Apnoea, persistent low SpO₂, inadequate feeding, severe distress; lower threshold for high-risk infants or social concerns.
Is there a clerking template for bronchiolitis?
Yes — there is a free clerking template for bronchiolitis on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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