An 8-month old female is presented to the emergency department (ED) with a 3-day history of reduced feeding and less wet nappies. Accompanied by her parents and 4-year old sister, they report no fever (Temperature is recorded as 37.8C) but are concerned regarding the lack of fluid and dietary intake. Over the last 12-hours they have become more worried about her breathing, which they describe as noisier than normal, and with feeding times becoming more distressing for all, have arrived at the ED for further assessment.
After a full history is taken and careful clinical examination the infant is diagnosed with Bronchiolitis, with moderate respiratory distress (RR 56 bpm, tracheal tug, and some mild nasal flaring), requiring oxygen therapy at 4 Litres in order to support saturation between 94-98%, and less than 3% dehydration (dry lips, reduced/less wet nappies).
Bronchiolitis is a common lower respiratory tract infection causing inflammation of the bronchioles. It affects infants and young children up to the age of 2-years, most commonly appearing between the age of 3 to 6-months (NICE, 2015). The Respiratory Syncytial Virus (RSV) is the commonest pathogen causing bronchiolitis (NICE, 2015; Carande et al, 2016; Vandini, 2016) with resulting peaks in prevalence occurring as expected over the winter months.
Coryzal prodome symptoms usually develop over a few days, climaxing between day 3 and 5 and may include:
- mild fever (only 1/3 of cases will present with fever, usually <39C)
- persistent cough (lasting for up to 3-weeks)
- signs of respiratory distress (commonly: nasal flaring, tracheal tug, costal, intercostal and sternal recession, and head bobbing in infants)
- rapid or noisy breathing (RR>60bpm or apnoea, grunting or widespread wheeze/coarse crackles heard on auscultation)
- difficulty/reduced feeding (less than half the usual amount over the last 2 or 3 feeds)
- reduced or less wet nappies (a dry nappy for 12-hours or more will require fluid challenge in order to establish adequate renal perfusion)
Suspect impending respiratory failure if:
- signs of exhaustion, e.g. floppy, listless or decreasing respiratory effort
- recurrent apnoea/cyanosis
- failure to maintain adequate oxygen saturation despite oxygen therapy
The presence of any of the ‘red flags’ (indicated above in bold) requires referral for paediatric assessment and admission.
Risk stratification for severe illness should also take under consideration those children whose past medical history includes; prematurity (<32-weeks), congenital heart disease, neuromuscular disorders, immunodeficiency and chronic lung disease (NICE, 2015). A lower threshold for admission to hospital with these children should be part of agreed locally protocols.
|+/- fever <39C||high fever >39C||persistent wheeze without crackles|
|Widespread wheeze/crackles||persistent focal crackles||recurrent episodic wheeze|
|atopy (or FH of)|
Treatment and management is predominantly supportive:
|At home||In hospital|
|Saline nasal drops – at least 4-hourly and prior to feeds to dilute secretions||Humidified High Flow Oxygen therapy administered for saturations <92%
(via head-box, nasal speculum, facemask) – consider occasional nasal suctioning and CPAP for those with impending respiratory failure (NICE, 2015)
|Positioning – slightly raise head of cot or mattress with a pillow underneath, sit-up after feeds||PEWS
Continuous pulse oximetry monitoring – consider CBG analysis for children receiving >50% oxygen requirement
|Taking adequate feeds –halve volume but increase frequency||Naso/Ora-gastric tube feeding
Intravenous fluids if required
|Monitor number and weight of nappies||Urinary output monitoring
There is NO place in the treatment and management of bronchiolitis for any of the following (NICE, 2015; Allen, 2016; Carende et al, 2016):
- bronchodilators (Salbutamol, Montelukast)
- nebulised hypertonic saline/adrenaline
- systemic or inhaled corticosteroids
- chest radiograph (X-ray)
- blood tests including routine blood gas analysis
- routine suctioning of secretions/chest physiotherapy
Safe Discharge should include consideration of the environmental factors from the infant/child’s social circumstances that may influence the likelihood of deterioration at home such as; confidence of the parent, parent smokers, ‘damp’ living conditions (NICE, 2016).
Most infants/young children will be presented to the ED at the peak of their symptoms, following comprehensive assessment it is possible to select those who are safe to manage at home, supported by clear aftercare advice and discussion of ‘red flags’ that would support immediate return for re-assessment and potential admission (NICE, 2015).
Allen, D. (2016) Bronchiolitis. Nursing Children and Young People, 28(8):11
Carande E.J., Pollard, A.J. and Drysdale, S.B. (2016) Management of Respiratory Syncytial Virus Bronchiolitis: 2015 Survey of Members of the European Society for Paediatric Infectious Diseases. [on-line] Canadian Journal of Infectious Diseases and Medical Microbiology https://www.hindawi.com/journals/cjidmm/2016/9139537/abs/ (accessed 2/12/16)
Driscoll, J. (2007) Practicing clinical supervision: a reflective approach for healthcare professionals (2nd edition). Elsevier, Edinburgh
National Institute for Clinical Excellence (NICE) (2015) Bronchiolitis in children: diagnosis and management. [on-line] https://www.nice.org.uk/guidance/ng9 (accessed 2/12/16)
Vandini, S., Faldella, G. and Lanari, M. (2016) Latest options for the treatment of Bronchiolitis in Children. Expert Review Of Respiratory Medicine 10:4