Bronchiolitis: Nasal Suctioning, Hydration, and Signs of Respiratory Distress
Teach gentle nasal suctioning with saline drops before feeds and sleep, small frequent feeds, and a wet-diaper count; fewer than 1 wet diaper every 8 hours requires a call. Bronchiolitis is viral, so antibiotics and cough medicines do not help. Call 911 for retractions, grunting, apnea, cyanosis, or an infant too tired to feed.
Who needs this teaching
Parents and caregivers of children under 2 years with bronchiolitis at home. Bronchiolitis is a viral lower respiratory tract infection. Respiratory syncytial virus (RSV) is the most common cause. Inflammation, edema, and mucus obstruct the bronchioles. Symptoms peak on days 3 to 5, and most infants recover within 2 to 3 weeks. Infants under 12 weeks, preterm infants, and infants with chronic lung disease or congenital heart disease have the highest risk of severe disease.
The priority teaching points
- Nasal suctioning. Young infants are obligate nasal breathers, and nasal secretions interfere with feeding and sleep. Instill 2 to 3 saline drops in each nostril, wait about 1 minute, then suction gently with a bulb syringe or nasal aspirator before feeds and sleep. Avoid deep suctioning; it irritates the nasal mucosa and increases edema.
- Hydration and feeding. Offer small, frequent feeds, and continue breastfeeding. Tachypnea above 60/min impairs feeding and increases the risk of aspiration (normal awake infant respiratory rate is 30 to 53/min). Count wet diapers. Fewer than 1 wet diaper every 8 hours indicates dehydration.
- Positioning and safe sleep. Hold the infant upright for comfort and feeding while awake. For every sleep, place the infant on the back on a firm, flat surface. Do not elevate the mattress or use wedges, positioners, or car seats for sleep. These increase the risk of sudden unexpected infant death.
- Medications. Antibiotics do not treat a viral infection. The AAP guideline does not recommend albuterol, corticosteroids, or chest physiotherapy for bronchiolitis. Do not give nonprescription cough and cold medicines; they are unsafe for infants and young children.
- Smoke and infection control. Keep the child away from tobacco smoke, vaping aerosol, and wood smoke, which increase the severity of bronchiolitis. RSV spreads by droplets and by contaminated hands and surfaces. Perform hand hygiene before and after contact. Keep the ill child away from young infants and out of child care until the provider advises.
- Prevention. A pregnant client receives the RSV vaccine at 32 to 36 weeks of gestation during the RSV season. Otherwise, the infant receives one dose of an RSV monoclonal antibody (nirsevimab or clesrovimab) before or during the first RSV season, at under 8 months of age. Some high-risk children receive nirsevimab before the second season.
Red flags the parent reports
| Call the provider the same day | Call 911 or the local emergency number |
|---|---|
| Fewer than 1 wet diaper every 8 hours | Retractions: the skin pulls in between or below the ribs |
| Feeding less than half the usual amount | Grunting, nasal flaring, or head bobbing with each breath |
| Any fever in an infant under 3 months: call immediately | Apnea (pauses in breathing) or cyanosis of the lips |
| Fever lasting more than 3 days, ear pulling, or breathing that worsens after improving | Infant too tired to feed, or difficult to arouse |
Teach-back questions
- "Show me how you use the saline drops and the bulb syringe."
- "When will you suction your baby's nose?"
- "How many wet diapers will you look for?"
- "How will you place your baby to sleep?"
- "What does the skin between the ribs look like when breathing is too hard?"
Teaching tips
- Observe a return demonstration of saline drops and bulb suctioning.
- Show the parent what retractions look like.
- Explain that symptoms worsen before they improve, with the peak on days 3 to 5.
- Ask about smokers in the home and offer cessation resources.
Read more on NCLEXPace
- Croup vs Epiglottitis vs RSV: The Airway Question the NCLEX Repeats
- Pediatric Vital Signs by Age: The Only Table You Need
- Infection Precautions: Airborne vs Droplet vs Contact
Sources
- Ralston SL, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502.
- Jones JM, et al. Use of Nirsevimab for the Prevention of Respiratory Syncytial Virus Disease Among Infants and Young Children: Recommendations of the Advisory Committee on Immunization Practices, United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(34):920-925.
- Fleming-Dutra KE, et al. Use of the Pfizer Respiratory Syncytial Virus Vaccine During Pregnancy for the Prevention of Respiratory Syncytial Virus-Associated Lower Respiratory Tract Disease in Infants: Recommendations of the Advisory Committee on Immunization Practices, United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(41):1115-1122.
- Moon RY, et al. Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics. 2022;150(1):e2022057990.
Why this matters for the NCLEX
Teaching is effective when the parent states, "I will put saline drops in and suction my baby's nose before each feeding," and "I will call 911 if the skin pulls in between my baby's ribs." Statements requiring further teaching include, "I will ask for an antibiotic so the virus goes away faster," "I will give a children's cough syrup at bedtime," and "I will prop my baby on a pillow to sleep."
Frequently asked questions
Why does the parent suction before feeds and sleep, and not continuously?
Suctioning before feeds and sleep clears the nasal passages when the infant needs them most. Frequent or deep suctioning irritates the nasal mucosa and increases edema.
Do antibiotics shorten bronchiolitis?
No. A virus causes bronchiolitis. Antibiotics treat only a confirmed bacterial infection, such as acute otitis media.
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