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PEDIATRICS AND NEONATAL NURSINGISSN 2377-1569Review*Corresponding authorHala Mohamed Assem, MDProfessor of PediatricsFaculty of MedicineBeirut Arab University (BAU)Fouad Arslan street, Beirut, Lebanon;Professor of PediatricsFaculty of MedicineAlexandria UniversityAlexandria, EgyptTel. 00961 76729768E-mail: [email protected];[email protected] 2 : Issue 1Article Ref. #: 1000PNNOJ2108Article HistoryReceived: April 2nd, 2015Accepted: April 29th, 2015Published: April 30th, 2015CitationAssem HM. Nursing care of infantsand children with bronchiolitis. Pediatr Neonatal Nurs Open J. 2015; 2(1):43-49. doi: 10.17140/PNNOJ-2-108Open ng Care of Infants and Children WithBronchiolitisHala Mohamed Assem1,2*1Professor of Pediatrics, Faculty of Medicine, Beirut Arab University (BAU), Fouad Arslanstreet, Beirut, Lebanon2Professor of Pediatrics, Faculty of Medicine, Alexandria University, Alexandria, EgyptABSTRACTBronchiolitis is the most common cause of lower respiratory infection in the first yearof life. It is a leading cause of acute illness and hospitalization for infants and young childrenworldwide. Previous studies have demonstrated that at least 1% of children younger than 24months of age are hospitalized for bronchiolitis. These hospitalizations have been found to consume a significant amount of health care resources. The primary treatment of bronchiolitis remains largely supportive with administration of fluids and supplementary oxygen, observationand mechanical ventilation if needed. Other types of treatment remain controversial. Successfultreatment of this diagnosis requires coordination of care of a multidisciplinary team. Pediatricnurses and advanced practice pediatric nurses in both primary and acute care clinical settingscan play a major role in educating other health care professionals on the use of Evidence-basedpractice and why it is important to decrease costs and improve patients’ outcome by changingthe traditional and habitual use of diagnostic and therapeutic options that are no longer recommended by the most recent guidelines. The purpose of this review was to identify the bestevidence available for the updated management of infants and children with bronchiolitis. Thisupdated simplified management of infants with bronchiolitis would result in not only decreasing the cost of care but also result in a better outcome as mentioned in guidelines according tothe recent literature.KEYWORDS: Bronchiolitis; Respiratory syncytial virus; Bronchiolitis management; Nursingcare.ABBREVIATIONS: RSV: Respiratory Syncytial Virus; LOS: Length of hospital stay; RR: Respiratory Rate; NG: Nasogastric; ADH: Antidiuretic Hormone; HS: Hypertonic Saline; CPT:Chest physiotherapy; ED: Emergency Department; HFNC: Humidified High-Flow Nasal Cannula; CPAP: Continuous Positive Airway Pressure; BPD: Broncho-pulmonary dysplasia; CF:Cystic Fibrosis.EPIDEMIOLOGYCopyright 2015 Assem HM. This is an openaccess article distributed under theCreative Commons Attribution 4.0International License (CC BY 4.0),which permits unrestricted use,distribution, and reproduction inany medium, provided the originalwork is properly cited.Pediatr Neonatal Nurs Open JRespiratory Syncytial Virus (RSV) accounts for 60-85% of cases. Rhinovirus, humanmetapneumovirus,1 adenovirus, parainfluenza, influenza, paramyxovirus (hMPV), Bocovirusor co-infection occur in 10-30% of cases.2 Associated bacterial infection was observed in 10%of cases.2-4 The incubation period is approximately 4 days, but the virus can be shed from nasalsecretions for up to 3 weeks.Bronchiolitis is highly contagious. The virus spread from person to person throughdirect contact with nasal or oral secretions, airborne droplets and fomites. RSV found in acuteinfection can survive on hard surface for approximately 6 hours and on soft surfaces for upto30 minutes.5Page 43

PEDIATRICS AND NEONATAL NURSINGISSN 2377-1569Open JournalCLINICAL PRESENTATIONInfants become fussy and have difficulty with feeding.6They are present with low grade fever, hypothermia in youngerinfants, running nose, and irritating cough.7,8 Concomitant otitismedia is common.8 Apnea may occur particularly in low-birthweight and preterm babies.8,9Severe cases may progress over 2 to 5 days to the following signs and symptoms due to spread of virus to lowerrespiratory tract:10 Cough, dyspnea, nasal flaring, tachypnea,tachycardia, irritability, fever, retractions, prolonged expiration,fine crackles (47%), diffuse fine wheezing, hypoxia and overexpanded chest.2,8,11RISK FACTORS FOR SEVERE DISEASELower birth weight, younger gestational