Intermountain Healthcare Bronchiolitis Update Intermountain Healthcare Pediatric Clinical Programs

Transcription

1 Intermountain Healthcare Bronchiolitis Update Intermountain Healthcare Pediatric Clinical Programs Updated 11/2008

2 Reviewed by: Intermountain Pediatric Education Team Intermountain Respiratory Therapy Team Anne Brenneman APRN, MS, CPNP Seasonal Outcomes Compiled by: Julie Ballard, BS, RRT

3 This Bronchiolitis Update Is Intended For: Physicians, Nurses, Respiratory Therapists and Other Healthcare Providers Who Care for Pediatric Patients Throughout Intermountain Healthcare. The important thing is not to stop questioning. Albert Einstein

4 Upon Completion of This Bronchiolitis Update, You Should Be Able To: Discuss the etiology, epidemiology, pathophysiology & management of RSV / Bronchiolitis Locate and utilize the Intermountain Newborn/Pediatric Bronchiolitis Protocol and Standardized Admit Orders (SAO) Discuss Seasonal Outcomes for your facility Pass the post-test as assigned The post test is available as an on-line test

5 Bronchiolitis Update Contents Definition of Bronchiolitis Epidemiology of RSV Pathophysiology Risk factors Clinical presentation Diagnosis Evaluation Intermountain protocol Therapy options Severe Bronchiolitis Prevention Discharge & followup Seasonal outcomes Articles

6 Definition of Bronchiolitis Common, acute, contagious respiratory illness of infants and young children that involves the lower respiratory tract Common causative agents include: Respiratory Syncytial virus (RSV) Parainfluenza types 1, 2, 3 Adenovirus Human Metapneumovirus (mpv) Rhinovirus Influenza types A, B Enterovirus

7 RSV is: RSV Epidemiology The most common cause of bronchiolitis Initially described over 100 years ago The leading cause of lower respiratory tract infections in infants and young children Infection spread by fomites and contact with infectious secretions Typically an upper respiratory tract infection in older children and adults A more severe illness in infants and small children, but infects all ages Duration of illness is 7-10 days Adults with RSV in one study had a mean work absence of 6 days

8 RSV Epidemiology Worldwide occurrence Peak incidence of RSV is in winter and early spring in the northern hemisphere, or rainy season in tropical climates Season is usually around 6 months (November April; Peak months are January & February) Most cases occur between 2-8 months of age /100 children are typically infected in the first year with most children demonstrating antibodies by 2nd - 3rd year of life 1-2% of all children are hospitalized

9 In one year: RSV Epidemiology 90, ,000 pediatric hospitalizations per year in the US Up to 510 deaths between * Mortality is 0.2-7% (depending upon risk factors; also some data was prior to current level of available ICU care) Recent data showed a 2-4% mortality in ICU patients * Shay DK, Holman, RC, et al. Bronchiolitis-Associated Mortality and Estimates of Respiratory Syncytial Virus-Associated Deaths among US Children J Infect Dis 2001; 183:16-22

10 RSV Epidemiology First-time infections are usually the most severe RSV can cause significant apnea via unknown mechanisms Apnea is the presenting symptom in approximately 20% of infants admitted to the hospital with RSV Infants at risk for developing apnea include: Premature infants < 32 wk gestational age Infants with a history of neonatal apnea Severe hypoxemia

11 Bronchiolitis Pathophysiology Obstruction of bronchioles Inflammation Edema Mucous Debris Increased airway resistance Hyperinflation Atelectasis V-Q mismatching Blood perfusing the lung is not exchanging gases due to atelectasis, mucous plugs, etc

12 Bronchiolitis Pathophysiology Infants are at highest risk due to small airways Recovery is slow Epithelium begins to regenerate in 3-5 days Cilia do not reappear for up to 2 weeks RSV may be shed by the nose for up to 21 days Cough may persist for weeks

13 Risk Factors for Developing Bronchiolitis Low birth weight, premature infants The younger the child, the higher the risk Lower socioeconomic group Crowded living conditions More than 2 children per bedroom Day care attendance Older siblings in preschool or school Being in a multiple birth set (eg. twins, triplets) Parental smoking

14 Risk Factors for Severe Disease* Prematurity Chronic lung disease, e.g. BPD Worse in the first 2 years of life Congenital heart disease Immunodeficiency states Symptomatic HIV disease, organ or bone marrow transplantation, elderly *Mortality is 3-5% in high-risk hospitalized patients and they tend to have more severe, protracted illness.

