BRONCHIOLITIS IN CHILDREN Type: Policy Register No: 09052 Status: Public Developed in response to: Safeguarding Children Every Child Matters CQC Fundamental Standard: 9, 12, 13 Consulted With Post/Committee/Group Date Alison Cuthbertson/ Clinical Director for Women s and Children s Division November 2017 Miss Rao Aloke Agrawal Muhammed Ottayil Sharmila Nambiar Sharon Lim Job Cyriac Ahmed Hassan Muthumeenal Srinivasagam Dean Lethaby Ranjith Joseph Toni Laing Mel Hodge Mary Stebbens Sarah Moon Deborah Lepley Claire Fitzgerald Matron Neonatal Unit Senior Sister, Phoenix Ward Clinical Facilitator Children s Acute Care Specialist Midwife Guidelines and Audit Senior Librarian, Warner Library Pharmacist Professionally Approved By Manas Datta, Clinical Lead CYP Consultant November 2017 Version Number 4.0 Issuing Division Women s and Children s Ratified by: DRAG Chairmans Action Ratified on: 2 nd January 2018 Executive Management Board Date February 2018 Implementation Date 6 th February 2018 Next Review Date December 2020 Author/Contact for Information Rachel Thomas, Associate Specialist Policy to be followed by (target staff) Nurses, Junior Doctors, Paediatricians Distribution Method Intranet & Website Related Trust Policies (to be read in conjunction with) Children s Transfer Policy Safeguarding Children Policy Infection Prevention policies Adult discharge policy Document Review History: Version No: Authored/Reviewed by: Active Date: 1.0 2009 1.1 Carol Newman 5th May 2010 2.0 Carol Newman 6 th October 2011 3.0 Rachel Thomas Associate Specialist 14 November 2017 4.0 Rachel Thomas Associate Specialist 6 th February 2018 1
Index 1. Purpose 2. Background 3. Scope 4. Staff Training 5. Diagnosis 6. Risk factors for severe bronchiolitis 7. Management of mild bronchiolitis 8. Criteria for admission 9. Investigations 10. Treatment 11. Criteria for discharge 12. Infection Prevention 13. Audit and Monitoring 14. Communication 15. Reference 2
1.0 Purpose 1.1 This guideline provides evidence based practice on the management of bronchiolitis for children admitted as inpatients. A revised AAP clinical practice guideline on the diagnosis and management of bronchiolitis updates the 2006 guideline with stronger recommendations, addition of new therapies and significantly revised recommendations on the use of palivizumab. 1.2 In 2012, a multi-disciplinary committee was formed to revise the 2006 guideline due to the publication of a new literature on the disease in the intervening years. The committee reviewed literature published since as well as the literature included in the earlier document. As a result, multiple changes were made. 1.3 The trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 2.0 Background 2.1 The diagnosis of bronchiolitis is a clinical one based on typical history and findings on physical examination. 2.2 Bronchiolitis is a viral seasonal illness from October to March with cases peaking in January. 2.3 The consensus guideline from the UK using a Delphi panel reported a 90% consensus on the definition of bronchiolitis as a seasonal viral illness characterised by fever, nasal discharge dry and wheezy cough. On examination there are fine inspiratory crackles and /or expiratory wheeze. 2.4 Bronchiolitis typically has a coryzal phase of 2-3 days which precedes the onset of other symptoms. 2.5 Bronchiolitis mainly affects children under two years of age. Ninety percent of cases requiring hospitalisation occur in infants under twelve months of age. Incidence peaks at age three to six months. 2.6 The first 72 hours of the illness, infants with bronchiolitis may deteriorate clinically before symptom improvement. 2.7 Many infants with bronchiolitis have feeding difficulties due to dyspnoea and this is often a reason for admission. 3.0 Scope 3.1 This guideline applies to babies less than 2 years with bronchiolitis. 4.0 Staff Training 3
4.1 All medical and nursing staff are to ensure that their knowledge, competencies and skills are up-to-date in order to complete their portfolio for appraisal. 4.2 During induction process junior medical staff will receive instruction on current policy and guidelines. 4.3 Where a patient s notes have demonstrated that the appropriate action has not been taken a risk event form is to be completed. This will address any further training needs for staff that require updating. 4.4 Reflective learning from difficult bronchiolitis cases will be encouraged by case presentation at junior doctor teaching sessions so that everyone can learn from the outcomes. 4.5 Staff of all grades should be familiar with how to recognise seriously ill children and be able to perform paediatric life support. They should undergo re-training at the statutory intervals. 