age,3 age 12weeks, lower post-natal weight, caesarean section delivery,2underlying cardiopulmonary disease, immunodeficiency,3,12 cystic fibrosis,13 and multiple congenital anomalies.14 The main riskfactor for hospitalization is chronologic age, with 58-64% occurring in first 5 months after birth.15 Other risk factors are positive RSV result, maternal age between 15-19 years, and maternalhistory of asthma and/or smoking.3,1612IMPORTANT NURSING ISSUESGood bed-side nursing care involves the recognition ofdeterioration that will necessitate treatment.8Repeated Clinical AssessmentScheduled intermittent checks of pulse oximetry andheart rate should be done. The use of supplemental oxygen therapy is recommended when SpO2 falls consistently below 90%.Factors to monitor include: cardiopulmonary monitoring, signsof increasing difficulty in feeding and associated risk of pulmonary aspiration, fatigue, work of breathing, and apneic episodes.Minimizing the impact of procedures (e.g. cannulation) as wellas giving support and education to parents is also important.8Nursing Management at HomeHome O2 is increasingly being used in patients withuncomplicated bronchiolitis and on-going hypoxia to reducehospital admission and LOS.3 Health setting at home is focusedon improving respiratory functions, preventing dehydration andpromptly identifying worsening respiratory functions.17 Patientpositioning should promote comfort and breathing. Activity thatinduce agitation should be avoided.3,17Patient EducationEducation should be provided regarding the following: Natural history of bronchiolitis.Pediatr Neonatal Nurs Open Jhttp://dx.doi.org/10.17140/PNNOJ-2-108 Importance of RSV prophylaxis for high-risk patients. Importance of avoiding RSV exposure in the first 2-3 monthsof life and contact with ill people and day-care centers.2 The importance of breast feeding, and avoidance ofsmoke.12,18 The importance of vitamin D supplementation should beemphasized as a prospective birth cohort study demonstrated6-folds risk of bronchiolitis if vitamin D is deficient.19 Methods for limiting transmission (hand washing and avoidingchildcare centers while ill).12 Criteria for return to the ED.2Prevention of nosocomial transmission of infectionThe following actions are needed as: Isolation or cohortnursing away from high risk infants,8 strict hands washing before and after direct contact with objects in the patients’ vicinityand after glove removal.20Alcohol-based rubs or antimicrobial soap should alsobe used21 plus the use of gloves, gowns, and face masks.3,18Nursing role in updating the management according tothe most recent guidelines and in advising other health professionals to omit some unnecessary diagnostic and therapeutic options. The justified use of only 2 or 3 truly needed diagnostictests and also the concentration on the supportive treatment withoxygen, gentle suction and hydration instead of using unnecessary therapeutic options as bronchodilators, antiviral drugs,corticosteroids and/or antibiotics as discussed in the followingsection.DIAGNOSISThe most common tests used in hospitalized cases withbronchiolitis, although most that are unnecessary, are:1. Rapid viral antigen testing of nasopharyngeal secretions forRSV. Although this test has little significance on outcome it mayinfluence treatment as physicians tend to stop antibiotics if it ispositive. However AAP guidelines reported that it is unnecessary 12 as multiple viruses may cause bronchiolitis.3,122. Arterial blood gases: ABG analysis.93. WBCs and differential4. C-reactive protein (CRP level)5. ECG or Echocardiography is reserved to cases with arrhythmia or cardiomegaly.26. Chest radiography: It is not routinely necessary. Findings fromchest radiography are variable. Hyperinflation is usually presentand 20-30% show lobar infiltration, atelectasis or both. Otherfindings are bronchial wall thickening, flattened diaphragm, increased AP diameter, peri-bronchial cuffing, tiny nodules andlinear opacities.227. Pulse oximetry is a good indicator of severity and if it is per-Page 44