15 Bronchiolitis Clinical Progression Incubation period 2-5 days Infants fussy with some difficulty feeding Typically low-grade fever (less than 38.6º C or 101.4º f) Fever is usually gone by the time the family seeks medical care Over the next 2-5 days Increased coryza and congestion 60% of infections are confined to the upper airway Gradual progression to lower respiratory tract Cough, dyspnea, wheezing, feeding difficulties worsen

16 Bronchiolitis Commonly Reported Symptoms Increased work of breathing Fussiness, inability to sleep Cough, post-tussive emesis Poor feeding Decreased urine and stool output (or loose stool)

17 Bronchiolitis Common Physical Findings Fever C ( º F) Up to 20% of patients may have a higher temperature Occasionally infants < 1 month may be hypothermic (< 36.5 C) Tachypnea, tachycardia, increased work of breathing (nasal flaring, retractions, grunting) Coarse crackles, wheezing Cyanosis Otitis media (in up to 40% of cases) Mild conjunctivitis or pharyngitis Palpable liver from pulmonary hyperinflation

18 Bronchiolitis Diagnosis Diagnosis is based on clinical findings Age, seasonal occurrence, common symptoms and physical findings Viral diagnostic studies can be helpful For cohorting, SBI exclusion, differential diagnosis

19 Differential Diagnosis of Infant With Respiratory Distress Reactive airway disease/asthma Sepsis Croup, Pertussis Pneumonia aspiration, bacterial, other virus Foreign body aspiration Congenital structural anomaly, vascular ring Bronchomalacia, tracheomalacia Congenital lobar emphysema Tracheal ring Bronchial cleft cyst Cystic fibrosis Chronic aspiration Congenital heart disease Congestive heart failure and/or pulmonary edema

20 Bronchiolitis Evaluation O2 saturation Good indicator of severity and correlates well with degree of tachypnea but not with severity of wheezing or crackles At high elevation, O2 saturations 88% CR monitoring <3 months, apnea, high risk (h/o prematurity, BPD or underlying lung or heart disease), bronchiolitis score greater than 6. Consider CBG or ABG for severe respiratory distress or possible fatigue

21 Bronchiolitis-Evaluation Consider other lab studies in special situations: Full sepsis evaluation (CBC, blood culture, UA, urine culture, CSF studies and culture) for fever in infants < 90 days or those with toxic appearance (see Febrile Infant Protocol) Electrolytes, stool studies for dehydration or diarrhea

22 Bronchiolitis Evaluation Viral identification of nasal secretions Positive viral study can prevent more invasive workup in small infants and allows for cohorting of patients with the same viral diagnosis Rapid viral tests are available (during respiratory season) for RSV and Influenza, but if results are negative, proceed to DFA (direct fluorescent antibody) DFA commercial tests are available for RSV, Parainfluenza 1,2,3, Influenza A & B, Adenovirus, Human Metapneumovirus Sensitivity varies depending on how sample is obtained, and kit used. Most have a sensitivity of >90% Specificity generally >95% Viral culture is 60% sensitive but 100% specific

23 Bronchiolitis Evaluation Radiology-Chest X-Ray: Not routinely needed unless diagnosis uncertain Neither specific nor prognostic Typically shows hyperinflation, atelectasis, and 20-30% may show lobar infiltrates

24 Bronchiolitis Evaluation Indications for admission Toxic or septic appearance Respiratory distress Apnea Low O2 saturation on room air (<88%) Dehydration Risk factors for severe disease present

25 Risk Factors for Severe Disease* Prematurity Chronic lung disease, e.g. BPD Worse in the first 2 years of life Congenital heart disease Immunodeficiency states Symptomatic HIV disease, organ or bone marrow transplantation, elderly *Mortality is 3-5% in high-risk hospitalized patients and they tend to have more severe, protracted illness.

