Clinical Pathways
Clinical Pathways
Not Unstable or in Severe Distress
Not Unstable or in Severe Distress

Not Unstable or in Severe Distress

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Action

  • Obtain history, physical examination, vital signs, pulse oximetry reading, respiratory status, hydration status, and ability to maintain hydration
    • Disease severity is assessed based on history and physical examination. Severe disease (as defined in the 2014 American Academy of Pediatrics guidelines): signs and symptoms associated with poor feeding; respiratory distress characterized by tachypnea, nasal flaring, and hypoxemia.
  • Assess risk for severe bronchiolitis and apnea (See Table 2)
  • Assess the patient frequently (due to variable disease course)
  • Consider nasal suction prior to repeated examinations

Decision

Is there improvement in respiratory status after suctioning?

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No → Arrange for transfer to higher level of care

Background

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Nasal Suction

Nasal suction should be used to clear secretions in infants with acute bronchiolitis if they exhibit respiratory distress or difficulties in feeding or sleeping. This is especially important in younger infants, who are obligatory nose breathers. One study reported that nasal aspiration decreased hospital length of stay; however, routine use of nasopharyngeal suctioning was associated with longer length of stay for patients admitted with bronchiolitis. This same study reported longer length of stays for hospitalized patients when >4 hour lapse in time occurred between suctioning.78^{78} This seemingly conflicting data is likely due to the retrospective nature of the study. Because of the limited studies available, the 2014 AAP guidelines did not make a recommendation for or against the use of suctioning.3^{3}

A small prospective study comparing nasal aspiration to nasopharyngeal suctioning demonstrated that nasopharyngeal suctioning resulted in more mucus removal than nasal aspiration. Nasopharyngeal suctioning had improved lung impedance 30 minutes post suctioning, which was not seen with nasal aspiration. This suggests that nasopharyngeal suctioning may be beneficial in some patients.79^{79}

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References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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Yes, Respiratory Status Improved
Yes, Respiratory Status Improved
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