acute bronchiolitis management in infants · bronchiolitis.8 apnoea, although uncommon, may be the...

CHS Document ID 00701 Acute Bronchiolitis Management in Infants Children’s Health Services

Custodian/Review Officer:

Chair, GBMA Clinical Procedures Editorial Group Version no: 1.0 Applicable To: Medical and nursing staff working in Children�’s Health Services Approval Date: 14/08/2011 Effective Date: 15/08/2011 Next Review Date: August, 2013 Authority: GBMA Clinical Procedures Editorial Group Approving Officer: CEO Children�’s Health Services Name: Dr Peter Steer �…�…�…�…�…�…�…�…�…�…�…�…�…�… Signature Supersedes: N/A Key Words: Infants; acute bronchiolitis; emergency management; and admission, discharge criteria, 00701. Accreditation References: EQuiP 5 criteria 1.3.1, 1.4.1, 1.5.1

1. Purpose This procedure provides clinical practice guidelines for the treatment of infants (< 12 months of age) with acute bronchiolitis.

2. Scope This procedure relates to all Children�’s Health Services (CHS) and Metro Children�’s Health Services staff involved with the care and management of infants with acute bronchiolitis.

3. Introduction Bronchiolitis is an illness characterised by widespread inflammation of the small airways of the lungs, leading to air trapping and impaired ventilation.1 It is commonly caused by RSV, but a number of other viruses may be responsible.2,3 The illness has a seasonal variation with a peak in presentations from late Autumn to early Spring. Bronchiolitis is the most common lower respiratory tract disorder in infants, accounting for approximately 2.3% of emergency presentations in Australia and New Zealand.4,5 It is the most common reason for admission to hospital for children under 6 months of age.6

Bronchiolitis commonly presents with feeding difficulties and respiratory distress.7 Infants generally experience coryzal symptoms for the first 1 to 3 days of the illness, then worsen on days 3 to 5, with increased work of breathing and auscultatory findings of crackles and possibly wheeze.7,8 Low grade fever (< 38.5oC) is seen in 50% of children with a diagnosis of bronchiolitis.8 Apnoea, although uncommon, may be the presenting feature, especially in the very young infant.8 Bronchiolitis is usually a self-limiting illness that resolves by one week in most previously well infants.6

Risk factors for severe bronchiolitis include:1

preterm delivery (< 32 weeks) chronological age < 6 weeks chronic respiratory condition, e.g. neonatal lung disease or CF congenital cardiac disease neurological or neuromuscular disorder immunodeficiency trisomy 21.

Version No.: 1.0 Effective From: 15/08/2011

of 11

CHS Proc 00701: Acute Bronchiolitis Management in Infants

Printed copies are uncontrolled


Version No.: 1.0; Effective From: 15/08/2011 of 11



4. Assessment Clinical assessment of acute bronchiolitis includes the evaluation of duration of illness, adequacy of feeding, hydration status, respiratory status and the presence of high risk features (Table 1). Table 1: Assessment of severity of acute bronchiolitis

MILD MODERATE SEVERE LIFE-THREATENING Normal behaviour Normal respiratory

rate Normal or minimal

accessory muscle use

Normal feeding No oxygen

requirement (SaO2 93%)

No apnoeic episodes

Adequate hydration

Lethargy/intermittent irritability

Increased respiratory rate

Moderate retractions Difficulty/reduced

feeding May appear short of

breath when feeding Dehydration Mild hypoxaemia

(SaO2 < 93% in room air) corrected by oxygen

May have brief apnoea

Increasing irritability +/- lethargy

Markedly increased or decreased respiratory rate

Marked retractions reluctance or inability

to feed Hypoxaemia may not

be corrected by oxygen (SaO2 < 90%)

May have increasingly frequent or prolonged apnoea

Grunting, head bobbing

Signs of CO2 retention (sweating or irritability)

Mottled skin

Obtundation Cyanosis Prolonged apnoea Bradypnoea (may

have reduced respiratory effort (due to fatigue)

Poor perfusion Bradycardia

Adapted from: Fitzgerald6 & Royal Children's Hospital, Melbourne9

It is also important to consider differential diagnoses. Other significant causes of acute airway obstruction in infants include:1

other pulmonary infections, e.g. pneumonia, pertussis pulmonary aspiration, e.g. milk, foreign body congestive heart failure cystic fibrosis tracheo- or bronchomalacia allergic reaction intrathoracic mass viral induced wheeze (in the older infant with a second or subsequent episode).

