Background: Bronchiolitis, in which 80% of cases are caused by the Respiratory syncytial virus, is a very common lower respiratory tract infection affecting infants under two years of age. Almost 1 in 3 children develop bronchiolitis in their first year of life, and in general, 2-3% require admission, creating a huge healthcare burden.
To standardise care, NICE issued a guideline in 2015, giving clear recommendations on assessment, diagnosis and management of bronchiolitis. This audit aims to evaluate the investigations and management of infants with bronchiolitis in Royal Devon and Exeter (RD&E) Paediatric Department during the 2024–2025 season and measured against recommendations from the NICE guideline. Areas of improvement are also identified to further promote safe and evidence-based care.
Method: A retrospective review was conducted using a patient list of children under five years with a positive RSV screen between November 2024 and January 2025. Patients over two years or lacking a paediatric clerking note were then excluded, resulting in 231 cases. A data collection tool was formulated based on the NICE guideline, recording patient demographics, presenting symptoms, examination findings, and management. Specific management strategies assessed included the use of chest X-rays, antibiotics, corticosteroids, inhalers, oxygen therapy, and blood tests. Collected data were then compared against NICE recommendations.
Results: Despite NICE guidance against routine imaging, 46 patients (19.7%) underwent CXR, most frequently in those aged over one year. Of these, 36 were subsequently prescribed antibiotics. In total, 64 patients (27.5%) received antibiotics, considerably higher than the expected 4% rate of bacterial co-infection. 28 children were prescribed antibiotics without imaging, and 12 were commenced in the community, and continued in hospital despite a bronchiolitis diagnosis.
Antibiotics prescribed were inconsistent, with a wide range of choices and durations. Oxygen therapy was given to 105 patients, but only 52 had saturations persistently <90%, suggesting potential overuse. Blood tests were performed in 48 patients (20%), mainly as blood gases, despite guidance against it being routinely done. These investigations were more common in severe cases, with many of the tested patients later requiring high-flow oxygen support. (table 1)
Conclusion: This audit highlights the variation from NICE guidelines that RD&E had in bronchiolitis management. Imaging and antibiotics were given more frequently than recommended by NICE, leading to potential unnecessary ionising radiation and overtreatment. To address this, a local guideline with flowcharts will be highly recommended to standardise care within the department, with particular focus on imaging and antibiotic prescribing. Community-initiated antibiotics should also be stopped once bronchiolitis is confirmed.
To evaluate the impact of these interventions and ensure safety and ongoing quality improvement, a re-audit after the next bronchiolitis season should be done.
