Emergency Department Clinical Pathway for Evaluation/Treatment of Children with Bronchiolitis

Hydration, nutrition
Supplemental oxygen
Pulse oximetry
Fever Management
Additional Treatment Considerations
  • Albuterol Trial
  • Racemic epinephrine
  • Antibiotics
  • Hypertonic Saline
Further Diagnostic Testing
Consider ED Asthma Pathway if:
  • Recurrent wheezing / prior steroid use
  • Age > 12 months
  • Strong response to albuterol
Consider Suction-bulb

Suction: Bulb

Bronchodilators not recommended for typical bronchiolitis. If used, document reason and response.

  • Suction: Bulb or wall
  • Bronchodilators not recommended for typical bronchiolitis. If used, document reason and response.
  • If no improvement after suctioning, assess with attending at bedside to discuss additional treatment including initiating HFNC oxygen at 1.5 L/kg/minute
  • See Enteral feeding guidelines
  • If required FiO2 > 0.4 or continued severe distress despite increase to 2 L/kg/min / Max HFNC settings, initiate CPAP at 8 cm/0.4 Fio2 and consult PICU.
Discharge Criteria
Admission Criteria
  • Oxygen saturation > 90% awake
  • Adequate oral intake
  • Mild/moderate work of breathing
  • Reliable caretaker
  • Able to obtain follow-up care
  • MDI/spacer teaching if response to albuterol
  • Base decision on:
    • Repeated assessments
    • Response to therapy
    • Stage of illness
  • Admit if discharge criteria not met:
    • Inpatient: Requires O2 or progression expected
    • EDECU: Mild disease with expected LOS < 24 hours
    • ICU: Apnea, severe distress
              Requires HFNC / CPAP / intubation
  • Infants with these risk factors present early in the illness have higher risk of progression:
    • Gestational age < 34 weeks
    • Respiratory rate ≥ 70
    • Age < 3 months
Posted: September 2005
Revised: September 2011, November 2013, November 2015, February 2016, October 2017, November 2017, March 2018, December 2019, July 2021, October 2021
Authors: R. Abaya, MD; K. Crescenzo, RN; E. Delgado, MD; M. Dunn, MD; M. Kerrigan RRT; N. Muthu MD; C. Nelson, MD;
A. Reardon CRNP; B. Rodio, RN; N. Strobel CRNP; D. Simpkins RRT; L. Tyler, RRT; J. Zorc, MD