Bronchiolitis — Additional Treatment Considerations — Clinical Pathway: Emergency and Inpatient

Additional Treatment Considerations

May be considered in infants with significant respiratory distress that is not alleviated sufficiently by supportive care interventions.

Albuterol Studies have NOT demonstrated a consistent benefit for albuterol treatment in infants with typical bronchiolitis. An albuterol trial may be considered in children with features suggestive of possible asthma (recurrent wheezing, age > 12 months, prior inhaled corticosteroid use).

Albuterol should NOT be continued if the child does not respond to test dose.
If responsive to albuterol test dose, may continue:
  MDI Frequency of every 1-4 hours as needed
  Intermittent nebulization Frequency of every 2-6 hours as needed
Racemic Epinephrine
  • α and β adrenergic agonist
  • Consider use in children with increasing severe respiratory distress
  • Requires MD order/bedside assessment for administration
  • Provides warmed, humidified air with adjustable oxygen concentration
  • Reduces WOB
  • Indicated only if not responding to supportive care
  • Initiate at 6-8 lpm and adjust as tolerated
  • Refer to HFNC Job Aid for guidelines on use in inpatient settings at CHOP Main. These recommendations are intended for use in an inpatient setting with the ability to escalate support with expedited transfer to an ICU. For community settings without an ICU, consider early transfer if increased support with HFNC is required. View Job Aid
  • HFNC Weaning Recommendations: Bronchiolitis
Hypertonic Saline
  • Current research does not support a role for routine use of hypertonic saline in the ED or inpatient unit.
  • Consider initiating a hypertonic saline regimen (standing every 6-8 hours) in children with a prolonged hospital stay or those not showing improvement over the first 48 hours of admission.