4.1 Investigations For infants presenting with mild acute bronchiolitis, no routine investigations are necessary.1,10 In infants with more severe bronchiolitis, the following may be considered:

CXR�—see below NPA or nasal swab1�—for admitted patients serum electrolytes, urea & creatinine�—in infants with significant dehydration where intravenous therapy

is to be commenced, a BSL should also be performed in these cases full blood count and blood culture in suspected sepsis blood gas analysis (venous or arterial)�—in tiring infant to assess for CO2 retention.

4.2 Is there a need for a chest x-ray in bronchiolitis? Consensus opinion is that a CXR should not be routinely performed in uncomplicated mild to moderate cases of bronchiolitis. Information from a systematic review shows that, in acute bronchiolitis presentations, a CXR rarely provides additional information that affects treatment.4 It should be considered in the following cases: 11





severe cases of bronchiolitis or sudden unexpected clinical deterioration atypical presentation or disease course that may prompt diagnostic uncertainty, e.g. high fever and

abnormal cardiovascular examination�—such as heart murmur, abnormal peripheral pulses, hepatomegaly.

4.3 Which is preferred—nasopharyngeal aspirate or nasal swab? Routine aspirates are not required for children with a typical clinical picture but may be helpful in admitted patients for isolation control (nosocomial infection and cross-infection can occur during bronchiolitis outbreaks).11 NPAs are more expensive and invasive than nasal swabs but have a greater sensitivity for identifying viral pathogens.12,13,14,15

5. Management Basic management for infants with bronchiolitis includes provision of nasal suctioning, supplemental oxygen (e.g. if SaO2 consistently < 93%), fluid management to prevent or treat dehydration, and other supportive therapies�—such as nasal clearance and comfort feeds. 5.1 Nasal clearance There is no evidence to support �“deep�” suctioning of the lower pharynx or larynx.1 However, regular nasal clearance is thought to be of benefit as nasal obstruction by secretions can significantly contribute to respiratory distress and poor feeding. Normal saline (0.9% NaCl) drops may be administered to both nostrils either alone or prior to active nasal suctioning.16 5.2 Hydration support Infants with acute bronchiolitis may be offered supplemental fluids by either enteral or parenteral routes. Currently, there are no published studies comparing NG and IV hydration in acute bronchiolitis.17 However, within Australia and New Zealand both routes have been used safely and a large multi-centre study on this topic is nearing completion.17,18 The approach to feeding should be based on clinical assessment including respiratory rate, likelihood of fatigue, and risk of aspiration.8

Feeds and fluids may be upgraded from oral to NG or IV fluids based on clinical condition.

Oral feeds may be offered as either breast or bottle feeds. Smaller volume feeds (i.e. shorter duration breast feeds) offered more frequently may be better tolerated. Oral feeds should be stopped if feeding results in increased work of breathing, fatigue, coughing or desaturations during feeding and an alternative method of fluid delivery employed.

Nasogastric feeds are indicated if the infant is unable to maintain normal hydration with oral intake or if feeding results in significant additional respiratory compromise (worsening desaturations, tachycardia, or tachypnoea). Expressed breast milk or formula may be given. Intermittent bolus feeds (every 2-3 hours) are the usual first line method but continuous feeds may be preferred for those with respiratory deterioration associated with bolus feeds. Enteral feed requirements for infants is summarised in Table 2. Table 2: Enteral feed requirements

Age in months Recommended requirement

Day 5 to 3 months 150 mL/kg/day (approx. 6 mL/kg/hr)

3 to 6 months 120 mL/kg/day (5 mL/kg/hr)

> 6 months (up to 10 kg) 100 mL/kg/day (approx. 4 mL/kg/hr) Note: For any infant weighing > 10 kg refer to the general method for calculation of intravenous fluid requirements (maintenance) for children (Table 3). Intravenous fluid support should be commenced on all infants with severe bronchiolitis and in those who have not tolerated oral or NG feeds. Collection of U&E's and a BSL should be performed when obtaining IV access.


Consensus opinion is that 0.9% Sodium Chloride (NaCl) + 5% Glucose is the preferred initial choice of IV fluid. Initial maintenance fluid requirements may be estimated using the below table (Table 3). Table 3: General method for calculation of intravenous fluid requirements (maintenance) for

children

Weight Method 1 Method 2

First 10 kg 100 mL/kg/day 4 mL/kg/hr

Second 10 kg 50 mL/kg/day 2 mL/kg/hr

Subsequent 10 kg 20 mL/kg/day 1 mL/kg/hr

Example calculation for a 12 kg child:

Method 1�—(10 x 100) + (2 x 50) = 1 100 mL/day = 46 mL/hr

Method 2�—(10 x 4) + (2 x 2) + = 44 mL/hr Severe bronchiolitis may be associated with raised ADH levels so consideration should be given to mild volume restriction (to 75% of maintenance) in children on IV fluids to avoid hyponatraemia. In the presence of signs of circulatory compromise, IV fluid boluses (10-20 mL/kg of 0.9% NaCl) may be warranted.

