J. A. HILDES NORTHERN MEDICAL UNIT DEPARTMENT OF COMMUNITY HEALTH SCIENCES AND DEPARTMENT OF PEDIATRICS AND CHILD HEALTH FACULTY OF MEDICINE

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1 J. A. HILDES NORTHERN MEDICAL UNIT DEPARTMENT OF COMMUNITY HEALTH SCIENCES AND DEPARTMENT OF PEDIATRICS AND CHILD HEALTH FACULTY OF MEDICINE Recommendations for Evidence-Based Care for Bronchiolitis 2005 This is circulated as a recommended approach to community-based care, and is consistent with guidelines of the Children s Hospital of Winnipeg. Ultimate decisions regarding treatment must be individualized. Target Population Infants < 24 months with a first episode of wheezing typical in presentation and clinical course with bronchiolitis; excluding those with cardiac conditions, severe respiratory distress/failure, history of extreme prematurity, other respiratory or immunologic problems. Typically bronchiolitis is a self-limited disease secondary to a viral infection, characterized by airway obstruction from mucosal and submucosal edema, increased mucus secretion and decreased mucus clearance. The basic management is to provide therapies that support adequate patient oxygenation and hydration. Caution RSV in neonates has been described as mild and atypical, with apnea, lethargy, and difficulty feeding being more common than acute lower respiratory illness. Consultation is recommended for all infants less than 3 months of age, and infants with a history of prematurity and/or chronic cardiorespiratory disease. Summary of Recommendations For patients in whom bronchodilator therapy is indicated: o A trial of inhaled epinephrine (adrenalin or Vaponefrin ) should be initiated as first line therapy if no contraindications. o Bronchodilator therapy must be assessed for therapeutic benefit by clinical scoring before and after administration. o Scheduled or serial use of bronchodilator therapy is not recommended unless the therapy is effective as evidenced by a decrease of 3 between pre- and posttherapy scores. If there is no clear evidence of effectiveness, bronchodilator therapy should be discontinued. Nasal suctioning is recommended prior to inhalation therapy and feeds in infants 3 months of age. In infants >3 months of age, suction prn prior to feeds and inhalations. Supplemental oxygen should be administered only if oxygen saturation in room air is 91%. Systemic steroids and steroid inhalations are not recommended. Antibiotics are not routinely indicated as concurrent serious bacterial infection is rare. Bronchiolitis Clinical Scoring Clinical scoring is useful in following the course of illness and therapy. Always record condition at initial presentation and response to therapeutic interventions on an appropriate clinical scoring sheet. February 2005 Page 1

2 Bronchodilator Therapy Levo-epinephrine (Adrenalin) and racemic epinephrine (Vaponefrin ) can be used with similar efficacy and adverse effect profile. Levo-epinephrine (Adrenalin) ml/kg/dose of epinephrine 1:1000. Maximum dose 5.0mL. Administer with humidified oxygen at 5 to 6L/minute. Racemic epinephrine (Vaponefrin ) ml/kg/dose. Maximum dose 0.5mL. Add sufficient unpreserved normal saline qs to 2mL in mask cup. Administer with humidified oxygen at 5 to 6L/minute. Notes Response to this therapy seems to be maximal at the onset and further gains are less distinguishable over time. Bronchodilator therapy must be assessed for therapeutic benefit by clinical scoring before and after administration. A decrease of 3 between pre- and post-therapy scores should be considered an adequate clinical response. Initial 2 doses can be given at 30 minute intervals. Subsequent doses may be given every 2 hours. If there is no clear evidence of effectiveness, bronchodilator therapy should be discontinued. Potential adverse effects with epinephrine include pallor; inhaled epinephrine does not result in greater tachycardia than _2 agonists. There is no need for lengthy observation post mask. There have been equivocal results with _2 agonists in clinical trials. There may be a subset of infants who respond to _2 agonists, although there are no successful predictors of response. Salbutamol (Ventolin ) 0.03mL/kg of 5mg/mL respirator solution. Add sufficient unpreserved normal saline qs to 2 ml in mask cup. Administer with humidified oxygen at 5 to 6L/minute. Investigation and Management Chest x-rays and other investigations for pyrexia are not recommended, and antibiotics are not indicated for non-toxic, vigorous infants with a diagnosis of viral bronchiolitis, as concurrent or secondary serious bacterial infection is rare. Although otitis media is commonly present this diagnosis does not necessitate antibiotic therapy. Parent Education Care-givers should be clearly advised regarding the criteria for reassessment. Instruction should be given regarding nasal suctioning. Prevention of spread to other infants and children can be reduced by hand washing. Exposure to environmental tobacco smoke should be eliminated. Criteria for Evacuation The decision to evacuate a patient to a secondary or tertiary center must be individualized. Consideration must be given to clinical state, response to therapy, rate of progression of illness, family supports, and the community s health facility and health professional resources. These recommendations are adapted for community-based care from approved guidelines prepared by the Bronchiolitis Working Group, a sub-committee of the Child Health Quality Council at the Winnipeg Children s Hospital. February 2005 Page 2

