A Clinical Guideline recommended Children s Assessment Unit (CAU), Buxton Ward, For use in: Children s Day Ward, Jenny Lind Out-patients Department, Accident and Emergency Department By: Medical and Nursing staff For: Children under 24 months with Acute Bronchiolitis Division responsible for document: Division 3 Key words: Names and job titles of document authors: Children, infants, bronchiolitis Dr Caroline Kavanagh, Paediatric Respiratory Consultant Dr Brett Kintu, Paediatric Registrar Name of document author s Line Manager: Frances Bolger Job title of document author s Line Manager: Head of Women s and Midwifery Services Supported by: Paediatric Medical consultants and nurses. Assessed and approved by the: Clinical Guidelines Assessment Panel (CGAP) Date of approval: 20 November 2018 Ratified by or reported as approved to: Clinical Standards Group and Effectiveness Sub-Board To be reviewed before: 20 November 2020 To be reviewed by: Dr Caroline Kavanagh Reference and/or Trustdocs ID No: 12244 Version No: 1.2 Description of changes: None new document Compliance links: If Yes does the Strategy policy deviate from the recommendations of NICE? If so, why? NICE Guideline: Bronchiolitis (NG9) No deviations This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavor to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document. Clinical Guideline for: Management of Author/s: Dr Caroline Kavanagh: and Dr Brett Kintu: Author/s title: Paediatric Respiratory Consultant: and Paediatric Registrar Approved by: CGAP Date approved: 20/11/2018 Review date: 20/11/2020 Available via Trust Docs Version: 1.2 Trust Docs ID: 12244 Page 1 of 7
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Objective A concise and uniform guideline to optimise the management of Bronchiolitis/probable Bronchiolitis in the Trust. Rationale Bronchiolitis is an acute infectious respiratory illness common in children under the age of two years, with a peak age of 3-6 months. It is prevalent between the months of November and March. It is usually a mild illness not necessitating admission. Only 3% of all under ones with bronchiolitis are hospitalised, although one third of all infants will develop bronchiolitis. Aetiology Bronchiolitis is mainly a clinical diagnosis. Respiratory Syncytial Virus (RSV) is the most common pathogen (70-80%). However other viruses such as include metapneumovirus, parainfluenza, influenza, adenovirus, rhinovirus and boca virus may cause the same clinical picture. Clinical Presentation Clinically, there are symptoms of coryza, cough, tachypnoea and reduced feeding. Symptoms usually peak between 3-5 days of the illness and the cough usually resolves in 90% of cases within 3 weeks. Bronchiolitis results in airway plugging with sloughed epithelium, mucus and oedema, leading to hyperinflation, atelectasis, and impaired gas exchange. Diagnosis Diagnosis can be made if the child has a coryzal prodrome lasting 1-3 days followed by pesistent cough, tachypnoea and/or chest recession and crackles and/or wheeze on auscultation. Fever (<39 o C) occurs in 30% of cases and poor feeding is common. Young infants may present with apnoeas as the only feature. Infants may be hypoxic. High grade fever (> 39 o C) is rare in bronchiolitis and alternative causes should be considered. It is important to take a feeding history when asking families about this illness. Differential Diagnosis Aspiration. Pertussis. Bacterial pneumonia if high fever and focal crackles. Congestive heart failure.
Viral induced wheeze / Early onset asthma in the older child. Structural abnormalities of airways (tracheo-oesophageal fistula etc.) Cystic fibrosis (CF). Investigations Pulse oximetry in all infants. Children s Early Warning Scores (CEWS) scores taken from observations. RSV status may be used to assist in cohorting patients early in the bronchiolitis season. A routine CXR is not recommended. Routine laboratory investigations are not recommended in straightforward bronchiolitis. High Risk Children Several risk factors put children with bronchiolitis at increased risk of severe illness. These include: Infants < 8 weeks of age. Ex-preterm infants. Congenital heart disease. Neuromuscular disorders. Chronic lung disease (BPD, CF, Diaphragmatic hernia, CCAM etc.) Syndromic disorders (e.g. Trisomy 21, Pierre-Robin etc.) Immune deficiency. Re-attendance. Management All children presenting with suspected bronchiolitis should have pulse oximetry recorded. Supportive Admit to hospital if SaO 2 < 92% in air, moderate breathing difficulties, feeding difficulties or if the family unable to provide appropriate supervision. Give oxygen via nasal cannulae or face mask to maintain SaO 2 > 92%. Vapotherm and CPAP may also be considered as may intubation and ventilation is severe cases. Maintain adequate hydration. Oral fluids are preferred, but feeding via nasogastric or
orogastric tube should be considered. The very sick child may require intravenous fluids. These should be restricted to two thirds of requirements to avoid inappropriate ADH secretion (see Trust Guideline on Intravenous fluids in children JCG0090 - id 1208).