PEDIATRICS AND NEONATAL NURSINGISSN n Journalsistently 92% indicates possible need for hospitalization.28. Electrolytes if the child needs IV fluids.39. Blood culture if temp 38.5 ºC.810. Other investigations are done only when needed as: Urineanalysis and culture, CSF analysis and culture or urine specificgravity.2Cultures and chest radiography and even CBC are unnecessary in previously healthy children as the risk of secondary bacterial infection is low.2,22 These tests are considered onlyin severe disease, or very ill appearance, infants 3 months,9pre-existing cardiac or pulmonary disease, a markedly elevatedtemperature or other risk factor of more severe disease or whenalternative diagnosis is suspected.3,8,9HydrationMild cases should be fed more frequently in smalleramounts to be better tolerated and breast feeding shouldn’t besuspended.13 Moderate cases who cannot tolerate oral feedingand RR 50/minute should receive NG feeding.2,18 Intravenousfluids are needed in breathless infants and those with risk of pulmonary aspiration.Overall fluid intake should be restricted to two thirds ofstandard maintenance fluid requirement, with blood electrolytesmonitoring because of the possibility of inappropriate ADHsecretion.3,9,20,25Nasal Suctioning and Saline Nasal DropsIn conclusion, many diagnostic tests for bronchiolitisare not needed in most cases. Diagnosis is based on clinical presentation, patient age, seasonal occurrence and findings from thephysical examination. Few laboratory tests are necessary as oximetry and serum electrolytes. Other tests are sometimes neededto exclude other diagnoses as pneumonia, heart failure or sepsis.Nasal congestion can be reduced by saline nasal drops(1-2 drops per nostril, 10-15 minutes before a feed 2-3 times/day for 3 days in hospitalized infant).2,9,26 Nasal Suctioning maybe used for inpatients. Superficial nasopharyngeal suctioningbefore inhalation and feeding and when needed may improvethe work of breathing and feeding but excessive suctioning mayincrease nasal edema.3,18,26The pediatric nurse has an important role here, to advise other health care professionals to exclude unnecessary diagnostic tests as radiology and viral detection to help to decreasethe cost of managementDeep pharyngeal suctioning is not supported and is evenassociated with longer LOS.20,27-29 The use of antihistamines, immunoglobulins, oral decongestants or nasal vasoconstrictors arenot recommended.12,21TREATMENTHypertonic Saline (HS)DiNicola is an extensive review that states most therapies used to treat bronchiolitis are still controversial.2 The authors addressed that issue extensively and reviewed previousliterature and some of the guidelines till 2014.It enhances mucociliary clearance by decreasing mucusviscosity. Evidence showed that it may decrease LOS by 25%and decrease admission.9,29 In addition, Zhang, et al.30 found thatnebulized hypertonic saline in conjunction with bronchodilatormay be effective in treatment and is better than 0.9% saline.Because no definitive treatment for the specific virusexists, therapy is directed toward symptomatic relief and maintenance of hydration and oxygenation.2,23Supportive CareSupplemental humidified Oxygen via nasal prongs,facemask or head box is the only intervention known to improveoutcome as it decreases V/Q mismatch caused by air trapping3,8and is recommended for previously healthy infants with oxygen saturations 90%21 or 92%.2,8,9 It was reported that, 90-92%in the recovery phase of un-distressed child is accepted.8 Pulseoximetry monitoring is reduced as the clinical condition improves.25As mild hypoxia is a major reason for hospitalization,treatment at home with Home oxygen therapy for those withhypoxia without other indications for admission was found todecrease need for hospitalization by almost 2 days with no difference in outcome.26Pediatr Neonatal Nurs Open JHowever, other studies show no short-term improvement in respiratory distress in ED.12,21 HS is mostly safe withoutbronchodilators, inexpensive and apparently effective as an adjunct treatment in inpatient setting but not in ED.30,32-34As regard mist-steam inhalation, there is insufficientevidence to show any benefit.13Bronchodilators: Short-Acting Beta2-AgonistsBeta-agonist effects reverse bronchoconstriction butevidence showed no difference in: hospital admission, LOS,oxygen saturation, or length of illness.9,18 Some cliniciansfavour a trial of inhaled beta2 agonists in a subset of patients(particularly 12 months age). Positive effects (25%) in clinicalscore after treatment may be observed but it is short-lived andshould be weighed against potential adverse effects.9Therefore it is not recommended for routine use andPage 45

PEDIATRICS AND NEONATAL NURSINGISSN 2377-1569Open Journalexperience suggests only a trial especially in older patients 24months, family history of asthma,12 or past history of wheezingand/or asthma.35,36 Bronchodilators should not be continued unless an objective evidence of improvement is observed.2,21 Recent evidence recommends against even a trial of bronchodilators (AAP Guidelines published online 2014)2,12 as its possibleeffect of small short improvement has