Which treatment would the nurse anticipate for an infant admitted with bronchiolitis caused by respiratory syncytial virus RSV?

Symptoms

People infected with RSV usually show symptoms within 4 to 6 days after getting infected. Symptoms of RSV infection usually include

• Runny nose
• Decrease in appetite
• Coughing
• Sneezing
• Fever
• Wheezing

These symptoms usually appear in stages and not all at once. In very young infants with RSV, the only symptoms may be irritability, decreased activity, and breathing difficulties.

Almost all children will have had an RSV infection by their second birthday.

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Call your healthcare professional if you or your child is having difficulty breathing, not drinking enough fluids, or experiencing worsening symptoms.

Care

Most RSV infections go away on their own in a week or two.

There is no specific treatment for RSV infection, though researchers are working to develop vaccines and antivirals (medicines that fight viruses).

Take steps to relieve symptoms

• Manage fever and pain with over-the-counter fever reducers and pain relievers, such as acetaminophen or ibuprofen. (Never give aspirin to children.)
• Drink enough fluids. It is important for people with RSV infection to drink enough fluids to prevent dehydration (loss of body fluids).
• Talk to your healthcare provider before giving your child nonprescription cold medicines. Some medicines contain ingredients that are not good for children.

RSV can cause more serious health problems

RSV can also cause more severe infections such as bronchiolitis, an inflammation of the small airways in the lung, and pneumonia, an infection of the lungs. It is the most common cause of bronchiolitis and pneumonia in children younger than 1 year of age.

Healthy adults and infants infected with RSV do not usually need to be hospitalized. But some people with RSV infection, especially older adults and infants younger than 6 months of age, may need to be hospitalized if they are having trouble breathing or are dehydrated. In the most severe cases, a person may require additional oxygen or intubation (have a breathing tube inserted through the mouth and down to the airway) with mechanical ventilation (a machine to help a person breathe). In most of these cases, hospitalization only lasts a few days.

Learn more about people at high risk for severe RSV infection.

Introduction 

Aim 

Definition of Terms

Assessment

Management 

Special Considerations

Companion Documents

Evidence Table

Introduction

Bronchiolitis is an acute viral infection of the lower respiratory tract (LRTI).  It generally affects children less than 12 months of age and it is the most frequent cause of hospitalization in infants under 6 months of age. Viruses that enter and infect the respiratory tract cause viral bronchiolitis. Most cases of viral bronchiolitis are due to respiratory syncytial virus (RSV). Viral outbreaks occur seasonally and most affect children under the age of 1 year old.

The condition is usually preceded by an Upper Respiratory Tract Infection (URTI) and is characterised by cough, tachypnoea, poor feeding, wheeze, crackles, apnoea, mucus production and inflammation causing obstruction at the level of the bronchioles.  The illness typically peaks around day 3 to 5 with a resolution of the wheeze and respiratory distress over 7 – 10 days. The cough may continue for up to 4 weeks.

Bronchiolitis is a self-limiting condition, but can be life-threatening in infants who have been premature or have underlying respiratory, cardiac, neuromuscular or immunological conditions.

Aim

To outline hospital management of infants with bronchiolitis admitted to the ward. Children who require additional support may be managed in the Paediatric Intensive Care Unit (PICU) or Neonatal Intensive Care Unit (NICU).

Definition of terms

• CLD – Criteria Led Discharge
• EMR – Electronic Medical Record
• FLOQ – Dry, sterile swab specifically for taking viral samples.
  
• FiO2 – Fraction of inspired Oxygen
• HFNP – High Flow Nasal Prongs *High flow is only available in Emergency, SugarGlider, Koala, Rosella and Butterfly *
• LFNP – Low Flow Nasal Prongs
• LRTI – Lower Respiratory Tract Infection
• NG – Nasogastric
• NP – Nasal Prongs
• NPA – Nasopharyngeal aspirate ** not routinely required in children with bronchiolitis
• PICU – Paediatric Intensive Care Unit
• RSV – respiratory syncytial virus
• SpO2 – Peripheral Capillary Oxygen saturations – acceptable saturations ≥90% as per oxygen delivery CPG Clinical Guidelines (Nursing) : Oxygen delivery
• UOAM – Use Of Accessory Muscles
• URTI – Upper Respiratory Tract Infection
• ViCTOR – Victorian Children’s Tool for Observation and Response
  • In the event of transgression in the orange and red zones of the chart, please follow local escalation and modification procedures
  • The orange and purple zones in EMR will appear as below:

