BRONCHIOLITIS

Etiology

The most common infectious agent causing acute bronchiolitis in children is the respiratory syncytial
virus (RSV)[1]. RSV is an enveloped, nonsegmented, negative, single-stranded RNA virus belonging to the
paramyxovirus. Other viruses that cause the condition include adenovirus, human metapneumovirus,
influenza, and parainfluenza.

If an adenovirus is identified, most clinicians use it to tailor investigations because the natural course of
the infection often presents as a prolonged febrile illness. Human metapneumovirus is not tested
routinely. This etiological agent should be suspected when the patient tests negative for the respiratory
syncytial virus (RSV), yet the clinical picture suggests a similar infection. Influenza positive patients might
benefit from antiviral treatment.

Epidemiology and Incidence

 Bronchiolitis and pneumonia resulting from RSV are more common in boys than in girls by a
ratio of approximately 1.5 : 1. Other risk factors with similar impact include 1 or more siblings in
the home, white race, rural residence, maternal smoking, and maternal education <12 yr. The
medical factors in infants associated with highest risk are chronic lung disease of prematurity,
congenital heart disease, immunodeficiency, and prematurity

 The incubation period from exposure to first symptoms is approximately 3-5 days.

 Spread of infection occurs when large, infected droplets, either airborne or conveyed on hands
or other fomites, are inoculated in the nasopharynx of a susceptible subject. RSV is probably
introduced into most families by young schoolchildren undergoing reinfection.

Respiratory Synctial Virus

Initial infection in young infants or children frequently involves the lower respiratory tract and most
often manifests as the clinical entity of bronchiolitis.

Inoculation of the virus occurs in respiratory epithelial cells of the upper respiratory tract.

Spread of the virus down the respiratory tract occurs through cell-to-cell transfer of the virus along
intracytoplasmic bridges (syncytia) from the upper to the lower respiratory tract.

The illness may begin with upper respiratory symptoms and progress rapidly over 1-2 days to the
development of diffuse small airway disease characterized by cough, coryza, wheezing and rales, low-
grade fever (< 101°F), and decreased oral intake.

Risk Factors

 Young children (younger than 1y/o)

 Childcare attendance
  Lower socioeconomic status
 Prematurity
 Immunocompromised children

Pathogenesis

 Bronchiolitis is caused by obstruction and collapse of the small airways during expiration. Infants
are particularly apt to experience small airway obstruction because of the small size of their
normal bronchioles; airway resistance is proportional to 1/radius4\

 Airway narrowing likely is caused by virus-induced necrosis of the bronchiolar epithelium,

hypersecretion of mucus, and round-cell infiltration and edema of the surrounding submucosa.

 The immune response required to eliminate virus-infected cells is a double-edged sword,

reducing the cells producing virus but causing host cell death in the process. A large number of
soluble factors, such as cytokines, chemokines, and leukotrienes, are released in the process,
and skewing of the patterns of these responses may predispose some individuals to more severe
disease. There is also evidence that genetic factors may predispose to more severe bronchiolitis

Pathophysiology

Bronchiolitis occurs as a result of the inflammation of the lining of the epithelial cells of the small
airways in the lungs causing mucus production, inflammation and cellular necrosis of those cells. It is the
inflammation of these cells that can obstruct the airway and ultimately result in wheezing.

Clinical Manifestations

 first sign of infection in infants with RSV is rhinorrhea

 Cough may appear simultaneously but more often does so after an interval of 1-3 days, at which
time there may also be sneezing and a low-grade fever. Soon after the cough develops, the child
who experiences bronchiolitis begins to wheeze audibly.

 Auscultation often reveals diffuse fine inspiratory crackles and expiratory wheezes. Rhinorrhea
usually persists throughout the illness, with intermittent fever.

 If the illness progresses, cough and wheezing worsen and air hunger ensues, with increased
respiratory rate, intercostal and subcostal retractions, hyperexpansion of the chest, restlessness,
and peripheral cyanosis. Signs of severe, life-threatening illness are central cyanosis, tachypnea
of >70 breaths/min, listlessness, and apneic spells. At this stage, the chest may be significantly
hyperexpanded and almost silent to auscultation because of poor air movement
  Chest radiographs of infants hospitalized with RSV bronchiolitis have normal findings in
approximately 30% of cases, with the other 70% showing hyperexpansion of the chest,
peribronchial thickening, and interstitial infiltrates.

 Fever is an inconstant sign in RSV infection. In young infants, particularly those who were born
prematurely, periodic breathing and apneic spells have been distressingly frequent signs, even
with relatively mild bronchiolitis

Diagnosis

Routine laboratory tests are of minimal diagnostic use in most cases of bronchiolitis or pneumonia
caused by RSV. The white blood cell count is normal or elevated, and the differential cell count may be
normal with either a neutrophilic or mononuclear predominance. Hypoxemia as measured by pulse
oximetry or arterial blood gas analysis is frequent and tends to be more marked than anticipated from
the clinical findings. A normal or elevated blood CO2 value in a patient with a markedly elevated
respiratory rate is a sign of respiratory failure.

Definitive diagnosis of RSV infection is based on the detection in respiratory secretions of live virus by
cell culture. The presence of viral RNA (detected by a molecular diagnostic test using reverse
transcription PCR) or viral antigens (detected by a rapid diagnostic test, usually a membrane blotting test
incorporating antibody detection of viral proteins) is strongly supportive in the right clinical setting. The
antigen test is less sensitive than culture, whereas reverse transcription PCR analysis is more sensitive
than culture.

