Question

BRONCHIOLITIS

Emmy, a 5-month-old girl, is brought to the emergency department (ED) with respiratory distress, hypoxia, and fever. Her parents state that she has had mild cold symptoms for a few days. She has breastfed poorly over the last few days, with a decreased number of wet diapers. You take her vital signs and complete an initial assessment.

Emmy's mother calls you to the room because her baby is “not right.” You note Emmy's respiratory rate is 20 breaths/min, and the retractions have increased. The Spo2 is 89% on 1.5L of oxygen. She is pale and listless and does not cry with stimulation. You are concerned and call the rapid response team. You check her Spo2 again with results of 88%. The HCP orders a portable chest x-ray (CXR) examination and capillary blood gas (CBG). The CXR is consistent with bronchiolitis with atelectasis. Emmy is transferred to the pediatric intensive care unit (PICU) and placed on a continuous positive airway pressure (CPAP) machine. You know from experience that patients are usually on CPAP for a couple of days before they are ready to be taken off and continue to improve until they are ready for discharge.

Why is the respiratory rate significantly lower even though other signs of respiratory distress have increased? You are reviewing the medication administration record. Which order(s) would you question? Explain.

After 2 days in the PICU, Emmy is transferred back to your unit. You note that she is taking increased oral fluids and requiring less suctioning. Her Spo2 is 96% to 98% on room air. As you are preparing the parents for discharge, they want to know how they can prevent this in the future. They ask whether there is a “shot” Emmy can get to avoid getting this again.

How would you address their concerns? Emmy's parents ask you for instructions about the treatment of cold symptoms/nasal congestion if Emmy develops them again. How would you respond?

Answer 1

Answer :

Bronchiolitis : it is inflammatoe]ry bronchial reaction in infants and young childrens. Almost always caused by a virus, transmitted either by airborne, through saliva, skin to skin contact.

Most common virus caused this condition is respiratory syncytial virus( RSV).

Symptoms starts out similar to common cold, then  prgress to coughing, wheezing, difficulty in breathing.

Complication of severe bronchiolitis include :

a) cyanosis

b) apnoea

c) dehydration

d) respiratory failure and low oxygen in blood

Here the child is 5 month old, with typical upper respiratory symptoms followed by breathing difficulty.

Patient is not active, not taking breast feed, not passed urine, pale, not crying with stimulations etc.. indicates severe bronchiolitis.

Her respiratory rate is 20 breath / min. ( normal for this age is 30 to 60 breath /min.) , lower than normal limit.It may be due to acute respiratory failure due to atlectasis or may be due to the effect of medication like cough syrup containing codeine, which causes respiratory depression.

While checking doctor's order, look for any sedative medications, it cause more respiratory depression.

2. Discharge Advise :

Preventive methods :

• The virus spread from person to person. So best way to prevents its transmission are wash your hands frequently, espesially before touching baby, when you have cold or other respiratory symptoms and wear a face mask at this time.
• Avoid contact of child with people who have fever or cold especially if the childe is pramature new born.
• Clean and disinfectant the surfaces like toys, floor, door knobes.
• Cover cough and sneeze with a tissue paper and wash hands or used alcohol based hand sanitizer.
• Don't share drinking glasses with others especially if the family members ill.
• Breast feed the baby at least for 6 months and can continue more than two years.
• Respiratory infections are less in well breast feed the babies.

Babies born prematurely or with a heart or lung disease or depressed immune system may be given the medication PALIVIZUMAB to decrease the chance of RSV infection.

If the child develop nasal discharge or congestion, you can use anti histamine syrup and saline nasal spray and syrup paracetamol for fever. If the child's condition not improving even after 2 days or develops cough, breathing difficulty, decreased food intake, less active, lethargy, decreased urine production, retraction of chest wall while breathing etc...,get medical help as soon as possible.