Clinical Guidelines (Nursing)

Bronchiolitis ward management

  • RCH: Consider Criteria Led Discharge

    Introduction 

    Aim 

    Definition of Terms

    Assessment

    Management 

    Special Considerations

    Companion Documents

    Evidence Table


    Introduction

    Bronchiolitis is an acute viral infection of the lower respiratory tract (LRTI).  It generally affects children less than 12 months of age and it is the most frequent cause of hospitalization in infants under 6 months of age. Viruses that enter and infect the respiratory tract cause viral bronchiolitis. Most cases of viral bronchiolitis are due to respiratory syncytial virus (RSV). Viral outbreaks occur seasonally and most affect children under the age of 1 year old.

    The condition is usually preceded by an Upper Respiratory Tract Infection (URTI) and is charactersied by cough, tachypnoea, poor feeding, wheeze, crackles, apnoea, mucus production and inflammation causing obstruction at the level of the bronchioles.  The illness typically peaks around day 3 to 5 with a resolution of the wheeze and respiratory distress over 7 – 10 days. The cough may continue for up to 4 weeks.  

    Bronchiolitis is a self-limiting condition, but can be life-threatening in infants who have been premature or have underlying respiratory, cardiac, neuromuscular or immunological conditions.

    Aim

    To outline hospital management of infants with bronchiolitis admitted to the ward. Children who require additional support may be managed in the Paediatric Intensive Care Unit (PICU) or Neonatal Intensive Care Unit (NICU). 

    Definition of terms

    • CLD – Criteria Led Discharge
    • EMR – Electronic Medical Record
    • FiO2 – Fraction of inspired Oxygen
    • FLOQ – Dry, sterile swab specifically for taking viral samples.
    • HFNP – High Flow Nasal Prongs *High flow is only available in Emergency, SugarGlider, Koala, Rosella and Butterfly *
    • LFNP – Low Flow Nasal Prongs
    • LRTI – Lower Respiratory Tract Infection
    • NG – Nasogastric
    • NP – Nasal Prongs
    • NPA – Nasopharyngeal aspirate ** not routinely required in children with bronchiolitis
    • PICU – Paediatric Intensive Care Unit
    • RSV – respiratory syncytial virus
    • SpO2 – Peripheral Capillary Oxygen saturations – acceptable saturations ≥90% as per oxygen delivery CPG Clinical Guidelines (Nursing) : Oxygen delivery
    • UOAM – Use Of Accessory Muscles
    • URTI – Upper Respiratory Tract Infection
    • ViCTOR – Victorian Children’s Tool for Observation and Response
      • In the event of transgression in the orange and red zones of the chart, please follow local escalation and modification procedures
      • The orange and purple zones in EMR will appear as below:

        EMR OrangeandPurple

    Refer to Clinical Guidelines (Nursing) : Nursing assessment

    History

    • Age - there is a higher risk of severe bronchiolitis if the child is less than 6 weeks of age
    • Duration of symptoms – peak severity is usually around day 3-5 of LRTI symptoms
    • History of prematurity-there is a higher risk of severe bronchiolitis in this patient group
    • History of previous medical conditions
    • Recent intake and output (including feeding history)
    • Family history of atopy or asthma
    • Apnoea - describe number, frequency, duration

    Physical Assessment

    Primary Assessment 

    • Implement Droplet Precautions
      • Wear a gown or apron and surgical mask when within 1 meter of patient and when performing aerosol generating procedures 
    • Assess and Document - admission assessment:
      • Temperature
      • Respiratory rate
      • Heart rate
      • Blood Pressure 
      • Oxygen Saturation (SPO2) and/or Oxygen requirements
      • Pain
      • Level of Respiratory Distress – Assessment of Severity of Respiratory Conditions
      • Central and Peripheral Capillary Refill Time
      • Colour – i.e.: pink, pale, grey, cyanosed, flushed
      • Feeding / Hydration Status / urine output
      • Level of consciousness / irritable/ consolable etc.

    Focused Assessment : Respiratory

    Social History

    • Parents/carers/guardian details
    • Living arrangements / legal orders (if applicable)
    • Siblings
    • Visiting plans
    • Specific cultural requirements

    Nutrition

    • Trial smaller, more frequent feeds if still tolerating oral intake (consider consequences of dehydration, hyponatremia and reduction in total fluid intake)
    • If increased coughing, respiratory distress, apnoeic episodes or visible tiring during oral feeds contact medical team to discuss changing to Nasogastric (NG) feeds
    • “Comfort feeds” refer to small feeds, often 10-30 ml for children with intravenous (IV) therapy, which can settle their hunger.  The child may not be capable of tolerating larger amounts.  They should be given with extreme caution and under strict supervision.
      • Nasogastric feeds Clinical Guidelines (Nursing) : Enteral feeding and medication administration
        • Commence 2 hourly NG bolus feeds with EBM or formula as appropriate, reduce total volume to 2/3 maintenance
        • Consider continuous NG feeds if not tolerating bolus feeds
        • Consideration needs to be made that an NG tube may cause increased resistance in the obligate nose breather.  Observe infant for increased work of breathing post insertion of NG tube and feeds.
      • Intravenous Therapy : Clinical Practice Guideline : Intravenous Fluids 
        • Intravenous therapy may be required for infants with severe bronchiolitis who may not be tolerant of oral or NG feeds