Frequency of observations of pulse, temperature, respiratory rate, SaO 2 and degree of recession should be guided by the child s condition, but at least 4-hourly initially if requiring oxygen, or otherwise very sick. Analgesics and anti-pyretics should be used as necessary, to keep the child comfortable. Chest physiotherapy is not beneficial unless there are relevant comorbidities. Drugs / Medication Oxygen should be administered as needed to keep saturations > 92%. Antibiotics are not required in bronchiolitis unless there is a concomitant bacterial infection or a strong suspicion of one. Oral or inhaled steroids are not recommended in bronchiolitis, there is no evidence that it is effective. There is no evidence that salbutamol or ipratropium bromide have any effect in bronchiolitis. If an infant is wheezy, these bronchodilators can be given and assessed for effect, especially in the older child. Nebulised adrenaline should not be used in bronchiolitis. Hypertonic sodium chloride is not currently recommended in the UK for use with bronchiolitis (it is used in USA). Montelukast is not recommended for use in bronchiolitis. If signs of moderate to severe bronchiolitis then immediate senior review Assessment of severity on presentation by admitting nursing and medical staff will determine management according to the algorithm. Moderate Bronchiolitis Severe Bronchiolitis O 2 Sats < 92 % (sustained > 5 minutes) O 2 Sats< 92% in > 2L/min N/C O 2 RR 60-70/minute (with increased work of RR > 70/minute breathing) CEWS 2-4 (re-assessed frequently) CEWS > 5 Feeds <50% (of normal for weight) Feeds <50% (of normal for weight) Alert, moderate recessions, well perfused Exhaustion > 2 apnoeas an hour ph < 7.25 (venous,arterial) CO 2 > 7 KPa Supportive respiratory management, if required, includes consideration of CPAP (refer to algorithm and see CPAP guideline CA5092- id 9079) and Anaesthetic/NICU review. Clinical audit standards
All children attending with a diagnosis of bronchiolitis has pulse oximetry undertaken. All children requiring CPAP/HDU admission must be discussed with the on-call consultant and NICU/ITU. All febrile infants (>39 o C) should be considered for a septic screen before commencing antibiotics. All families at discharge should be given Bronchiolitis advice leaflets. Summary of development and consultation process undertaken before registration and dissemination The guideline was drafted by Dr Caroline Kavanagh and Dr Brett Kintu. It has been circulated to the Jenny Lind Children s Hospital (Acute Paediatrics and Neonatal Consultants, Specialist Registrars, Nursing staff on the Children s Assessment Unit and Buxton Ward), Accident and Emergency Consultants and Paediatric Anaesthetists for comments. Distribution list / dissemination method To CAU, Paediatric Wards, A&E and the above Departments, and on the Intranet. References 1. Ralston SL et al. Clinical Practice Guideline: The diagnosis, management and prevention of bronchiolitis. American Academy of Pediatrics. Pediatrics 2014, 134, e1474-e1502. 2. NICE guideline: Bronchiolitis (NG9) May 2015. 3. SIGN. Scottish Intercollegiate Guideline Network. 91, Bronchiolitis in children November 2006. 4. Subcommittee on Diagnosis and Management of Bronchiolitis Pediatrics October 2006; 118:4 1774-1793; doi:10.1542/peds.2006-2223. Glossary of terms ADH Anti-diuretic Hormone BLS Basic Life Support BPD Bronchopulmonary Dysplasia CEWS Children's Early Warning Scores CATS Children s Acute Transport CF Cystic Fibrosis Service CCAM Congenital Cystadenomatoid Malformation CPAP Continuous Positive Airway Pressure NGT Naso-Gastric Tube NPA Nasopharyngeal Aspirate OGT Orogastric Tube