4.6 Nasal CPAP training will be provided with periodic retraining made available. A competency based assessment will need to be completed including both clinical and theoretical knowledge with regard to all aspects of caring for an infant whilst receiving nasal CPAP therapy. 4.7 Only trained and competent nursing staff should care for infants receiving nasal CPAP therapy. 5.0 Diagnosis 5.1 A diagnosis of acute bronchiolitis should be considered in an infant with nasal discharge and dry wheezy cough becoming moist, in the presence of fine inspiratory crackles and/or high pitched expiratory wheeze. Apnoea may be a presenting feature. 5.2 The new document, from the AAP Subcommittee on Bronchiolitis, emphasizes that bronchiolitis is a clinical diagnosis that may be caused by a number of viruses. Up to 30% of patients may be co-infected with more than one virus. As a result, testing for respiratory syncytial virus (RSV) or other viruses adeno-para influenza, influenza, enterovirus and rhinovirus generally is unnecessary. 5.3 May have nasopharyngeal aspirate positive to any of the following: Respiratory Syncytial Virus (RSV) Adenovirous Parainfluenza Influenza Enterovirus 4
Rhinovirus (uncommon) 6.0 Risk Factors for Severe Bronchiolitis Younger the infant higher the risk of hospital admission Infants born < 35 weeks gestation Major congenital heart disease Chronic lung disease secondary to prematurity Passive smoking may prolong recovery time 7.0 Management of Mild Bronchiolitis 7.1 An infant with mild bronchiolitis who is alert and pink in air and taking 50% or more of usual feeds can be managed at home. With an O2 saturation > 92% and above 7.2 Advise parents to give smaller and more frequent feeds. 7.3 Provide the parents with written information on how to manage the child at home. 7.4 Provide open access to the ward for 24 hours if not managing at home. 8.0 Criteria for admission 8.1 Any one of the following indicators should prompt admission. Poor feeding (< 50% of usual fluid intake in preceding 24 hours) Lethargy History of apnoea Respiratory rate 60/min Presence of nasal flaring and/or grunting Severe chest wall recession Cyanosis Oxygen saturation 92% in air Uncertainty regarding diagnosis 8.2 Indications for high dependency: 5
Failure to maintain oxygen saturations of >92% with increasing oxygen therapy Deteriorating respiratory status and increasing Children s Early Warning Tool score Recurrent apnoea 9.0 Investigation 9.1 Oxygen saturation should be performed on all children attending with suspected bronchiolitis. 9.2 The new document, from the AAP Subcommittee on Bronchiolitis, emphasizes that bronchiolitis is a clinical diagnosis that may be caused by a number of viruses. Up to 30% of patients may be co-infected with more than one virus. As a result, testing for respiratory syncytial virus (RSV) or other viruses generally is unnecessary. A nasopharyngeal aspirate should be sent to microbiology. 9.3 Chest x-ray (CXR) should not be performed in infants with typical acute bronchiolitis. Chest radiography most commonly leads to over diagnosis of pneumonia, resulting in unnecessary antibiotic therapy. 9.3.1 CXR is performed on children who are being considered for CPAP to exclude pneumonia as this is a complication and may be a reason for deterioration (CXR and blood gas are part of the assessment indicated prior to commencement of CPAP). 9.4 Blood tests are not routinely indicated in assessing and management of infants with typical acute bronchiolitis. 9.5 Measurement of urea and electrolytes should only be considered in severe cases of bronchiolitis and those requiring intravenous fluids. 9.6 Blood gases should only be considered in severe cases and those children with increasing oxygen requirements, and CEWT score. 10.0 Treatment 10.1 Oxygen therapy via either nasal cannula to maintain oxygen saturation > 92%.Based on a low level of evidence and reasoning from first principles, clinicians may choose not to administer oxygen if the oxyhaemoglobin saturation exceeds 90%. 10.2 Consider Heated Humidified High Flow oxygen (optiflow) as an alternative to nasal cannula. (Refer to the guideline entitled Administering oxygen ; register number 10102) 10.3 Consider nebulised Hypertonic Saline (3% sodium chloride) 4mls eight hourly. This may reduce airway oedema and mucous plugging and therefore decrease airway obstruction. Adverse effects such as acute broncho spasm 6