• WOB - Work Of Breathing – refer to severity scale Bronchiolitis Severity Scale

Assessment

Refer to Clinical Guidelines (Nursing) : Nursing assessment

History

• Age - there is a higher risk of severe bronchiolitis if the child is less than 6 weeks of age
• Duration of symptoms – peak severity is usually around day 3-5 of LRTI symptoms
  
• History of prematurity or cardiac disease - there is a higher risk of severe bronchiolitis in theses patient groups
  
• History of previous medical conditions
  
• Recent intake and output (including feeding history)
  
• Family history of atopy or asthma
  
• Apnoea - describe number, frequency, duration
  

Physical Assessment

• Implement Droplet Precautions On room entry place a transmission based precaution sign Droplet Poster found at Infection Control Signage
• Bronchiolitis is caused by a virus most commonly respiratory syncytial virus (RSV)which is transmitted via droplets. Should an aerosol generating procedure by undertaken then increase to airborne precautions by donning N95/P2 mask for at least the duration of the procedure.. 
  • Place patient in own room, patients may be cohorted based on known clinical diagnosis
    • Wear a gown or apron, surgical mask and eye protection when within 1 meter of patient and when performing aerosol generating procedures 
• Assess and Document - admission assessment:
  • Temperature
  • Respiratory rate and effort 
  • Heart rate
  • Blood Pressure 
  • Oxygen Saturation (SPO2) and/or Oxygen requirements
  • Pain
  • Level of Respiratory Distress – Assessment of Severity of Respiratory Conditions
  • Central and Peripheral Capillary Refill Time
  • Colour – i.e. pink, pale, grey, cyanosed, flushed
  • Feeding / Hydration Status / urine output
  • Level of consciousness / irritable/ consolable etc.

Focused Assessment: 

Clinical Guidelines (Nursing) : Nursing assessment (rch.org.au)

• Respiratory Assessment – hourly or more if requiring oxygen or unstable, 2-4 hourly if not requiring oxygen and clinically stable. 
• Suctioning requirements - oral & nasal toilets
  
• Pain management and analgesic requirements Clinical Guideline (Nursing) : Pain Assessment and Measurement
  
• Hydration assessment

Social History

• Parents/carers/guardian details
  
• Living arrangements / legal orders (if applicable)
  
• Siblings
  
• Visiting plans
  
• Specific cultural requirements
  

Nutrition

• Trial smaller, more frequent feeds if still tolerating oral intake (consider consequences of dehydration, hyponatremia and reduction in total fluid intake)
  
• If increased coughing, respiratory distress, apnoeic episodes or visible tiring during oral feeds contact medical team to discuss changing to Nasogastric (NG) feeds
  
• “Comfort feeds” refer to small feeds, often 10-30 ml for children with intravenous (IV) therapy, which can settle their hunger.  The child may not be capable of tolerating larger amounts.  They should be given with extreme caution and under strict supervision.
  
  • Nasogastric feeds Clinical Guidelines (Nursing) : Enteral feeding and medication administration
    
    • Commence 2 hourly NG bolus feeds with EBM or formula as appropriate, reduce total volume to 2/3 maintenance
      
    • Consider continuous NG feeds if not tolerating bolus feeds
      
    • Consideration needs to be made that an NG tube may cause increased resistance in the obligate nose breather.  Observe infant for increased work of breathing post insertion of NG tube and feeds.
      
  • Intravenous Therapy : Clinical Practice Guideline : Intravenous Fluids 
    
    • Intravenous therapy may be required for infants with severe bronchiolitis who may not be tolerant of oral or NG feeds

Investigations 

• Hydration status : Clinical Practice Guideline : Dehydration
  
• Weight 
  
• Urea and Electrolytes  – required daily if a child is on IV fluids :Clinical Practice Guideline : Intravenous Fluids
  
• FLOQ Swabs-  if requested or Nasopharyngeal aspirates (NPA) - not routinely required
  • Medical indications might include history of apnoea’s, severe or atypical illness or a clinical suspicion of pertussis
• Chest X-rays – not routinely required but may be performed if clinically indicated
  
• Blood gases – not routinely required but may be performed if clinically indicated 
  

Management

Acute management

• Patient observations Nursing Guideline: Observation and Continuous Monitoring
  • On presentation complete and document a full respiratory assessment and a full set of observations 
• For infants with mild bronchiolitis 
  • document respiratory assessment and observations every four hours as a minimum
  • offer smaller more frequent oral feeds
  • cluster cares / minimal handling
• For infants with moderate bronchiolitis
  If patient transgresses into ViCTOR orange zone consider escalation and/or medical modification of patient vital sign: RCH Escalation of Care : ViCTOR 
  • Perform continuous oximetry, frequent respiratory assessment and note effort, document observations hourly
    