5.3 Comfort feeds Comfort feeds (small volumes, up to 20 mL, of feed given via breast, bottle or syringe) may be given for children on IV fluids to assist with settling but should not replace a formal feeding regime. As comfort feeding may result in increased respiratory distress, this should be done with medical approval and supervision by nursing staff.

5.4 Oxygen Consensus opinion is that supplemental oxygen is indicated if an infant�’s SaO2 fall persistently below 93% in the acute phase. There are no universally accepted thresholds for introducing and weaning supplemental oxygen therapy in bronchiolitis. It may be trialled if there is a combination of significant respiratory distress, elevated respiratory rate for age, or difficulty feeding.1 However, medical assessment must be made as to whether this results in an objective improvement. Oxygen may be delivered, ideally humidified, via nasal prongs or Hudson mask. During recovery, in an infant who is feeding well and otherwise ready for discharge, a SaO2 > 93% may be tolerated.6

ALERT: Non Invasive Ventilation For infants with respiratory distress which has not responded to standard therapies such as supplemental oxygen, nasal suction, and cessation of enteral feeds, NIV is a valuable alternative to intubation and ventilation.19

If there is inability to maintain SaO2 > 93% despite oxygen via Hudson mask, or the infant has any deteriorating work of breathing, tachycardia, and tachypnoea, modalities such as high flow oxygen, CPAP or BiPAP may be commenced. Infants being considered for NIV should have a normal level of consciousness, if this is not the case, intubation and ventilation is more appropriate.

Commencement of NIV is guided by CHS NIV protocol, and should involve liaison with a Level 6 PICU. In addition, the infant should be nursed 1:1 nurse�—patient ratio in an acute area such as a resuscitation room with continuous oximetry and ECG monitoring. Vascular access must be secured and the infant must remain nil by mouth.








5.5 Bronchodilators There is insufficient evidence to support the routine use of bronchodilators for all infants with bronchiolitis.16,20 Given that some infants may have a reversible reactive airways component, a trial of salbutamol (via MDI plus spacer or nebuliser) may be considered if the infant is > 6 months of age and has any of the following:

family history of asthma previous episode of bronchiolitis previous response to bronchodilators wheeze on auscultation.

A trial of salbutamol requires assessment immediately prior and then 10 minutes post administration by a Medical Officer. The clinical finding which represents a true response to treatment is the improvement in respiratory distress/work of breathing or improvement in air entry.

Any trial of salbutamol must be documented in the clinical record, including indications, clinical assessment and response.

5.6 Steroids Steroids are not recommended in the treatment of infants with acute bronchiolitis. A Cochrane review has determined that systemic corticosteroids have no impact on clinical course, admission rates or length of stay.21

5.7 Nebulised adrenaline Nebulised adrenaline is not used in the treatment of acute bronchiolitis. A large Australian randomised controlled trial and a Cochrane review have failed to show any benefit of nebulised adrenaline for infants admitted with acute bronchiolitis.22,23

5.8 Hypertonic saline Nebulised 3% NaCl has been shown to reduce the length of hospital stay in infants with bronchiolitis.24 Hypertonic saline may induce bronchospasm and in the majority of studies it was used in conjunction with bronchodilators.24 Nebulised hypertonic saline may be trialled using a dose of 4 mL of 3% NaCl. An assessment of response to the therapy must be performed at 30 minutes post administration by a Medical Officer. Any trial of hypertonic saline must be documented in the clinical record, including indications, clinical assessment and response. See the flow chart on emergency management of infants with bronchiolitis �– Appendix 1.

6. Disposition The majority of infants with mild bronchiolitis may be safely discharged from the emergency service, contingent upon on their ability to sustain adequate levels of hydration and oxygenation (SaO2 > 93%).8 Careful observation in hospital is usually warranted for infants identified as high risk or those who are more unwell.