3 Evidence-Based Care for Bronchiolitis 2005 NASAL SUCTIONING Introduction The recommendations for Evidence-Based Care for Bronchiolitis were modified in 2005 to include: Nasal suctioning prior to inhalation therapy and feeds in infants 3 months of age; and Nasal suctioning in infants> 3 months of age prn prior to feeds and inhalations. The recommendations reflected expert opinion from critical care and respirology groups at Winnipeg Children s Hospital and are consistent with other existing guidelines and pathways and one randomized controlled trial. Technique Nasal secretions associated with bronchiolitis may be very tenacious. Administering saline drops may be helpful in loosening secretions to facilitate suctioning. Use 1-2 drops of saline solution into each nostril if required. To suction squeeze the air out of the bulb before inserting it into the nostril. Gently place the tip of the bulb into a nostril. Slowly allow air to come back into the bulb. Repeat as necessary. You may find more secretions are removed when you close the other nostril with your finger. Squeeze mucus out of bulb into a tissue. Make sure that the bulb suction is empty. Suction the other nostril the same way. Gently wipe off the mucus around the nose with tissues to prevent skin irritation. Image courtesy of CPEM; gif 47. Cleaning the bulb suction The bulb suction device should become patient-specific and may be provided to the child s parent or guardian for continuing home use. As a minimum the bulb suction should be flushed with clean soapy water then rinsed with clean water, emptied of all excess water and then air dried. If the bulb suction is to be used for other patients, locally approved infection control guidelines should be followed. Text adapted from, and courtesy of Winnipeg Children s Hospital. JAHNMU 2005/01 February 2005 Page 3

4 Patient Name: Date of Birth: Assign a score based on the criteria below*. 1. Score child at rest pre-therapy and 30 to 60 minutes post-therapy. 2. Therapy may be considered effective if there is a decrease of 3 from pre- to post-therapy score. 3. No adventitious sounds in the absence of breath sounds should be scored as 3. Medications: A = adrenalin V = vaponephrin S = salbutamol Date y/m/d Time 00:00 Pre Rx Post Rx O 2 : Flow rate (L/min) or R/A Med n O 2 S a O 2 HR General Appearance Respiratory Rate Retractions Breath Sounds (A/E) Adventitious Sounds Total Score Score Difference Comments Initials General Appearance Criterion Active and alert Irritable but responds to comfort, interested in feeds Unsettled, no interest in toys/environment Unresponsive to environment, focused on breathing < 6 months < >70 Respiratory Rate > 6 months < >60 Retractions* None Mild Moderate Severe Breath Sound Intensity* ( Air Entry ) Adventitious Sounds Good A/E Slightly decreased Decreased Barely audible/absent Clear Intermittent wheezes/crackles Widespread wheezes/crackles Widespread W/C &/or grunting/stridor

5 Retractions Mild: Subcostal indrawing only (see Fig 1). Moderate: Retractions in subcostal region and one of following: nasal flaring (see Fig 2), substernal, subclavicular, intercostal indrawing (see Fig 3) or tracheal tug (see Fig 4). Severe: Retractions in more than two anatomic regions. Breath Sound Intensity (Air Entry) Slightly decreased: Air entry decreased in a single lobe or generalized mild decrease in the intensity of vesicular breath sounds Decreased: Air entry decreased in two or more lobes &/ or only bronchial breath sounds audible &/or inspiratory breath sounds < expiratory breath sounds. Figure 1. Subcostal Indrawing Label1 Suprasternal Figure 2. Nasal Flaring Supraclavicular Intercostal Subcostal Figure 4. Tracheal Tug Figure 3. Indrawing

6 . Instructions for Parents and Other Family Care Givers NASAL SUCTIONING Why does the baby need to be suctioned? When babies have bronchiolitis, the nose can often get plugged with thick secretions. Suctioning is used to clear the baby s nose of extra secretions. Babies younger than 6 months normally breathe through their nose. Taking the secretions out of the baby s nose with the bulb suction makes it easier for him/her to breathe and eat. Studies have also shown that babies may also respond better to medication delivered by mask following nasal suctioning. When should the baby be suctioned? You do not need to suction an infant routinely. Signs that the baby may need their nose suctioned include: Secretions that spill out of the nose Nasal congestion or stuffy nose Noisy Breathing (snorting or snuffly sounds) Babies less than 3 months of age may feed better if you suction the nose before feeding. Do not suction the baby immediately after feeding. How to suction the baby s nose. Sometimes it is hard to suction secretions out of the nose because they are very thick. When this happens, putting saline (salt water) drops into the nose will help to loosen the secretions. You can make a saline solution easily by thoroughly mixing 1/2 teaspoon of salt to 1 cup of warm water in a clean jar that has a tight lid. The solution can be kept for one week and then should be discarded. Drop 1-2 drops of saline solution into each nostril to help thin the secretions. To suction squeeze the air out of the bulb before inserting into the nostril. Gently place the tip of the bulb into a nostril. Slowly allow air to come back into the bulb. This will produce suction and pull the secretions out of the nose and into the bulb. Repeat this if there are still lots of secretions. You may find more secretions are removed when you close the other nostril with your finger. Squeeze mucus out of bulb into a tissue. Make sure that the bulb suction is empty. Suction the other nostril the same way. Gently wipe off the mucus around the nose with tissues to prevent skin irritation. September 2006 Page A

7 Instructions for Parents and Other Family Care Givers NASAL SUCTIONING Image courtesy of CPEM; gif 47. How to clean the bulb suction. Clean the bulb suction after you are finish suctioning your child. Squeeze the air out of the bulb and insert into a fresh, clean cup with soapy water. Squeeze the bulb several times to clean out the mucus. Rinse well with clean water and squeeze the bulb to remove all of the excess water. Allow the bulb suction to air dry. Questions? If you have any questions regarding the child s care for bronchiolitis, and if you need more instructions regarding nasal suctioning, do not hesitate to contact the Nursing Station or Health Centre. Text adapted from, and courtesy of Children s Hospital Patient Education Committee. JAHNMU 2005/01 September 2006 Page B