  • Cluster cares / minimal handling
  • Maintain a strict fluid balance chart including the weighing of all nappies and document on fluid balance flowsheet
  • Provide nasal toilets, and gentle nasal suction to clear nasal passages as required
    
  • Provide effective analgesia - consider use of oral 33% sucrose for procedures 
    
  • Administer O2 to maintain saturations ≥90%, consider humidification of O2
    
  • Consider NG insertion if not tolerating oral feeds > 50% of normal volumes, suggested is to provide 2 hourly bolus feed or consider continuous feeds at 2/3 maintenance
    
• For infants with severe bronchiolitis: include above management and if patient transgresses into ViCTOR red zone escalate as per: RCH Escalation of Care : ViCTOR
  • Continuous cardiorespiratory monitoring, respiratory assessment and document 
  • Consider use of High Flow Nasal Prong (HFNP) therapy Clinical Guidelines (Nursing) : High Flow Nasal Prong (HFNP) therapy
  • Discuss with bed card team, PICU involvement, may need to be considered for escalation of respiratory support or transfer
  • Consider stopping NG feeds and PRN aspiration of NG tube to decompress the stomach
  • May need to be considered for IV fluids at 2/3 maintenance to provide adequate hydration
  • Consider nursing patient in the prone position - Educate parents and carers about safe sleeping practices and SIDS recommendations and how the highly monitored hospital environment differs from the home environment 
    • Clinical Guideline (Nursing): Safe Sleeping

Ongoing management

• Potential complications 
  • Nasal trauma
  • Aspiration
  • Increasing respiratory distress
  • Dehydration
• Discharge Planning and Criteria Led Discharge (CLD)
  • Infant can tolerate oral feeds >50% of daily requirement
  • Mild or regular work of breathing
  • Infants should be observed for 4 hours post weaning oxygen
  • Criteria Led Discharge (CLD) as per EMR
• Follow-up / Review
  
  • Review by local GP if parental concerns 
  • Discharge summary given on discharge
• Parent / Guardian Education Needs
  • Educate parents and visitors on how and when to perform hand hygiene and promote cough etiquette
  • Cluster cares and minimal handling  Clinical Guidelines (Nursing) : Ward Management of a Neonate
  • Provide advice to parents on expected course of illness Kids Health Info : Bronchiolitis
  • Breastfeeding Support and Promotion Clinical Guidelines (Nursing) : Breastfeeding support and promotion
  • Consider environmental factors such as lowering lighting and reducing noise levels
  • Promotion of rest and comfort measures such as positioning and analgesia
  • Educate parents and carers about safe sleeping practices and SIDS recommendations and how the highly monitored hospital environment differs from the home environment Clinical Guidelines (Nursing) : Safe Sleeping

Special considerations

Patient Safety Alerts

• Record infection risk EMR banner add infection risk “acute respiratory symptoms” or by virus type for example RSV. 
• In EMR order isolation type droplet (transmission based precaution). 
• Apply door signage at patient room entry.
• Pre-existing co-morbidities such as prematurity, known cardiac or respiratory disease may cause more severe disease symptoms and prolong course of illness. 
• Refer to HFNP guideline for weaning flow and offering oral feeds Clinical Guidelines (Nursing) : High Flow Nasal Prong (HFNP)
  

Companion documents

• Parent information (Kids Health Info) Kids Health Info : Bronchiolitis
• Procedures
  • Policies and Procedures : Nasogastric and Orogastric Tube Insertion
• Assessment tools: 
  • Clinical Guidelines (Nursing) : Nursing assessment
  • Clinical Guidelines (Nursing) : Nursing documentation
  • victor.org.au
    
• High Flow Nasal Prong Therapy Guideline (as per use in SugarGlider, Koala, Butterfly ED or Rosella) Clinical Guidelines (Nursing) : High Flow Nasal Prong (HFNP) therapy
• Oxygen Delivery Nursing Guideline Clinical Guideline (Nursing) : Oxygen delivery
• Enteral Feeding and medication administration nursing guideline:  Clinical Guidelines (Nursing) : Enteral feeding and medication administration (rch.org.au)

Evidence table

Evidence Table for this guideline can be viewed here. 

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Casey Clarke, CSN, Sugar Glider and approved by the Nursing Clinical Effectiveness Committee. Updated September 2021.  

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