When a decision is made to transfer a child to a Level 6 facility, referral must be made through RSQ.25

Activation of the QLD emergency medical system coordination centre (QCC)

Further information on the preparation of a infant prior to transport can be obtained through RSQ Clinical Guidelines paediatric section (page 31-35).25

Statewide RSQ clinical guidelines�—Paediatrics

http://qheps.health.qld.gov.au/rts/docs/rsq_activation.pdf

http://qheps.health.qld.gov.au/rts/docs/clin_guide_pt2.pdf





7. Abbreviations Term Definition

ADH Antidiuretic hormone

BiPAP Biphasic positive airway pressure

BSL Blood sugar level

CF Cystic fibrosis

CHS Children's Health Services

CO2 Carbon dioxide

CPAP Continuous positive airway pressure

CXR Chest x-ray

DDx Differential diagnosis

ECG Electrocardiogram

GP General practitioner

Infants < 12 months of age

IV Intravenous

MDI Metered dose inhaler

NaCl Sodium chloride

NBM Nil by mouth

NG Nasogastric

NIV Non invasive ventilation

NPA Nasopharyngeal aspirate

PICU Paediatric Intensive Care Unit

RSQ Retrieval Services Queensland

RSV Respiratory syncytial virus

SaO2 Oxygen saturations

U&E's Urea and electrolytes (serum electrolyte analysis)

VBG Venous blood gas

8. References and Suggested Reading 1. American Academy of Pediatrics. Diagnosis and management of bronchiolitis. Pediatrics. 2006; 118

(4): 1774-1793.

2. Wright AL., Taussig LM., Ray CG., et al. The Tucson children�’s respiratory study: II. Lower respiratory tract illness in the first year of life. American Journal of Epidemiology. 1989; 129 (6): 1232-1246.

3. Wolf DG., Greenberg D., Kalkstein D., et al. Comparison of human metapneumovirus, respiratory syncytial virus and influenza A virus lower respiratory tract infections in hospitalized young children. The Pediatric Infectious Disease Journal. 2006; 25 (4): 320-324.

4. Agency for Healthcare Research and Quality. Management of bronchiolitis in infants and children: Summary. US Department of Health & Human Services (USA); 2003. AHRQ publication no. 69.

5. Acworth J., Babl F., Borland M., et al. Patterns of presentations to the Australian and New Zealand paediatric emergency research network. Emergency Medicine Australasia. 2009; 21 (1): 59-66.





6. Fitzgerald D. Viral bronchiolitis for the clinician. Journal of Paediatrics and Child Health. 2011; 47 (4): 160-166.

7. Shah S., Sharieff GQ. Pediatric respiratory infections. Emergency Medicine Clinics of North America. 2007; 25 (4): 961-979.

8. Fitzgerald DA., Kilham HA. Bronchiolitis: Assessment and evidence-based management. Medical Journal of Australia. 2004; 180 (8): 399-404.

9. Royal Children�’s Hospital, Melbourne Australia. Bronchiolitis management [internet]. Melbourne (AU): Royal Children�’s Hospital; 2009 [cited May 6]. Available from: http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5157

10. Bordley WC., Viswanathan M., King VJ., et al. Diagnosis and testing in bronchiolitis: A systematic review. Archives of Pediatrics & Adolescent Medicine. 2004; 158 (2): 119-126.

11. Zorc J., Hall C.B. Bronchiolitis: Recent evidence on diagnosis and management. Pediatrics. 2010; 125 (2): 342-349.

12. Abu-Diab A., Azzeh M., Ghneim R., et al. Comparison between pernasal flocked swabs and nasopharyngeal aspirates for detection of common respiratory viruses in samples from children. Journal of Clinical Microbiology. 2008; 46 (7): 2414-2417.

13. Chan KH., Peiris JSM., Lim W., et al. Comparison of nasopharyngeal flocked swabs and aspirates for rapid diagnosis of respiratory viruses in children. Journal of Clinical Virology. 2008; 42 (1): 65-69.

14. Lambert SB., Whiley D.M., O�’Neill DT., et al. Comparing nose-throat swabs and nasopharyngeal aspirates from children with symptoms for respiratory virus identification using real-time polymerase chain reaction. Pediatrics. 2008; 122 (3): e615-e620.

15. Walsh P., Overmyer CL., Pham K., et al. Comparison of respiratory virus detection rates for infants and toddlers by use of flocked swabs, saline aspirates, and saline aspirates mixed in universal transport medium for room temperature storage and shipping. Journal of Clinical Microbiology. 2008; 46 (7): 2374-2376.

16. Steiner RWP. Treating acute bronchiolitis associated with RSV. American Family Physician. 2004; 69 (2): 325-330.

17. Babl FE., Sheriff N., Neutze J. et al. Bronchiolitis management in pediatric emergency departments in Australian and New Zealand. Pediatric Emergency Care. 2008; 24 (10): 656-658.

18. Paediatric Research in Emergency Departments International Collaborative (PREDICT). A prospective radomised trial comparing nasogastric with intravenous hydration in children with bronchiolitis (protocol): The comparative rehydration in bronchiolitis study (CRIB). BMC Pediatrics. 2010; 10: 37.

