Dramatically improve care of peds with bronchiolitis

The sound of a small child breathing in gasps and wheezes can alarm even experienced ED nurses, and your assessment of this vulnerable patient is key to ensuring a good outcome, says Lynn Daum, RN, BSN, special projects coordinator for emergency services at Cincinnati Children’s Hospital Medical Center.

"I think the most important thing for nurses to remember is to look at the whole patient and not get sidetracked by the noisy breathing," she says. "These kids sound horrible, and it is easy to panic."

From December 2003 to July 2004, the ED at Children’s Medical Center Dallas treated 1,369 patients with a primary diagnosis of bronchiolitis. "The busiest months were January and February, with about 500 bronchiolitis patients each month," reports Andrea Bracken, RRT-NPS, respiratory therapy educator for the ED.

You can improve care of children with bronchiolitis by doing the following:

  • Consider the airway first.

A patent airway is the first thing to consider with any child presenting with a respiratory illness, advises Bracken.

To determine if secretions block the airway, look for increased work of breathing, use of accessory muscles, and nasal flaring, she says. "How long has the patient been breathing like this? Are they going to tire out and progress to respiratory failure if no interventions are made?" she asks.

You will get the best assessment if you listen to patients when they are calm and not crying, Bracken notes.

"Listen at the nose and upper airway. Do you hear coarseness that would indicate the presence of secretions in the nose and upper airway?" she asks. "Listen over the lung fields for wheezes or crackles that may indicate airway obstruction, constriction, or secretions in the airway."

  • Avoid unnecessary diagnostic tests.

Because bronchiolitis easily can be diagnosed clinically, there is no need for nasal washes, argues Daum. "If it looks like, sounds like, and has a history like bronchiolitis, then it is," she says.

The nasal wash tests, which involve normal saline squirted in the child’s nose and then sucked back out, were distressing to nurses and families, Daum adds.

Parents felt as though the child was being drowned, she says. "And of course, the child would cry, cough, and snort — they sounded worse than when they came in," she explains.

The situation was scary for everyone involved, adds Daum. "So staff are happier, and so are the parents, which is very important."

Chest X-rays are no longer done for these patients, she adds. "Once again, they did not change diagnosis or treatment, so why subject the child to an X-ray?" Daum points out.

A single aerosol treatment is done, but only if the patient meets specific criteria. The patients are scored on a respiratory flow sheet before anything else is done, then they are suctioned. "If the score is 2 or greater with a family history of wheezing, and after being suctioned, the MD will consider an aerosol," she says. (See the ED’s bronchiolitis respiratory flow sheet.)

If the child’s score is 3 to 5, an aerosol treatment is given, and the respiratory score then is repeated to measure improvement. "If there wasn’t any, then another aerosol is not indicated," she explains. "In other words, an aerosol treatment is only repeated if there is documented improvement."

An already sick child doesn’t have to receive a treatment that is not effective, Daum says.

  • Assess the need for admission.

If the child was born prematurely or has other respiratory or systemic problems, further support may be needed, she says. "A child with a narrowed trachea, who presents with bronchiolitis, will be visiting the hospital."

However, because treatment is supportive, most bronchiolitis patients can be sent home, she says. Of 745 bronchiolitis patients seen from January to March 2004, 200 were admitted and 545 were discharged from the ED, she reports.

"With proper education, the parents or caregivers are very able to care for these children," Daum says. "If the child is pink, has moist mucous membranes, is feeding well, and has normal diapers, the patient can go home — even if respiratory rate is in the 60s."

  • Teach parents to suction.

Many times children come to the ED with large amounts of secretions, and parents don’t know how to handle this problem at home, notes Bracken.

"Frequently, before any other interventions, the child is bulb suctioned," she says. "This goes a long way in improving their status."

Teach parents how to aggressively bulb suction their children and have them demonstrate this procedure before leaving, recommends Bracken.

"Otherwise, the child will be presenting again in the ED with the same complaints," she says. "Written discharge instructions on bulb suctioning and bronchiolitis also are helpful."

  • Make sure the patient is hydrated.

The patient’s hydration status is important to move secretions, says Ginger Young, RN, clinical educator for the ED at Children’s. "If the child is not drinking, an IV often is initiated, and parents are instructed to keep them well-hydrated at home," she says.

Sources

For more information on bronchiolitis, contact:

  • Andrea Bracken, Educator, Respiratory Therapy, Children’s Medical Center Dallas, 1935 Motor St., Dallas, TX 75235. E-mail: andrea. bracken@childrens.com.
  • Lynn Daum, RN, BSN, Emergency Services Nursing, Special Projects Coordinator, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039. Telephone: (513) 636-1831. E-mail: Lynn.Daum@cchmc.org.
  • Ginger Young, RN, Clinical Educator, Emergency Center, Children’s Medical Center Dallas, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 456-5686. E-mail: ginger.young@childrens.com.