Intended for healthcare professionals

Practice Change

Avoid doing chest x rays in infants with typical bronchiolitis

BMJ 2021; 375 doi: (Published 22 October 2021) Cite this as: BMJ 2021;375:e064132

Linked Editorial

Sustainable practice: what can I do?

  1. Jeremy N Friedman, associate paediatrician-in-chief1,
  2. Tessa Davis, consultant in paediatric emergency medicine2,
  3. Aarani Somaskanthan, paediatric emergency medicine trainee3,
  4. Amy Ma, co-chair Family Advisory Forum4
  1. 1Paediatrics, Hospital for Sick Children, Toronto, Ontario M3B 3E8, Canada
  2. 2Paediatric Emergency Department, Royal London Hospital, London, UK
  3. 3Sydney Children’s Hospital Network, Australia
  4. 4Family Advisory Forum, Montreal Children's Hospital, Montreal, Quebec, Canada
  1. Correspondence to: J N Friedman jeremy.friedman{at}

What you need to know

  • The diagnosis of bronchiolitis is based on history and physical examination findings and does not require any confirmatory testing

  • Performance of a chest x ray in cases of typical bronchiolitis increases the rate of incorrect diagnosis of bacterial pneumonia and unnecessary use of antibiotics

  • Abnormal chest x ray findings, such as peribronchial infiltrates and atelectasis, are common on imaging in typical bronchiolitis, but abnormalities leading to a new diagnosis are uncommon and likely seen in <1% of cases

Bronchiolitis is a viral lower respiratory tract infection occurring mainly in the winter months, most commonly caused by respiratory syncytial virus (RSV). It is seen primarily in infancy but occurs up to 2 years of age and is the most common indication for hospitalisation in this age group. Ninety percent of children are infected with RSV in their first 2 years, and up to 40% will experience bronchiolitis during the initial infection.1

Bronchiolitis usually begins with a viral upper respiratory tract prodrome (rhinorrhoea and cough) followed by increasing respiratory effort (tachypnoea and/or accessory muscle use) with wheezing and/or crackles heard on chest auscultation. Diagnosis and assessment of disease severity is based on history and physical examination findings and does not require any confirmatory testing (box 1).1

Box 1

Guidance on optimal assessment of infants with bronchiolitis12

  • Typical features include coryzal prodrome followed by persistent cough, tachypnoea and/or chest recession, and wheeze and/or crackles on auscultation. If these are not present consider alternative diagnoses

  • Immediate referral for emergency hospital care if any apnoea, infant looks seriously unwell, severe respiratory distress (such as grunting, marked chest recession, or respiratory rate >70/min, cyanosis, or persistent low oxygen saturations <92%)

  • Consideration for referral to secondary care includes concerns over dehydration or difficulty with adequate oral intake (<75% of usual), or a persistent elevated respiratory rate >60/min

  • Risk factors for more severe illness include …

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