26 The Bronchiolitis Protocol Intended for inpatient management The protocol exists to create consistency among caregivers, emphasize effective treatments and reduce use of unnecessary therapies A team approach utilizes a standardized order set & the protocol Review Bronchiolitis Standardized Admit Orders (SAO) Review Bronchiolitis Newborn Pediatric Protocol

27 Bronchiolitis Protocol: Scoring Bronchiolitis score The score is an attempt to create consistency in assessment among caregivers The scoring system is not validated but inter-rater reliability has been demonstrated Intervention effectiveness is measured through rescoring after the intervention

28 Bronchiolitis Protocol: Bronchiolitis Score Score Respiratory Rate < 1 year > 1 year Wheeze Retractions 0 < 40 < 30 None None Expiration 1 location Insp/Exp 2 locations 3 > 65 > 45 Diminished > 3 locations 0-1= Normal 2-3=Mild 4-6=Moderate 7-9=Severe

29 Bronchiolitis Protocol: Inpatient Management The mainstay of therapy is supportive care Suctioning to assist with clearance of secretions Naso-pharyngeal (NP) suction with an 8 Fr. catheter, advanced into the hypopharynx BBG or bulb suction for nasal secretions for tight or bloody nares Oxygen to maintain saturations in the normal or desired range Hydration Oral intake, IV fluids and/or nasogastric tube Patients are usually made NPO if respiratory rate is > 65 BPM due to risk of aspiration

30 Bronchiolitis Protocol: Oxygen O2 therapy is indicated if saturations are <88%, or below goal saturation Nasal cannula administration preferred O2 humidified with bubbler can prevent irritation and bleeding of nares Room air trial every 4 hours when stable & sp02 flow rate of 0.1 liter/min for patient < 6 months, or.25 liter/min for patients 6-24 months Evaluate work of breathing carefully during weaning process

31 Bronchiolitis Protocol: Monitoring Cardiorespiratory monitoring is indicated for: Infants less than 3 months of age History of apnea or experiencing apnea Bronchiolitis score greater than 6 History of prematurity, BPD, or cardiorespiratory disease

32 Bronchiolitis Protocol: Suctioning Suctioning improves patient comfort and decreases work of breathing and may increase the ability to feed Indications for suctioning include: Increased work of breathing Increased retractions Decreased saturations or increased oxygen requirement Worsening bronchiolitis score Occasionally utilized if PO intake is marginal and it is thought that suctioning may help infant with troublesome secretions Patient is scored before and 15 minutes after suctioning

33 Suctioning Bronchiolitis Protocol: Suctioning Methods NP (nasopharyngeal) suction with an 8 Fr. catheter, advanced into the hypopharynx. May consider transition to BBG or bulb suction prior to discharge

34 Bronchiolitis Protocol: Isolation Droplet precautions Mask & gloves when entering room Gown, mask & gloves with patient contact When suctioning eye protection is a required precaution Hand hygiene before and after patient contact Cohort patients only with the same infectious agent

35 Bronchiolitis Protocol: Bronchodilator Trials A trial treatment of nebulized Albuterol or Racemic Epinephrine may be given and patient response evaluated: Steps include: Obtain baseline Bronchiolitis score Suction nasopharynx Obtain Bronchiolitis score 15 post sx Administer medication treatment Obtain Bronchiolitis score 15 post medication treatment A positive response = score decreases by at least one point Wheezing may become audible if breath sounds were diminished before treatment

36 Therapy Options: Bronchodilators Albuterol or other ß-agonists Meta-analyses reveal modest/short term improvement, inconclusive findings or no benefit Occasionally utilized in patients with recurrent wheezing or diagnosis of RAD Trial of nebulized albuterol may be considered in select patients (family history of asthma or personal history of multiple episodes of wheezing) Patient is scored before and 15 minutes after intervention

37 Therapy Options: Bronchodilators Racemic epinephrine Studies show some efficacy Stimulates alpha and beta receptors Vasoconstriction may decrease airway inflammation and mild bronchodilator effect Trial of nebulized epi may be considered if albuterol is ineffective Patient is scored before and 15 minutes after intervention CR monitoring recommended Concern for hypokalemia, hypertension, arrhythmia, tachycardia with use

