Download This Item - Mid Essex Hospital Services NHS Trust

Type:
Policy
Bronchiolitis in Children
Register No: 09052
Status:
Public
Developed in response to:
Safeguarding Children
Every Child Matters
4
Contributes to CQC Outcome:
Consulted With
Post/Committee/Group
Date
Alison Cuthbertson/
Miss Rao
Mahesh Babu
Manas Datta
Aloke Agrawal
Muhammed Ottayil
Sharmila Nambiar
Sharon Lim
Ahmed Hassan
Rachel Thomas
Toni Laing
Mel Hodge
Andrea Stanley
Sarah Moon
Professionally Approved By
Clinical Director for Women’s, Children’s
and Sexual Health Directorate
Paediatric Consultant
Paediatric Consultant
Paediatric Consultant
Paediatric Consultant
Paediatric Consultant
Paediatric Consultant
Paediatric Consultant
Associate Specialist
Lead Nurse
Senior Sister, Phoenix Ward
Clinical Facilitator Children’s Acute Care
Specialist Midwife Guidelines and Audit
Job Cyriac Clinical Lead CYP consultant
November 2014
Version Number
Issuing Directorate
Ratified by:
Ratified on:
Executive Management Board Date
Implementation Date
Next Review Date
Author/Contact for Information
Policy to be followed by (target staff)
Distribution Method
Related Trust Policies (to be read in conjunction
with)
Document Review History
Review No
1.0
1.1 Minor Changes
2.0
3.0
November 2014
3.0
Children & Young People
DRAG Chairmans Action
20th November 2014
December 2014
20th November 2014
November 2017
Rachel Thomas Associate Specialist
Nurses, Junior Doctors, Paediatricians
Intranet & Website
Children’s Transfer Policy
Safeguarding Children Policy
Infection Prevention policies
Adult discharge policy
Reviewed by
Carol Newman
Carol Newman
Rachel Thomas Associate
Specialist
Review Date
2009
5th May 2010
6th October 2011
20 November 2017
Index
1.0
Purpose of guideline
2.0
Background
3.0
Scope
4.0
Staff Training
5.0
Diagnosis
6.0
Risk factors for severe bronchiolitis
7.0
Management of mild bronchiolitis
8.0
Criteria for admission
9.0
Investigations
10.0
Treatment
11.0
Criteria for discharge
12.0
Infection Prevention
13.0
Audit and Monitoring
14.0
Communication
15.0
Reference
1.0
Purpose of Guideline
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.
In 2012, a multi-disciplinary committee was formed to revise the2006
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.
2.0
Background
2.1
The diagnosis of bronchiolitis is a clinical one based on typical history and
findings on physical examination.
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
Bronchiolitis typically has a coryzal phase of 2- 3 days which precedes the
onset of other symptoms
2.2
Bronchiolitis is a viral seasonal illness from October to March with cases
peaking in January.
2.3
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.
2.4
The first 72 hours of the illness, infants with bronchiolitis may deteriorate
clinically before symptom improvement.
2.5
Many infants with bronchiolitis have feeding difficulties due to dyspnoea and
this is often a reason for admission.
2.6
The trust is committed to the provision of a service that is fair, accessible and
meets the needs of all individuals.
3.0
Scope
3.1
This guideline applies to all clinical staff caring for babies with bronchiolitis.
4.0
Staff Training
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, mphasizes
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
May have nasopharyngeal aspirate positive to any of the following
• Respiratory Syncytial Virus (RSV),
• Adenovirous
• Parainfluenza.
• Influenza
• Enterovirus,
• 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 hrs 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
• Failure to maintain oxygen saturations of >92% with increasing oxygen
therapy
• Deteriorating respiratory status and increasing Childrens Early Warning Tool
score
• Recurrent apnoea
9.0
Investigation
9.1
An 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 mircrobiology.
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.
9.4
Blood test 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 oxyhemoglobin
saturation exceeds 90%.
10.2
consider Heated Humidified High Flow oxygen (optiflow) as an alternative to
nasal cannula. See oxygen guideline: Administering oxygen 10102 for further
details.
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
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
Apnoeas& bradycardias (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
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).
10.7
Bronchodilators, corticosteroids and chest physiotherapy, should not be used
(the new guideline uses the wording should not ) Antibacterial medications
unless there are signs of a specific bacterial infection.
10.8
Hydration is important in the supportive care of hospitalised patients with
bronchiolitis. Fluids may be given via the intravenousor nasogastric routes
with equal efficacy. New literature also suggests that hypotonic maintenance
fluids carry a risk of iatrogenic hyponatremia in the disease
11.0
Discharge criteria
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 may be considered for
discharge.
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.
12.2
New data prompt update to AAP guideline on diagnosis, management of
bronchiolitis with recommendations from the centers downloaded from
http://aapnews.aappublications.org/ by guest on November 16, 2014 for
Disease Control and Prevention and World Health Organization. Also
consistent with AAP policies, the guidelines recommend breastfeeding until at
least 6 months and avoidance of tobacco smoke. The recommendation to
provide smoking cessation counselling for parents of children with
bronchiolitis is reinforced by recent literature. It is important to educate
medical staff, including nurses, and parents about these recommendations in
a warm and personal manner.
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.
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.
Admission Criteria
Apnoea
Requiring oxygen to maintain SpO2
Discharge criteria
Stable and improving
SpO2 maintained >92% in air for
period of 8-12 hours including a
period of sleep
Requiring support with
hydration/nutrition
Discharge advice & education:
Feeding adequately (more than 2/3
normal feeds)
Family confident in their ability to
manage
Refrain from smoking
Symptoms may persist for 10-14
days
Re-infection may occur
Increased risk of wheezing after
bronchiolitis
15.0
References
15.1
Scottish Intercollegiate Guidelines Network (SIGN) 2006 Bronchiolitis in
Children. A national clinical guideline
15.2
Clinical Practice Guideline: The Diagnosis, Management,and Prevention of
Bronchiolitis -Paediatrics oct 27 2014
15.3
AAP news 2014; 35;1 – official news magazine of the American academy of
paediatrics