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Referral and warning signs
When to refer
Referral to hospital (HC4/H) indicated for: Severe bronchiolitis criteria met (SpO2 <92%, RR >60-70, severe retractions, inability to feed, apnoea, cyanosis). Underlying high-risk conditions (prematurity <32wks, age <3mo, chronic lung/heart disease). Dehydration requiring IV fluids/NG feeding. Diagnostic uncertainty.
Red flags
- SpO2 <92% on room air
- Severe respiratory distress (marked retractions, grunting, nasal flaring, RR >70)
- Apnoeic episodes
- Cyanosis
- Inability to feed / Signs of dehydration
- Lethargy or reduced responsiveness
Signs and symptoms
- Initial phase (1-3 days): Upper respiratory symptoms (rhinorrhea, cough, low-grade fever) - resembles common cold.
- Progressive phase: Increased cough, tachypnea (rapid breathing), expiratory wheezing, fine inspiratory crackles.
- Respiratory distress: Nasal flaring, intercostal/subcostal retractions, grunting.
- Feeding difficulties due to breathlessness.
- Apnoea (especially in young infants <3 months or premature).
- Severity criteria: Age <3mo, worsening condition, pallor/cyanosis, severe distress, RR >60, feeding difficulty, SpO2 <92%.
Risk factors
- Age < 6 months (peak 3-6 months)
- Prematurity
- Chronic lung disease (e.g., bronchopulmonary dysplasia)
- Congenital heart disease
- Immunodeficiency
- Exposure to tobacco smoke
- Crowded living conditions / Daycare attendance
- Lack of breastfeeding
Diagnosis
Clinical assessment
Diagnosis is primarily clinical, based on age (<2 years, peak <6 months), typical seasonal occurrence (often rainy season), history of initial URI symptoms followed by lower respiratory signs (wheeze, crackles, tachypnoea, retractions). Differential diagnosis: Asthma (usually older children, recurrent episodes, better response to bronchodilators), Pneumonia (high fever, focal crackles/consolidation signs), Foreign body aspiration (sudden onset choking/cough), Heart failure, Pertussis.
Investigations
- Pulse Oximetry (SpO2): Essential for assessing severity/hypoxia.
- Chest X-ray: Not routinely recommended for typical cases. Consider if diagnosis uncertain, severe disease, or suspecting complications (pneumonia, atelectasis). May show hyperinflation, peribronchial thickening, atelectasis.
- Nasopharyngeal Aspirate (NPA) for virology (e.g., RSV antigen test or PCR): Can confirm viral etiology but usually doesn't change management.
- Blood tests (CBC, blood gas): Usually not needed unless severely ill or complications suspected.
Diagnostic criteria
Clinical diagnosis based on typical age, history, and examination findings (tachypnoea, wheeze, crackles, retractions) in an infant/young child.
Management
Non-pharmacological management
- Supportive Care (Mainstay of treatment):
- - Maintain adequate hydration: Encourage continued breastfeeding/oral fluids in small, frequent amounts. NG tube feeding or IV fluids if unable to feed orally due to respiratory distress.
- - Nasal Suctioning/Saline Drops: Clear nasal secretions to ease breathing and feeding.
- - Oxygen Therapy: Supplemental humidified oxygen via nasal prongs/cannula to maintain SpO2 ≥92% (or per local guideline).
- - Minimal handling to reduce distress.
- - Monitor respiratory status (RR, work of breathing, SpO2), hydration, and feeding.
Pharmacological treatment
- Bronchodilators (Salbutamol): Routine use NOT recommended. A trial may be considered (e.g., 2 puffs via spacer Q30min initially or nebulized 2.5mg); continue ONLY if objective clinical improvement observed (reduced work of breathing, improved SpO2). Stop if no response.
- Nebulized Adrenaline (Epinephrine): May provide short-term benefit in moderate-severe cases (0.4 mg/kg, max 5mg of 1:1000 solution diluted in NS, nebulized Q2-4H). Use with caution, monitor heart rate.
- Hypertonic Saline (3%) Nebulization: May improve mucociliary clearance and reduce length of stay in hospitalised infants (requires multiple doses/day - specialist use).
- Corticosteroids (Systemic or Inhaled): NOT recommended.
- Antibiotics: NOT recommended unless strong suspicion of secondary bacterial pneumonia.
- Antivirals (e.g., Ribavirin): Limited role, only considered for very high-risk infants by specialists.
- Fever management: Paracetamol if fever causing distress.
Monitoring
- Respiratory rate, work of breathing (retractions, flaring).
- Oxygen saturation (SpO2).
- Heart rate.
- Hydration status (urine output, mucous membranes).
- Feeding tolerance.
- Level of activity/alertness.
Complications
- Apnoea
- Respiratory failure
- Dehydration
- Secondary bacterial pneumonia
- Atelectasis
- Otitis media (common co-infection)
Prevention
- Handwashing (RSV spreads via droplets/contact).
- Avoid exposure to tobacco smoke.
- Breastfeeding.
- Avoid contact with individuals with respiratory infections.
- Palivizumab prophylaxis (monoclonal antibody): For selected high-risk infants (very premature, chronic lung disease, certain heart conditions) during RSV season (specialist decision, expensive).
Patient education
- Explain bronchiolitis is usually viral (like a cold in the chest for babies).
- Antibiotics are not usually needed.
- Focus on supportive care: nasal suctioning, hydration, monitoring.
- Teach parents signs of worsening respiratory distress and when to seek urgent care.
- Explain feeding strategies (small, frequent feeds).
- Advise on prevention (handwashing, avoiding smoke/sick contacts).
- Reassure that most infants recover fully, though cough/wheeze may linger.
Uganda-specific notes
Common cause of infant hospitalisation, especially during rainy seasons. Oxygen therapy and fluid management are key interventions. Bronchodilators often trialed but should be stopped if ineffective. Steroids/antibiotics generally not indicated.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 5, Section 5.2.1