Executive summary
- Clinical diagnosis: typically in infants <2 years (peak 3–6 months) with coryzal prodrome → cough, tachypnoea, increased work of breathing, and widespread crackles/wheeze.
- Key assessments: work of breathing, respiratory rate, oxygen saturation, and feeding/fluids.
- Most cases are managed at home with safety-netting — but recognise admission triggers early (apnoea, low saturations, severe distress, poor intake).
- Do not prescribe salbutamol, steroids, antibiotics, montelukast, ipratropium, or nebulised adrenaline for routine bronchiolitis.
- Referral/admission thresholds depend on age and comorbidity; saturations are interpreted differently in <6 weeks or significant underlying disease.
Assessment in primary care
- Feeding: quantify intake (rough % of usual), vomiting, wet nappies/urine, dehydration signs.
- Breathing: RR, recession, nasal flaring, grunting, apnoea (reported or observed), cyanosis, fatigue.
- Pulse oximetry: helpful if available; interpret alongside clinical picture and age/comorbidity.
- Risk factors for severe disease: prematurity (esp <32 weeks), age <3 months, chronic lung disease, haemodynamically significant CHD, neuromuscular disease, immunodeficiency.
- Differentials: pneumonia, sepsis, congenital heart failure, inhaled foreign body, pertussis, early asthma/recurrent viral wheeze (older children).
When to refer / admit (high-yield thresholds)
- Consider hospital referral if RR >60, clinical dehydration, marked feeding difficulty (e.g., ~50–75% of usual), or persistent oxygen saturation <92% in air.
- Admission is likely if apnoea, severe distress, or persistently low saturations: <90% (≥6 weeks) or <92% (<6 weeks or any age with underlying conditions).
- Social factors matter: carer confidence, ability to recognise red flags, and distance to care should influence decisions.
Home management + safety-netting
- Supportive care: small frequent feeds, manage nasal congestion (gentle suction where appropriate), avoid smoke exposure.
- Antipyretics: if fever/distress (dose by weight; follow local paediatric formulary).
- Red flags for urgent review: apnoea, cyanosis, severe recession/grunting, exhaustion, poor intake with dehydration, or worsening breathing.
- Explain trajectory: often peaks day 3–5; cough may persist for weeks even as breathing improves.
Frequently asked questions
Should I try salbutamol “just in case”?
Not for routine bronchiolitis. NICE advises against bronchodilators and other ineffective therapies; focus on supportive care and appropriate escalation.
What saturation threshold should trigger escalation?
Persistently <92% in air is a common referral trigger; admission thresholds are <90% in air for children ≥6 weeks and <92% for babies <6 weeks or any age with significant underlying conditions (use clinical judgement and local policy).
When should I worry about apnoea?
Any observed or reported apnoea is a significant risk marker and usually warrants hospital assessment.
Do antibiotics help?
Not routinely. Consider only if a bacterial complication is suspected (e.g., pneumonia/otitis) with supportive clinical evidence.
How do I counsel parents tonight?
Explain supportive care, expected peak around days 3–5, and give explicit red-flag return advice (breathing effort, colour, apnoea, feeding/urine).
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.