    Investigations 

    • Hydration status : Clinical Practice Guideline : Dehydration
    • Weight 
    • Urea and Electrolytes  – required daily if a child is on IV fluids :Clinical Practice Guideline : Intravenous Fluids
    • FLOQ Swabs-  if requested or Nasopharyngeal aspirates (NPA) - not routinely required
      • Medical indications might include history of apnoea’s, severe or atypical illness or a clinical suspicion of pertussis
    • Chest X-rays – not routinely required but may be performed if clinically indicated
    • Blood gases – not routinely required but may be performed if clinically indicated 

    Management

    Acute management

    • Patient observations Nursing Guideline: Observation and Continuous Monitoring
      • On presentation complete and document a full respiratory assessment and a full set of observations 
      • For infants with mild bronchiolitis 
        • document respiratory assessment and observations every four hours as a minimum
        • offer smaller more frequent oral feeds
        • cluster cares / minimal handling
      • For infants with moderate bronchiolitis
        If patient transgresses into ViCTOR orange zone consider escalation and/or medical modification of patient vital sign: RCH Escalation of Care : ViCTOR 
        • Perform continuous oximetry, frequent respiratory assessment and note effort, document observations hourly
        • Cluster cares / minimal handling
        • Maintain a strict fluid balance chart including the weighing of all nappies and document on fluid balance flowsheet
        • Provide nasal toilets, and gentle nasal suction to clear nasal passages as required
        • Provide effective analgesia - consider use of oral 33% sucrose for procedures 
        • Administer O2 to maintain saturations ≥90%, consider humidification of O2
        • Consider NG insertion if not tolerating oral feeds > 50% of normal volumes, suggested is to provide 2 hourly bolus feed or consider continuous feeds at 2/3 maintenance
      • For infants with severe bronchiolitis: include above management (if patient transgresses into ViCTOR red zone escalate as per: RCH Escalation of Care : ViCTOR)
        • Continuous cardiorespiratory monitoring, respiratory assessment and document 
        • Consider use of High Flow Nasal Prong (HFNP) therapy Clinical Guidelines (Nursing) : High Flow Nasal Prong (HFNP) therapy
        • Discuss with bed card team, PICU involvement, may need to be considered for escalation of respiratory support or transfer
        • Consider stopping NG feeds and PRN aspiration of NG tube to decompress the stomach
        • May need to be considered for IV fluids at 2/3 maintenance to provide adequate hydration (consider risk of SIADH and total fluid intake)
        • Consider nursing patient in the prone position - Educate parents and carers about safe sleeping practices and SIDS recommendations and how the highly monitored hospital environment differs from the home environment 

    Ongoing management

    • Potential complications 
      • Nasal trauma
      • Aspiration
      • Increasing respiratory distress
      • Dehydration
    • Discharge Planning and Criteria Led Discharge (CLD)
      • Infant can tolerate oral feeds >50% of daily requirement
      • Mild or regular work of breathing
      • Infants should be observed for 4 hours post weaning oxygen
      • Criteria Led Discharge (CLD) as per EMR
    • Follow-up / Review
      • Review by local GP if parental concerns 
      • Discharge summary given on discharge
    • Parent / Guardian Education Needs

    Special considerations

    Infection prevention  

    • Bronchiolitis is caused by a viral infection which is transmitted via droplets and is highly contagious
    • When providing direct care staff shall wear face protection, gown or apron, 
    • Place patient in own room, patients may be cohorted based on known clinical diagnosis 
    • On room entry place a transmission based precaution sign Droplet Poster found at Infection Control Signage
    • Educate parents and visitors on hand hygiene and promote cough etiquette
    • Ensure suction catheters / spigots / containers are changed regularly, staff should ensure they wear appropriate eyewear /  mask when suctioning

    Patient Safety Alerts

    • In EMR banner add infection risk “acute respiratory symptoms” or by virus type for example RSV. 
    • In EMR order isolation type droplet (transmission based precaution). 
    • Apply door signage at patient room entry.
    • Pre-existing co-morbidities such as prematurity, known cardiac or respiratory disease may cause more severe disease symptoms and prolong course of illness.
    • Refer to HFNP guideline for weaning flow and offering oral feeds Clinical Guidelines (Nursing) : High Flow Nasal Prong (HFNP)

    Companion documents

    Evidence table

    Evidence Table for this guideline can be viewed here. 

     

    Please remember to read the disclaimer.

     

    The development of this nursing guideline was coordinated by Bec McGrath, CSN, Sugar Glider and approved by the Nursing Clinical Effectiveness Committee. Updated October 2018.