19. Deis JN., Estrade CM., Abramo TJ. Noninvasive ventilation techniques in the emergency department: Applications in pediatric patients. Pediatric Emergency Medicine Practice. 2009; 6 (6): 1-18.

20. Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database of Systematic Reviews. 2010; Issue 12, Art. No.: CD001266.

21. Fernandes RM., Bialy LM., Vandermeer B., et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database of Systematic Reviews. 2010; Issue 10, Art. No.: CD004878.

22. Wainwright C., Altamirano L., Cheney M., et al. A multicenter, randomized, double-blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. New England Journal of Medicine. 2003; 349 (1): 27-35.

23. Hartling L., Russell KF., Patel H., et al. Epinephrine for bronchiolitis (review). Cochrane Database of Systematic Reviews. 2004; Issue 1, Art. No.: CD003123.

24. Zhang L., Mendoza-Sassi RA., Wainwright C., et al. Nebulized hypertonic saline solution for acute bronchiolitis in infants (review). Cochrane Database of Systematic Reviews. 2008; Issue 4, Art. No.: CD006458.

25. Statewide Clinical Coordination and Retrieval Services. Clinical guidelines: Section two [intranet]. Brisbane (AU): Queensland Government (Queensland Health); 2008 [cited July 25]. Available from: http://qheps.health.qld.gov.au/rts/docs/clin_guide_pt2.pdf

http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5157

http://qheps.health.qld.gov.au/rts/docs/clin_guide_pt2.pdf





9. Supporting Documents Acute bronchiolitis flow chart Bronchiolitis fact sheet

10. Consultation Key stakeholders who reviewed this version are:

Paediatric Registrar �– Emergency, Royal Children�’s Hospital Clinical Nurse Consultant Emergency Department, Mater Children�’s Hospital Staff Specialist �– Emergency Department, Mater Children�’s Hospital Director of Paediatrics, Ipswich Hospital Clinical Nurse Consultant Emergency Department, Logan Hospital Nurse Practitioner �– Paediatrics, Logan Hospital Manager �– Clinical Standards, Queensland Ambulance Service Director of Paediatric Emergency Medicine, Children�’s Health Services Clinicians (medical, nursing, allied health) working within Level 4, Level 5 and Level 6 Children�’s Health

and Metro Children's Health Services in emergency, inpatient and ambulatory services Children�’s Health Services District clinical leaders �— medical, nursing and allied health District Chief Executive Officers �— Children�’s Health Services, Metro South, Metro North and West-

Moreton Health Service Districts Queensland Ambulance Services �— Manager Clinical Standards.

Acknowledgements:

Children�’s Health Services would like to acknowledge the contribution made by: Dr Jason Acworth�—Director of Paediatric Emergency Medicine, Children's Health Services Donna Franklin�—Project Manager SEQ PP, Children's Health Services Dr John Gavranich�—Director of Paediatrics, Ipswich Hospital Dr Sharon Anne McAuley �—Staff Specialist (ED), Mater Children's Hospital Dr Michelle Davison�—Staff Specialist (ED), The Prince Charles Hospital Dr Katie Reeves�—Medical Officer, Royal Children�’s Hospital Shahn Horrocks�—Nurse Practitioner (ED), Gold Coast and Logan Hospitals Andrea Hetherington�—Clinical Nurse Consultant (Paediatrics) (ED), Logan Hospital Elizabeth Ruddy�—Clinical Nurse Consultant (ED), Mater Children's Hospital.

11. Procedure Revision and Approval History Version No Modified by Amendments authorised by Approved by

1.0 Greater Brisbane Metropolitan Area Clinical Procedures Editorial Group

Children�’s Health Services Patient Safety and Quality Committee

Chief Executive Officer, Children�’s Health Services

http://qheps.health.qld.gov.au/ed/docs/child_bronchiolitis.pdf





12. Audit / Evaluation Strategy Level of risk High

Audit strategy 1. Staff survey to evaluate awareness of procedure and emergency management practices

2. Observe practice

Review documentation, i.e. chart audit, to evaluate compliance with procedure

Audit tool attached Nil

Audit date Annual snapshot review (August)

Audit responsibility Individual Greater Brisbane Metropolitan hospitals, i.e. Ipswich, Logan, Redland, MCH, RCH, TPCH, Redcliffe, Caboolture

Key Elements / Indicators / Outcomes

KPI 1 �— greater than 80% staff awareness of procedure

KPI 2 �— greater than 80% compliance with procedure


13. Appendix 1 – Emergency Management of Infants with Acute Bronchiolitis





14. Appendix 2 – Admission/Discharge Criteria for Infants with Acute Bronchiolitis


