15.10 Bronchiolitis

Bronchiolitis, or inflammation of the bronchioles in the lower respiratory tract, is an acute respiratory condition that is commonly seen in children. It is most commonly caused by respiratory syncytial virus (RSV), but can also be caused by rhinovirus, metapneumovirus, adenovirus, coronavirus, and parainfluenza virus. Read more information about RSV in the “Respiratory Viral Infections” section.

Bronchiolitis can occur at any age, but infants tend to have the most severe symptoms. Cases typically occur during the fall and winter months. Risk factors for the development of this disorder include the following^[1]:

• Infants who are premature or less than five months in age
• Clients of a low socioeconomic status or living in close quarters
• Clients with chronic lung disorders or immunosuppression
• Clients who are exposed to tobacco smoke

Pathophysiology

The causative virus of bronchiolitis infects cells of the airway and leads to inflammation, abnormal function of the cilia, and cell death. The inflammation results in edema and narrowing of the airways, which leads to the symptoms seen in bronchiolitis.^[2]

Assessment (Recognizing Cues)

Physical Exam

The client with bronchiolitis will initially present with upper airway dysfunction and have a cough, runny nose, and elevated temperature. Symptoms generally last seven to ten days, but symptoms can linger for up to three weeks. As the disorder progresses to the lower respiratory tract (within two to three days), symptoms of respiratory distress can occur. Symptoms of respiratory distress include the following^[3]:

• Adventitious lung sounds such as crackles, wheezing, or rhonchi
• Elevated respiratory rate
• Retractions
• Grunting
• Cyanosis
• Excessive mucus production
• Difficulty breathing
• Irritability and poor feeding in infants

Potential complications of bronchiolitis are pneumonia and pneumothorax (air leaking into the thoracic space that causes a collapsed lung). Small populations of pediatric clients also develop a concurrent urinary tract infection, but the link between urinary tract infections and bronchiolitis is not yet well understood.^[4],[5]

Common Laboratory and Diagnostic Tests

Bronchiolitis is a clinical diagnosis, and testing may only be done to rule out other disorders. If complications are suspected, a chest X-ray may be ordered. If a urinary tract infection is suspected, urine testing may be ordered. Arterial blood gas tests are ordered in severe cases to assess the extent of respiratory distress and the need for intubation.^[6],[7]

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with bronchiolitis include symptom management, preventing complications, and controlling the spread of infection to others.

Nursing diagnoses for clients with bronchiolitis are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment.

Possible nursing diagnoses for clients with bronchiolitis are as follows:

• Ineffective airway clearance r/t airway edema
• Ineffective breathing pattern r/t disease process
• Fatigue r/t increased work of breathing

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, and realistic. These outcomes should be achievable within a set time frame based on the application of appropriate nursing interventions.

Sample expected outcomes include the following^[8]:

• The client will exhibit a patent airway and no signs of respiratory distress during the course of the illness.
• The client will demonstrate an appropriate respiratory rate for their age within 24 hours of medical treatment.
• The client will display increased energy and engage in age-appropriate play within one week of medical treatment.

Interventions (Generate Solutions & Take Action)

Medical Interventions

Medical treatment for clients with bronchiolitis consists of supportive care. Clients with mild symptoms can be treated at home with saline nasal spray, fever-reducing medications, and a cool-mist humidifier. Clients with severe symptoms and/or dehydration are hospitalized and receive humidified oxygen, hypertonic saline via a nebulizer, and hydration. Hypertonic saline nebulizer treatments reduce edema and the viscosity of secretions. Clients with very severe symptoms may require admission to the intensive care unit and respiratory support via intubation and mechanical ventilation.^[9],[10]

Nursing Interventions

Registered nurses plan interventions based on the expected outcomes for each client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client.

When caring for a client with bronchiolitis, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching as described in the following subsections.^{[11],[12],[13]}

Nursing Assessments

• Monitor respiratory status, including respiratory rate and pattern, pulse oximeter readings, and the presence of nasal flaring, shortness of breath, or the use of accessory muscles. Changes in respiratory status indicate a change in condition and may require emergent interventions.
• Monitor lung sounds. Excessive edema in the bronchioles can lead to obstruction and atelectasis (collapse of alveoli), causing absent breath sounds in affected areas of the lung.
• Monitor intake and output because dehydration can occur due to diminished fluid intake and increased fluid loss due to fever and elevated respiratory rate. Monitor other indicators of dehydration such as elevated heart rate, decreased skin turgor, and dry mucous membranes.

Nursing Actions

• Administer prescribed medications, fluids, and oxygen therapy. Medications may be prescribed to manage fever. Fluids should be administered orally when possible, but intravenous fluids may be required for clients who are NPO or have an elevated respiratory rate. Oxygen should be humidified and should be titrated to keep oxygen saturation levels greater than 90%.
• Encourage rest periods and cluster nursing cares to reduce disruptions and help prevent fatigue. Prolonged crying can increase fatigue and should be avoided as much as possible.
• Hold infants with bronchiolitis in an upright position and elevate the head of the bed for children. These positions allow for optimal lung expansion and improved gas exchange.
• Encourage parents/caregivers to stay with hospitalized pediatric clients and perform cares such as feeding and bathing to decrease anxiety.

Client Teaching

• Teach the client and their caregivers to avoid exposure to cigarette smoke because this is a risk factor for bronchiolitis.
• Educate the client and their caregivers about effective handwashing and respiratory etiquette to help prevent the spread of infection to others.
• Teach caregivers to perform nasal suctioning prior to feeding infants because this can improve their ability to eat.
• Encourage parents/caregivers to vaccinate their children against RSV to prevent a decreased risk for developing bronchiolitis. Vaccines are further discussed in the “Respiratory Viral Infections” section.

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.