08.03 Bronchiolitis and Respiratory Syncytial Virus (RSV)

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Overview

  1. Inflammation of the bronchioles
    1. Bronchioles are the smallest branches off of the bronchi that lead to the alveoli
      1. Alveoli = tiny air sacs where gas exchange occurs
  2. Results in thick mucus production that occludes airways.

Nursing Points

General

  1. Most often occurs < two yrs
  2. Winter illness (usually)
  3. Common cause is Respiratory Syncytial Virus (RSV)
    1. Highly contagious
    2. Spread via contact with airway secretions.
  4. Symptoms worse days 4-6 of illness
  5. Condition can deteriorate rapidly

Assessment

  1. Copious nasal secretions
  2. Coughing
  3. Fever
  4. Increased Work of Breathing
    1. Shortness of breath
    2. Retractions
    3. Nasal flaring
  5. Tachypnea → progressing to episodes of apnea
    1. (>70 rpm)
  6. On auscultation
    1. Crackles
    2. Wheezing
  7. Hypoxia
  8. Poor feeding
  9. Lethargy

Therapeutic Management

  1. Treatment is generally supportive (symptom management)
  2. Monitor and assess respiratory status
    1. Work of breathing
    2. Continuous SpO2
  3. Maintain airway
    1. Position the child in semi fowlers
      1. Neck extended to best open the airway
    2. Keep suction equipment at bedside
  4. Provide humidified air or oxygen
    1. Nasal cannula
    2. High Flow Nasal Cannula
  5. Maintain adequate fluid intake
    1. NG tube
    2. IV fluids
    3. Suction nose prior to feeding
  6. Medications
    1. Antivirals (ribavirin)
    2. Controversial use of surfactant, CPT, and bronchodilators
      1. *See AAP (2015) https://pedsinreview.aappublications.org/content/35/12/519
  7. Infection Control
    1. Isolation
    2. Contact precautions
    3. Good hand hygiene

Nursing Concepts

  1. Oxygenation
  2. Gas Exchange
  3. Infection Control

Patient Education

  1. Isolate from other children
  2. Help parents know the prognosis and plan of care to ease anxiety
  3. Prevention
    1. Palivizumab
      1. Primarily for babies born prematurely or with other risk factors like Cystic Fibrosis or Down Syndrome.

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Video Transcript

Hey Everybody! In this lesson we are going to be going over the diagnosis of Bronchiolitis.

Bronchiolitis is a very common reason for admission in the pediatric world. It’s known as being a winter and spring illness and it’s caused by a virus called Respiratory Syncytial Virus, which from now on I will just refer to as RSV. Babies who have RSV can deteriorate really quickly, so your knowledge about this diagnosis and ability to know when they are tanking really and truly can save lives! So let’s get started!

Alright so bronchiolitis is infection and inflammation of the lower airways, specifically the bronchioles. The major characteristic of this illness to know about is that there is a ton of thick mucus that can lead to obstruction in both the upper airways and the lower airways.

So for the upper airway you are getting blocked noses and for babies who prefer to breath out of their noses this leads to difficulty with feeding and ultimately dehydration, which can really complicate the illness.

In the lower airways the bronchioles are getting blocked with mucus which, affects gas exchange which results in hypoxia.

Okay, so let’s pause to remember a little about the lungs. The bronchioles are the smallest branches of the bronchi in the peripherals of the lungs and at the end of these bronchioles are all of the millions of teeny tiny alveoli, or tiny air sacs, and this is where gas exchange happens.

The first thing you’ll notice on assessment is the copious mucus we talked about. And what that looks like is, lots and lots of snot and boogers!

These babies have will have a cough and likely a fever as well. And of for the first few days of the illness this may be all. It may just look like a regular cold with upper respiratory symptoms.

Then you may begin to see increased work of breathing, so things like nasal flaring and retractions- which are signs that the baby is having to work harder to move air in and out of their body. So the nasal flaring is just the baby trying to increase the size of their airway and retractions are a sign that they are having to use those extra muscles in the chest well to help them breath. You can see them in the photo here. They will also start breathing faster to try and compensate.

These symptoms are so important because when you pick up on the fact that a baby is having to work really hard to breath, you can contact the provider or respiratory therapist even and get the baby some help so they don’t get over tired and crash! Always remember, increased work of breathing trumps a normal oxygen saturation! A baby may have an SpO2 of 96% but if you notice severe retractions and nasal flaring and they look tired, we need to step in. Don’t wait for those O2 Sats to drop!

When you listen to a bronchiolitis chest you are going to hear a lot of noise! All that mucus is causing wheezing and crackles, plus there will be a lot of upper airway noises as well!

When you check their oxygen saturations they may be hypoxic.

And you’ll likely see problems with feeding as well. Which could be either from the fact that they are tired or from having a blocked nose that prevents them from being able to feed. So make sure to keep an eye out for signs of dehydration.

Therapeutic management of bronchiolitis is pretty much just supportive. So most of the time what you are going to be doing is giving oxygen and fluids.

