1. BRONCHIOLITIS
BY: NICOLE STEVENS

2. Objectives Discuss the pathophysiology of bronchiolitis
Identify the risk factors
Identify the causative agents
Describe the clinical signs and symptoms
Discuss assessment of the child and determination of severity
Discuss medical and nursing management
Discuss possible investigations
Discuss medications that may be used
Discuss infection control measures

3. Pathophysiology Viral, lower respiratory tract infection
Causes swelling of the mucosa
Bronchi and bronchiole walls are infiltrated with inflammatory cells
The lumina are obstructed on expiration
Widespread, small-airway narrowing due to oedema resulting in air trapping and inadequate oxygenation of pulmonary blood flow

4. Pathophysiology
Dilation of the bronchial passages on inspiration allows for adequate space for intake of air
In contrast the narrowing of the air passages on expiration prevents air from leaving the lungs
Resulting in over inflation of the lungs
Self-limiting condition, but can be life threatening particularly in premature infants and those with underlying respiratory, cardiac, neuromuscular and immunological conditions.
Same concept as what happens with mec aspiration syndrome

5. Pathophysiology

6. Risk Factors Generally affects children under 12 months of age
Most frequent cause of hospitalisation in children under 6 months of age
Usually occurs in winter and spring
More boys are usually affected than girls
Exposure to cigarette smoke
Attendance at child care facilities
Having older siblings
Not being breastfed

7. Causative Agents
Usually respiratory syncytial virus (RSV), in approximately 80% of cases
Less common: metapnuemovirus, adenovirus, parainfluenza, rhinovirus
Human Metapnuemovirus (hMPV): similar to RSV, cold like symptoms
Adenoviruses: very common, about 50 subtypes, symptoms of common cold, conjunctivitis, tonsillitis, ear infections, sore throat
Parainfluenza: leading cause of croup; can cause encephalitis (inflammation of the brain), menigitis (inflammation of the tissues surrounding the brain and the CNS)

8. Signs & Symptoms Cough Tachypnoea Wheeze Crackles Poor feeding
Hyperinflation
Apnoea
Low grade fever

9. Assessment Take a history: Age (higher risk if less than 6 wks old)
Duration of symptoms (peak severity is typically day 3 – 5 of illness, so is the child likely on the improve, or is the worse still to come)
Any apnoeas (number, frequency, duration)
Colour (pink, pale, cyanotic, grey)
Feeding (able to suck at breast/bottle, tolerating?)

10. Assessment cont... Physical appearance:
Colour, general observations, WOB
Behaviour (irritable, exhausted)
Hydration (tissue turgor, capillary refill, peripheral circulation)
Auscultation of chest (typically reveals end expiratory crackles and/or wheeze)
Observe feeding (monitor SaO2 during)

11. Assessment of Severity
MILD
MODERATE
SEVERE
Behaviour
Normal
Some/intermittent irritability
Increasing irritability and/or lethargy
Respiratory Rate
Increased Resp 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
May have difficulty with feeding or reduced feeding
Reluctant or unable to feed
Oxygen
No oxygen requirement (Sa02 > 93%)
Mild hypoxemia corrected by oxygen** (Sa %)
Hypoxemia, may not be corrected by oxygen** (Sa02 < 90%)
Apnoeic episodes
None
May have brief apnoeas
May have increasingly frequent or prolonged apnoeas

12. Management
Severity (mild): manage at home, small frequent feeds, see GP in 24 hours
Severity (moderate): admit; give O2 PRN; consider IVT at 75% maintenance (potential for syndrome of inappropriate ADH secretion); 1 – 2 hrly observations
Severity (severe): admit; consider CPAP or ventilation; continuous cardiorespiratory monitoring
ADH: antidiuretic hormone

13. Nursing management Minimal handling, cluster cares
Reduce the lighting and noise levels
Promote rest and position comfortably
Observations as required
Feeds/fluids: may be a combination of IV fluids or milk feeds (depends on babies WOB, tolerance, risk of aspiration, secretions etc)
Comfort feeds if mainly on IVT
PRN normal saline nasal drops/suction to remove secretions
Manage oxygen therapy/respiratory support as prescribed.
Studies at RCH are inconclusive as to whether milk feeds via NGT is preferential or not to IV fluids.

14. Investigations
In most children with brochiolitis no investigations are required; if there is uncertainty of diagnosis an NPA may be taken and a chest x-ray (in case of bronchiolitis will typically show hyperinflation, peribronchial thickening, and patchy areas of consolidation and collapse).
Blood tests: daily U&E if on IV fluids
Blood culture only taken if other diagnosis suspected
Blood gas not routine, decision to ventilate would be made on clinical signs

15. Investigations
An xray of a child RSV showing the typical bilateral perihilar fullness of bronchiolitis
Hilar (area above and around heart)

16. Medications Consider bronchodilators in child > 6 months
Consider regular salbutamol if there is a positive response
Don’t continue bronchodilators if no response to initial dose
Paracetamol for comfort/pain relief
Oral sucrose for painful procedures
Above and behind the cardiac impression (where the heart sits in relationship to the lungs) is a triangular depression named the HILUM, where the structures which form the root of the lung enter and leave the viscus. These include the pulmonary artery, the superior and inferior pulmonary veins, lymphatic vessels and the bronchus, with bronchial vessels surrounding it. The area around the hilum is called "perihilar". Congestion is fluid or exudates (pus) in this region...that have infiltrated from surrounding tissue.

17. Infection Control
Droplet and contact precautions, spread by infective secretions
Incubation 2 – 8 days
Course of illness 7 – 10 days
Virus can live for 4 hours on benchtops
Infants with bronchiolitis may be cohorted together
Patients with suppressed immunity, underlying respiratory disease and infants less than 2 years of age should not be nursed in the same room as infants with bronchiolitis

18. References
“Brochiolitis – ongoing management”