Explainers

Bronchiolitis: Recognise and Assess


This article is intended to be read in conjunction with ‘Paediatric Respiratory Assessment


Starship Hospital’s Clinical Guidelines define bronchiolitis as ‘A viral lower respiratory infection which affects children, usually under 12 months of age, with younger infants often more severely affected’ The literal translation of bronchiolitis is ‘ inflammation of the bronchioles’.

Respiratory syncytial virus (RSV) is one of the most common causes of bronchiolitis, though other respiratory virus’s, such as parainfluenza and adenovirus, can also lead to the infection. It is the most common reason for children under twelve months to be admitted to hospital and is a leading cause of morbidity in this age group.

Children presenting with bronchiolitis may have a fever. They often have a cough and sometimes an audible wheeze or ‘crackles’ on auscultation of the chest. Signs of respiratory distress/work of breathing, such as tracheal tug, nasal flaring, recession and head bobbing in infants are usually present. Vital signs will show tachypnoea, tachycardia and on occasion, hypoxia. Due to the thick secretions associated with bronchiolitis babies may have difficulty feeding. Secretions block the nares making breast and bottle feeding difficult. Babies struggle to breath and feed at the same time and can tire quickly.

The natural course of the illness lasts for seven to ten days, with symptoms worsening on days three and four. The duration of illness is important when assessing severity of illness and the potential for children to become sicker. If you have a sick looking baby on day one or two, then it is likely that they will worsen over the course of the following days.

Assessing Severity

The Starship guidelines have produced the below table to aid clinicians in severity assessment:

Mild Moderate Severe
Wheeze None or end expiratory Entire expiration Inspiratory & expiratory
Feeding Normal Less than usual.

Frequently stops feeding.

More than 1/2 normal feeds.

Not interested.

Gasping/ coughing.

Less than 1/2 normal feeds.

Oxygen No oxygen requirement May require oxygen Requires oxygen
Indrawing No/ mild indrawing Intercostal and/or tracheosternal Severe with nasal flaring
Behaviour Normal Some/ intermittent irritability Irritability and/or lethargy

The Melbourne Royal Children’s Hospital have the below table in their guidelines:

Mild Moderate Severe
Behaviour Normal Some/ intermittent irritability Increasing irritability and/ or lethargy/ fatigue
Respiratory Rate Normal Increased respiratory rate

Tracheal tug

Nasal flaring

Marked increase or decrease

Tracheal tug

Nasal flaring

Accessory Muscle Use None or minimal Moderate chest wall retraction Marked chest wall retraction
Feeding Normal May have difficulty with feeding or reduced feeding Reluctant or unable to feed
Oxygen No oxygen requirement

(Sa02 > 93%)

Mild hypoxemia corrected by oxygen*

(Sa02 90-93%)

Hypoxemia, may not be corrected by oxygen*

(Sa02<90%)

Apnoeic Episodes None May have brief apnoeas May have increasingly frequent or prolonged apnoeas

*A child who has congenital cardiac disease may have low baseline Sa02, e.g. <90% (Note: Correlation between Sa02 and Bronchiolitis severity may vary significantly. Do not use Sa02 as a primary determinant of severity).
Both are similar and appear to be fairly standard guidelines and definitions of severity. Interestingly ,the Royal Children’s Hospital are cautious of using saturation levels as an indicator of severity. Children are very good at compensating for a long time before they drop their saturations. They also recommended that O2 should not be applied for work of breathing alone.

Treatment

Bronchiolitis is caused by a virus and therefore does not respond to antibiotics. Salbutamol has shown to be ineffective in alleviating wheezing. The mainstay of bronchiolitis treatment is the management of symptoms. Minimal handling and a calm, quiet environment has been a long recommended strategy. The more the child becomes distressed, the more they experience respiratory problems.

Bronchiolitis

Normal saline drops to the nares helps loosen secretions to allow feeding. Occasional nasal suctioning may be required. Babies who have severe difficulty feeding may require nasogastric (NG) feeding, either by continuous feed or by bolus feeding. This is often preferable to intraventricular (IVT), as babies still feel hungry and may caused further distress. Of note, frequent small feeds are often preferred over large feeds (either oral or NG) as a distended abdomen can also put pressure on immature lungs and increase respiratory distress.

Nebulised three per cent hypertonic saline is occasionally used. The theory is that this delivery mode will loosen secretions and aid air entry. Although used fairly widely there has been limited evidence for this treatment’s effectiveness. A recent Cochrane review however, did note that hypertonic has been shown to reduce the length of a hospital stay in some infants. Specialised solution should be made up by a pharmacy department.

High flow nasal oxygen is also an emerging treatment in infants with bronchiolitis. This method is used to provide positive end-expiratory pressure (PEEP) and avoid nasal irritation often caused by ‘dry’ oxygen alone. Occasionally administered in the emergency department, it appears to provide relief to infants, and once the nasal cannulas are tolerated, babies seem to settle well. A large prospective randomised control trial is currently underway in Australasia looking at the use of high flow on infants with bronchiolitis.

Conclusion

Bronchiolitis is one of the leading causes of hospitalisation of children under twelve months of age. Knowing how to recognise the severity of infection and manage its symptoms will help nurses to provide the best patient care, particularly in the coming winter months, when the illness is most prevalent.

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References

  • Franklin, D, Dalziel, S, Schlapbach, L, Babl, F, Oakley, E, Craig, S, Furyk, J, Neutze, J, Sinn, K, Whitty, J, Gibbons, K, Fraser, J & Schibler, A 2015, ‘Early high flow nasal cannula therapy in bronchiolitis, a prospective randomised control trail(protocol),’ A paediatric acute respiratory intervention study (Paris), BMC Pediatrics, 15;183, viewed 12 March 2016 bmcpediatr.biomedicalcentral.com.
  • Franz, F, Sheriff, N, Neutze, J, Borland, M & Oakley, E 2008, ‘Bronchiolitis management in pediatric emergency departments in Australia and New Zealand,’ A PREDICT Study Pediatric Emergency Care, vol 24, no 10, pp. 656-658.
  • Starship children’s health clinical guidelines – Bronchiolitis 2010, viewed 20 February 2016 https://www.starship.org.nz/for-hea…s
  • Royal Children’s Hospital Clinical Practice Guidelines, ‘Bronchiolitis,’ Melbourne, viewed 20 February 2016 http://www.rch.org.au/clinicalguide/…tis/
  • Zhang, L, Mendoza-Sassi, RA, Wainwright, C, Klassen, TP 2013, ‘Nebulised hypertonic saline solution for acute bronchiolitis in infants (Review),’ The Cochrane collaboration, John Wiley & Sons, Ltd.

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