Noisy Breathing/
Croup Congenital Anomaly Airway Hematoma
URI Usually viral
Apnea & Periodic Breathing Periodic Breathing May be normal
-Cessation of breathing > 10-20 sec. Bronchiolitis(RSV)
Cyanosis & Blue Spells Cyanosis
Rapid, unlabored respiration Cyanotic Heart Disease (R to L shunt)
Irregular, Shallow Respiration Sepsis
CNS Disease
Metabolic Disorder
Labored breathing w/grunting & retraction Pulmonary Disease Pneumonia




Physical exam

Diagnostic testing

Differential Diagnosis


  1. Stabilize ABCs
  2. Monitor pulse, resp. rate, pulse Ox
  3. Humidified O2 if SaO2 < 95%
  4. Isolate patient in own room, if possible
  5. Bronchodilators controversial
  6. NO role shown for corticosteroids
  7. If RSV washing positive, treat for RSV
  8. If resp failure (PaO2 <50 & PaCO2 >50):
  9. Antibiotics NOT indicated unless signs of infection


  1. Admission criteria
  2. Discharge criteria
  3. Provide parental education

Admit Orders: Bronchiolitis

1. Admit to:

2. Diagnosis: Bronchiolitis

3. Condition:

4. Vital Signs: Call MD if:

5. Activity:

6. Nursing: Pulse oximeter, peak flow rate. Respiratory isolation.

7. Diet:

8. IV Fluids: D5 ½ NS at 125 cc/h.

9. Special Medications:

-Oxygen, humidified 1-4 L/min by NC or 40-60% by mask, keep sat >92%.

Nebulized Beta-2 agonists:

-Albuterol (Ventolin, Proventil) (5 mg/mL soln) nebulized 0.2-0.5 mL in 2 mL NS (0.10-0.15 mg/kg) q1-4h prn.

Treatment of Respiratory Syncytial Virus (severe lung disease or underlying cardiopulmonary disease):

-Ribavirin (Virazole) therapy should be considered in high risk children <2 years with chronic lung disease or with history of premature birth less than 35 weeks gestational age. Ribavirin is administered as a 6 gm vial, aerosolized by SPAG nebulizer over 18-20h qd x 3-5 days, or 2 gm over 2 hrs q8h x 3-5 days.

Prophylaxis Against Respiratory Syncytial Virus:

-Recommended use in high risk children <2 years with BPD who required medical management within the past six months, or with history of premature birth less than or equal to 28 weeks gestational age who are less than one year of age at start of RSV season, or with history of premature birth 29-32 weeks gestational age who are less than six months of age at start of RSV season.

-Palivizumab (Synagis) 15 mg/kg IM once a month throughout RSV season (October-March)

-RSV-IVIG (RespiGam) 750 mg/kg IV once a month throughout RSV season (October to March).

Influenza A:

-Oseltamivir (Tamiflu)

>1 year and <15 kg: 30 mg PO bid

15-23 kg: 45 mg PO bid

>23 - 40 kg: 60 mg PO bid

>40 kg: 75 mg PO bid

>18 year: 75 mg PO bid

[cap: 75 mg; susp: 12 mg/mL]

Approved for treatment of uncomplicated influenza A or B when patient has been symptomatic no longer than 48 hrs. OR

-Rimantadine (Flumadine)

<10 year: 5 mg/kg/day PO qd, max 150 mg/day

>10 year: 100 mg PO bid

[syrup: 50 mg/5 mL; tab: 100 mg].

Approved for treatment or prophylaxis of Influenza A. Not effective against Influenza B OR

-Amantadine (Symmetrel)

1-9 year: 5 mg/kg/day PO qd-bid, max 150 mg/day

>9 year: 5 mg/kg/day PO qd-bid, max 200 mg/day

[cap: 100 mg; syrup: 50 mg/5 mL].

Approved for treatment or prophylaxis of Influenza A. Not effective against Influenza B.


The estolate salt is preferred because of greater penetration.

-Erythromycin estolate 50 mg/kg/day PO q8-12h, max 2 gm/day

[caps: 125, 250 mg; drops: 100 mg/mL; susp: 125 mg/5 mL, 250 mg/5 mL; tab: 500 mg; tabs, chew: 125,250 mg]

-Erythromycin lactobionate (Erythrocin) 20-40 mg/kg/day IV q6h, max 4 gm/day

[inj: 500 mg, 1 gm].

Oral Beta-2 agonists and Acetaminophen:

-Albuterol liquid (Proventil, Ventolin)

2-6 years: 0.1-0. mg/kg/dose PO q6-8h

6-12 years: 2 mg PO tid-qid

>12 years: 2-4 mg PO tid-qid

[soln: 2 mg/5 mL; tabs: 2,4 mg; tabs, SR: 4, 8 mg]

-Acetaminophen (Tylenol) 10-15 mg/kg PO/PR q4-6h prn temp >38̊.

10. Extras and X-rays: CXR PA and LAT, posteroanterior X-ray of neck.

11. Labs: CBC, CBG/ABG, blood culture and sensitivity; UA, culture and sensitivity. Urine antigen screen.


Immunocompetent Patient

A. Therapy with oral acyclovir is not recommended routinely for the treatment of uncomplicated varicella in the otherwise healthy child <12 years of age.

B. Oral acyclovir may be given within 24 hours of the onset of rash. Administration results in a modest decrease in the duration and magnitude of fever and a decrease in the number and duration of skin lesions.

C. Acyclovir (Zovirax) 80 mg/kg/day PO q6h for five days, max 3200 mg/day [cap: 200 mg; susp: 200 mg/5 mL; tabs: 400, 800 mg]

Immunocompromised Patient

A. Intravenous acyclovir should be initiated early in the course of the illness. Therapy within 24 hours of rash onset maximizes efficacy. Oral acyclovir should not be used because of unreliable bioavailability.

Dose: 500 mg/m2/dose IV q8h x 7-10 days

B. Varicella zoster immune globulin (VZIG) may be given shortly after exposure to prevent or modify the course of the disease. It is not effective once disease is established.

Dose: 125 U per 10 kg body weight, IM, round up to nearest vial size to max of 625 U [vial: 125 U/1.25ml].