Bronchiolitis (suspected)

Infants, 4 weeks to 12 months, presenting with increased work of breathing, typically in the context of recent respiratory tract infection.

12 months and over, switch to wheeze (including viral induced or suspected asthma) protocol.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort Reduce handling

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning Consider superficial nasal suction Sodium chloride 0.9% nasal drops may be used to clear the airway and support feeding

Breathing

Assessment	Intervention
Severe bronchiolitis: Oxygen saturations less than 90% in room air (RA) Tachypnoea Apnoea Marked chest wall retraction Marked nasal flaring Grunting Marked substernal retractions Irritability or fatigue	Escalate as per local CERS protocol immediately Maintain oxygen saturations at 90% and above If severe respiratory distress with persistent hypoxia, assist ventilation with BVM or T-piece infant resuscitator, e.g. Neopuff™ Cease oral feeds Continuous cardiorespiratory and oxygen saturation monitoring If oxygen saturations remain below 90% following oxygen therapy, prepare for humidified high-flow nasal cannula (HFNC), if treatment is supported by the care facility If HFNC required, insert nasogastric tube for gastric decompression, if indicated
Moderate bronchiolitis: Tachypnoea Moderate chest wall or suprasternal retraction Nasal flaring Brief self-limiting apnoea Oxygen saturation 90–92% in RA Intermittent irritability	Close nursing observation and reassess for deterioration Manage as for severe bronchiolitis if oxygen saturations fall below 90% Small frequent feeds
Mild bronchiolitis: Respiratory rate normal to mild tachypnoea Nil to mild chest wall retraction Oxygen saturations over 92% in RA Grizzly

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern Consider 12 lead ECG
IVC and/or pathology	Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL

Disability

Assessment	Intervention
AVPU	If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses
NBM	Consider clear fluids or NBM based on red flags and clinical severity

Glucose

Assessment

Intervention

BGL

Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: milk feed and/or 40% glucose gel, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access escalate as per local CERS protocol

Focused assessment

Complete a respiratory focused assessment.

Complete a dehydration focused assessment.

Precautions and notes

• Bronchiolitis should be managed symptomatically.
• Tests are not routinely performed.
• Peak severity is usually at around day two or three of the illness.
• Dehydration can occur secondary to bronchiolitis.
• Differential diagnoses may share some common presenting features with bronchiolitis, including pneumonia, congestive heart failure, pneumothorax and foreign-body inhalation.

Interventions and diagnostics

Specific treatment

• Infants with severe bronchiolitis will require hydration via a nasogastric tube (NGT) or IV. Escalate as per local CERS protocol for advice.
• A period of observation may be required to assess oxygenation and hydration status.
• Provide oxygen support as needed.
• Sodium chloride 0.9% nasal drops can be used to aid in nasal clearance for feeding.
• Consider nasogastric feeding if infant is tiring, or not tolerating oral feeds.

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Analgesia

If pain score 1–6 (mild–moderate):

Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg

and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg

If severe pain present, give analgesia and escalate as per local CERS protocol.

Consider non-pharmacological pain relief (appendix).

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Procedural analgesia

For pain relief required during procedures only, not used to replace appropriate analgesia.

Sucrose 24%

• 1–18 months: give 1–2 mL orally per procedure
• Maximum dose:
  • 1–3 months: up to 5 mL in 24 hours
  • 3–18 months: up to 10 mL in 24 hours.

Repeat as needed up to the maximum dose.

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Radiology

Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.

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Pathology

Not usually indicated. If there is concern for urgent pathology, escalate care as per local CERS protocol.

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au