are avoided if nebulised hypertonic saline is administered in conjunction with a nebulised Bronchodilator such as Atrovent. Nebulised hypertonic saline is a relatively new therapy that was not referenced in the 2006 guideline. A significant volume of literature shows that it does not prevent hospitalization when used in the short term in the emergency department. When used in the hospital, it may be effective in shortening the length of stay (LOS), but this appears limited to situations where the average LOS is longer than three days. The preponderance of the literature suggests that it may be a useful therapy when deployed over the longer term, and further outpatient trials would be a priority. 10.3 Continue small frequent oral feeds if tolerated. 10.4 If oral feeds are not tolerated commence naso-gastric feeds and if necessary intravenous fluids. 10.5 Continuous positive airway pressure (CPAP) should be commenced in babies with worsening respiratory distress/apnoea/fatigue (as per CPAP policy). Indications for commencement include: Signs of deterioration indicated by the CEWT score Increased respiratory rate and effort Expiratory grunting Intercostal recession, sternal recession and nasal flaring Apnoea and bradycardia (particularly in bronchiolitic babies) Increasing oxygen requirements (i.e. FiO2 >60% in oxygen) Deteriorating blood gases (i.e. ph <7.25 with evidence of CO² retention) Atelectasis shown on x-ray 10.6 Bronchodilators, corticosteroids and chest physiotherapy should not be used. Antibacterial medications may be considered if there are signs of a specific bacterial infection. 10.7 Hydration is important in the supportive care of hospitalised patients with bronchiolitis. Fluids may be given via the intravenous or nasogastric routes with equal efficacy. New literature also suggests that hypotonic maintenance fluids carry a risk of iatrogenic hyponatremia in the disease. 11.0 Advice to Parents 11.1 The AAP guidelines recommend: Breastfeeding should continue until at least 6 months Avoidance of tobacco smoke - the recommendation to provide smoking cessation counselling for parents of children with bronchiolitis is reinforced 11.0 Discharge Criteria (Refer to Table 1) 7
11.1 Once infants can maintain an adequate daily oral intake (>75% of usual intake). 11.2 Infants with oxygen saturation >94% in room air for period of 8-12 hours including a period of sleep may be considered for discharge. Table 1: Admission Criteria Apnoea Requiring oxygen to maintain SpO2 Requiring support with hydration/nutrition Discharge advice & education: Refrain from smoking Symptoms may persist for 10-14 days Re-infection may occur Increased risk of wheezing after bronchiolitis Discharge Criteria Stable and improving SpO2 maintained >94% in air for period of 8-12 hours including a period of sleep Feeding adequately (more than 2/3 normal feeds) Family confident in their ability to manage 12.0 Infection Prevention 12.1 All staff should follow Trust guidelines on infection prevention ensuring that they effectively decontaminate their hands before and after each procedure. Hand hygiene before and after direct contact with the patient, after removing gloves, and contact with inanimate objects in the direct vicinity of the patient. Alcohol rubs are preferred, consistent with recommendations from the centres. 12.3 Bronchiolitis is highly infectious and all patients should be nursed under standard isolation precautions. 13.0 Audit and Monitoring 13.1 An annual audit of children receiving CPAP therapy will be undertaken as per the CPAP clinical guideline. 13.2 An audit of compliance with this policy will be undertaken at least 2 yearly. Where deficiencies are identified, an action plan will be developed to address these issues and findings will be fed back to relevant staff at departmental meetings. 13.3 The Lead Nurse for Children s Services will review all risk event report forms that relate to the care of children admitted with bronchiolitis to identify any training issues. 8
13.4 As an integral part of the knowledge, skills framework, staff are appraised annually to ensure competency in computer skills and the ability to access the current approved guidelines via the trust s intranet site. 14.0 Communication 14.1 Approved guidelines are published monthly in the Trust Focus Magazine that is sent via email to all staff. 14.2 Approved guidelines will be disseminated to appropriate staff quarterly via email. 14.4 Regular memos are posted on the Risk Management notice boards in each clinical area to notify staff of the latest revised guidelines and how to access guidelines via the intranet or clinical guideline folders. 15.0 References Scottish Intercollegiate Guidelines Network (SIGN) 2006 Bronchiolitis in Children. A national clinical guideline Clinical Practice Guideline: The Diagnosis, Management and Prevention of Bronchiolitis -Paediatrics October 2014 http://aapnews.aappublications.org/ by guest on November 16, 2014 for Disease Control and Prevention and World Health Organization. 9