The oxygen may be given via nasal cannula, or sometimes we have to use something called High Flow oxygen. This gives some positive pressure to the lungs and helps keep those tiny airways open, the alveoli and the bronchioles that we talked about before.

Fluids may be given through IV or through NG tube. We like for babies to continue feeding as they normally would for as long as possible but if they are tired and lethargic or breathing really fast we don’t want to risk them aspirating! So we need to give them fluids through IV or NG.

It’s important to know that bronchiolitis does not respond to antibiotics so these kids will not be given them.

Other treatments like chest physiotherapy, antivirals and bronchodilators are considered to be controversial.

So, lets just expand on the topic of bronchodilators a bit because you may see them ordered in clinical practice even though the research shows that for the most part they are not effective. The reason they aren’t considered to be effective with bronchiolitis is because the wheeze you get with it is primarily because the airways are clogged with mucus. Bronchodilators are effective when the wheeze is caused by inflammation and narrowing in the airway or bronchospasms, which is what happens in a patient with asthma or COPD.

But in more complex cases- like maybe the baby has an underlying disorder or maybe the have had multiple episodes of wheezing- In these instances, a bronchodilator may be prescribed as a trial to see if it helps. If this is the case, it’s very important to assess for its effectiveness immediately following the treatment. If it had no effect on the wheeze then it should be discontinued immediately because of the side effects, like tachycardia and hyperkalemia.

The key thing to remember though is that most of the time we are giving support treatment like O2 and fluids, but you may these some of these other things in more complex patients.

So in addition to the oxygen and fluids we already mentioned, there are a few other important nursing interventions that will help these babies.

First, we have to keep a really close eye on their oxygen levels, so they need to be on continuous pulse ox monitoring. These babies are also very prone to apneic episodes, especially if they were born prematurely so there may be a need for an apnea bradycardia monitor as well.

Make sure to elevate the head of bed or the head of the crib because this can help them manage the secretions. Remember babies have big heads, so sometimes it helps to put a rolled up towel under the shoulders to help keep their heads from falling forward and occluding their airway.

Regular nasal suctioning really helps these babies a lot! I’m not talking about deep suctioning here just using a regular bulb syringe or a neosucker attached to bedside suction. This not only helps them breathe but it also helps them feed!

Last but not least, RSV is spread through both droplet and contact so when you go in the room you’ll need gown, gloves and mask!

Your priority nursing concepts for a pediatric patient with bronchiolitis are oxygenation, gas exchange and infection control!
Okay guys, let’s go over your key points for this lesson on bronchiolitis! Okay so bronchiolitis is an infection of the lower respiratory tract (specifically, in the bronchioles. It mostly occurs in the winter and spring and is usually caused by a virus called RSV or respiratory syncytial virus. The most important characteristic of this illness to know is that there is a lot of mucus that leads to obstruction in the lower airways. So there will be a lot of nasal secretions and the baby will have difficulty feeding and breathing.

Treatment is primarily giving oxygen and fluids.

These babies have to be monitored really closely because they can tire out and deteriorate really quickly. I’ve seen it happen, so remember their work of breathing trumps the O2 sat. A baby who has retractions, nasal flaring and is tachypneic needs intervention. Don’t want on those sats to drop to step in.

RSV is spread by droplet and contact so make sure you get on the gown, gloves and mask when going into to take care of these little ones.

That’s it for our lesson on how to care for a patient with bronchiolitis. Make sure you check out all the resources attached to this lesson. We have links to 2 really great videos about bronchiolitis. One is an interview with a parent about the experience their child had and the other is a patient education video that goes over all the things you should be able to talk to families about! Now, go out and be your best self today. Happy Nursing!

Read more

  • Question 1 of 7

The nurse caring for a 6-month-old diagnosed with bronchiolitis knows which of the following is most likely the cause?

  • Question 2 of 7

A nurse has been assigned to float to the pediatrics unit for a shift. The nurse has been assigned three clients, including an infant with rotavirus, a child recovering from an appendectomy, and a baby with respiratory syncytial virus. Which practices should be implemented that would best protect the nurse from contracting an infectious disease? Select all that apply.

  • Question 3 of 7

A three month old infant needs an IM injection of palivizumab for prevention of RSV. Which site is most appropriate for the nurse to administer this medication?

  • Question 4 of 7

As the nurse caring for a 9-month-old with bronchiolitis, which of the following do you expect to be a part of their care while in hospital? Select all that apply.

  • Question 5 of 7

The nurse caring for a 4-month-old with bronchiolitis knows that which of the following complications commonly occurs with this respiratory illness?

  • Question 6 of 7

A nurse is expecting an 18-month-old with bronchiolitis from the emergency department, Which of the following protective gear should be worn when entering the child’s room? Select all that apply.

  • Question 7 of 7

An infant in the pediatrics unit has been diagnosed with respiratory syncytial virus (RSV). The nurse should include which of the following precautions in caring for this infant? Select all that apply.

Module 0 – Pediatrics Course Introduction

Module 5 – Metabolic And Endocrine Disorders

Module 12 – Musculoskeletal Disorders

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