38 Therapy Options: Steroids Multiple studies with varying results Some show effectiveness, some do not Randomized control trial (RCT) underway to determine if steroids administered in ED decrease admissions Occasionally utilized in patients with recurrent wheezing or diagnosis of RAD (reactive airway disease) or CLD (chronic lung disease) Not a component of the bronchiolitis protocol

39 Therapy Options: Antibiotics Serious bacterial co-infection unlikely in patients with known viral diagnosis (<1% association) Indicated for strong evidence of bacterial superinfection or otitis media Broad-spectrum antibiotics are used in infants 1-90 days in whom SBI (serious bacterial infection) is suspected and cultures are pending or in critically ill infants

40 Therapy Options: CPAP Non-invasive ventilation (CPAP or HFNC): May be used for infants who are tiring and have increasing respiratory insufficiency Help to maintain patency of the smaller airways preventing atelectasis

41 Management of Severe Bronchiolitis ICU care needed for the following: ABG or CBG showing respiratory acidosis and/or climbing PCO2 Severe distress not responding to conservative therapy (oxygen, suctioning, hydration, bronchodilators) Severe hypoxia requiring non-invasive ventilation Respiratory failure

42 Bronchiolitis Prevention Vaccines Attempts at developing a vaccine have yet to be successful. Presence of antibodies do not confer immunity Re-infection is common and, in vaccine studies, more severe

43 Bronchiolitis Prevention Palivizumab (Synagis) Monoclonal antibody against the F (fusion) protein of RSV Monthly IM injection, administered during peak RSV season Shown to decrease both risk for hospitalization (down 55%) and severity of subsequent infections Used in a very select patient population

44 Bronchiolitis Prevention Palivizumab (Synagis) indications: Refer to: Synagis order form for additional guidelines Infant < 24 months with chronic lung disease, CF or CHD Premature infants born at less than 28 weeks gestational age (WGA) Must be < 1 year old at the start of the RSV season Premature infants born at WGA Must be < 6 mos old at the start of the RSV season Infants born at WGA Must have additional risk factors with other criteria Infant received palivizumab (Synagis) one month previously

45 Bronchiolitis Discharge Discharge planning Consider discharge if patient: Has low and stable scores and no evidence of respiratory distress or cyanosis Tolerates room air or has a low, stable oxygen need Is able to maintain hydration with feeds Has clearly defined follow up care with primary care physician Caregivers should be reliable, have transportation, and have the ability to call for help

46 Bronchiolitis Discharge Plan for discharge with oxygen and any other equipment or supplies at least one day in advance Discharge teaching very important for parents Review Bronchiolitis Teaching Outline

47 Teach parents: Bronchiolitis Discharge Teaching To evaluate respiratory status, hydration, manage oxygen and other equipment To perform bulb or other suctioning, particularly prior to feedings To administer medications properly To understand when to call for assistance or seek medical care To understand hand washing, risk of irritants such as tobacco smoke, and avoidance of daycare while the child is ill Review Bronchiolitis Let s Talk About and provide a copy for the family

48 Bronchiolitis Follow up Care Follow up Contact with primary care physician is required before discharge Follow up in 2-3 days if stable and breathing easily without supplemental oxygen Follow up in 1-2 days if on oxygen or if patient has significant co-morbidities REMEMBER, patients can shed virus in their secretions for up to 21 days after the onset of symptoms, and the cough can last for weeks

49 Intermountain Healthcare Seasonal Outcomes To view Intermountain Healthcare outcomes, click on the above link and then select a link under Bronchiolitis Seasonal Outcomes

50 Articles American Academy of Pediatrics, Clinical Practice Guideline, Diagnosis and Mangement of Bronchiolitis, PEDIATRICS Volume 118, Number 4, October 2006 DeNicola, LK. Bronchiolitis. Emedicine article: Last Updated: December 11, 2006.

51 Articles Krilov LR. Respiratory Syncytial virus infection. Emedicine articles: Last Updated: March 24, 2006 Louden, M. Pediatrics, Bronchiolitis. Emedicine article: Article Last Updated: Nov 1, 2007.