An aspirate of mucus or a nasopharyngeal wash from the child’s posterior nasal cavity is the optimal
specimen. The specimen should be placed on ice, taken directly to the laboratory, and processed
immediately for culture, antigen detection, or PCR analysis. The virus is thermolabile, so it degrades over
relatively short periods of time unless frozen at a low temperature such as −80°C (−112°F) in freezers
used in research settings.

Treatment

Humidified oxygen and suctioning are usually indicated for hospitalized infants who are hypoxic. Many
infants are slightly to moderately dehydrated, and therefore fluids should be carefully administered in
amounts somewhat greater than those for maintenance. Often, intravenous or tube feeding is helpful
when sucking is difficult because of tachypnea.

In nearly all instances of bronchiolitis, antibiotics are not useful, and their inappropriate use contributes
to development of antibiotic resistance Interstitial pneumonia in infants 1-4 mo old may be caused by C.
trachomatis, and macrolide therapy may be indicated for that infection.

Ribavirin is an antiviral agent delivered through an oxygen hood, face mask, or endotracheal tube with
use of a small-particle aerosol generator most of the day for 3-5 days.

The monoclonal antibody palivizumab is licensed for prophylaxis in high-risk infants during the RSV
season, and does prevent about half of the expected hospitalizations in that population
There are strict criteria outlined by the American Academy of Pediatrics (AAP) for identifying those
patients that are eligible to receive palivizumab. These patients include infants born before 29 weeks
who are younger than 12 months at the start of the RSV season, patients who are less than 32 weeks
gestation who have chronic lung disease, hemodynamically significant congenital heart disease who are
less than 12-months old, children that are 12 months or younger with anatomic pulmonary disorders
and neuromuscular disorders that inhibit their airway clearance, patients that are 12 months and
younger that are immunocompromised, and patients with other comorbid genetic diseases who also
have the conditions mentioned should also be considered for prophylaxis

Nursing Assessment

Vital signs. Assess the patient’s vital signs especially the respiratory rate and cardiac rate.

History. Interview patient and caregivers regarding the medical history of the child.

Physical examination. Note if there are any retractions and signs of severe respiratory distress.

Nursing Diagnoses

Impaired gas exchange related to possible viral pneumonia.

Fluid volume deficit related to decreased fluid intake.

Hyperthermia related to dehydration.

Nursing Care Planning and Goals

Patient will experience ease of breathing.

Patient will not experience dyspnea at rest.

Respiratory rate is within normal limits.

Absence of fever.

Nursing Interventions

The NICE guidelines recommend immediate referral by emergency ambulance in cases where:

 Apnea is observed or reported.

 The child looks seriously unwell to a healthcare professional.
 There is severe respiratory distress – grunting, marked recession or a respiratory rate of more
than 70 breaths per minute.
 The child has central cyanosis.
 Sp02 is persistently below 92% when breathing air.
Use of humidified air. Keep the room warm but not overheated; if the air is dry, a cool-mist humidifier
or vaporizer can moisten the air and help ease congestion and coughing; be sure to keep the humidifier
clean to prevent the growth of bacteria and molds.

(Traditionally nebulised therapies such as adrenaline, ipratropium bromide, salbutamol and hypertonic
saline have been trialled in the management of bronchiolitis.)

Encourage oral fluid intake. Keep a steady supply of cool water at the bedside; offer warm fluids, such
as soup, which may help loosen thickened secretions; ice pops may be soothing as well; continue breast-
feeding or bottle-feeding your infant as you would normally.

Encourage good hygiene habits. Teach your children the importance of hand-washing; use your own
glass or disposable cups when you or someone else is sick; label each person’s cup.

Administer medications. Give prescribed medications and encourage compliance.

(bronchodilators,antivirals)

In those infants who are deemed fit to be managed at home, parents should be given the following
advice:

1. Feeding: Offer small volumes of feeds more frequently. For infants who are not yet weaned, fluid
requirement is usually 150ml/kg/day. While unwell with bronchiolitis an intake of approximately 75% or
110ml/kg/day would be acceptable.1,4

2. Handheld suction devices: These are increasingly available from community pharmacies. Parents
often enquire about these devices. There is no evidence to support their use, but anecdotally parents
have described benefit where secretions are hindering the infant’s ability to feed.

3. Infection control: Bronchiolitis is highly contagious. Transmission is both through aerosolised droplets
and close contact with contaminated secretions. The virus can live for several hours on hard surfaces
and 30 minutes on hands. The best way to reduce the spread of bronchiolitis is with regular hand-
washing. Any toys that are shared among siblings should be disinfected regularly.6

4. Course of illness: It is useful to make parents aware of the natural course of bronchiolitis as described
in the section on signs and symptoms. In particular, remind parents that the cough may persist for
several weeks and that no treatment is needed for this in an otherwise well infant.

5. Antipyretics: Bronchiolitis is often associated with a mild pyrexia. Advise parents on appropriate
dosing and use of paracetamol and/or ibuprofen. If the temperature is above 39°C it would be advised
to attend for reassessment.4

Evaluation

Patient experienced ease of breathing.

Patient experienced dyspnea at rest.

 Respiratory rate is within normal limits.

Absence of fever.

Documentation Guidelines

Temperature and other assessment findings, including vital signs.

Causative and contributing factors.

Impact of condition on personal image and lifestyle.

Plan of care.

Teaching plan.

Responses to interventions, teaching, and actions performed.

Attainment or progress towards desired outcomes.

Modifications to plan of care.