BRONCHIOLITIS RESPIRATORY SYNCYTIAL VIRUS
Bronchiolitis occurs when a viral or bacterial infection invades the lower respiratory tract, causing inflammation and obstruction of the bronchioles (Ball, Bindler, Cowen, & Shaw, 2017). While there are a variety of viruses that can cause bronchiolitis, respiratory syncytial virus (RSV) is the leading cause of bronchiolitis, and the leading cause of severe lower respiratory tract infections in young children (Walsh, 2017). Bronchiolitis occurs when a viral or bacterial infection invades the lower respiratory tract, causes inflammation and obstruction of the bronchioles (Ball et al., 2017). RSV attacks and kills the mucosal cells lining the small bronchi and bronchioles, obstructing the bronchioles and irritating the airway (Ball et al., 2017). This irritation leads to excessive mucus production, cough, wheezing, hyperexpansion of the lungs, hypoxia, and respiratory distress (Zhou et al., 2015). Current nursing care for infants and young children with RSV bronchiolitis focuses on supporting the child, maintaining respiratory function, and supporting fluid balance and rest.
According to the Centers for Disease Control and Prevention (CDC), RSV infections lead to 57,527 hospitalizations and 2.1 million outpatient visits among children younger than 5 years old in the United States each year (CDC, 2016). In fact, RSV is the most important reason previously healthy infants are admitted to the hospital, predominantly due to an immature immune system and smaller dimensions of the airways of the lungs of infants and young children (Pickles & DeVincenzo, 2015). Infants who were born prematurely are at an even higher risk for a RSV infection causing hospitalization than infants born at term (Figueras-Aloy et al., 2016).
RSV is an extremely common infection, and by the age of 2 years, almost all children have been infected with RSV at least once (Figueras-Aloy et al., 2016). The transmission of RSV happens most effectively through contact of nasal secretions; RSV can survive for several hours on hard surfaces and hands, so the virus is transmitted via direct contact with objects that have been contaminated (Walsh, 2017). The season for RSV infections in the United States starts in October, peaks in December through February, and finishes in March or April (Bont et al., 2016).
Although all people contract RSV several times throughout their lifetimes, infants and young children are at the greatest risk for severe complications from the virus. The risk factors for an RSV infection progressing to severe bronchiolitis have been identified: less than 3 months at the time of infection, premature birth, and/or underlying immunodeficiency or cardiopulmonology disease 27(Pickles & DiVincenzo, 2015). These risk factors are all important, but the age of infection seems to be the most significant risk factor. In fact, 80% of infants hospitalized with a RSV infection younger than the age of 2 months had no significant past medical history (Pickles & DiVincenzo, 2015). Additionally, studies have shown that the disease can impact a child long after the child’s hospital discharge. In fact, children who were hospitalized as infants with RSV bronchiolitis have a higher prevalence of asthma when compared to matched control infants (Mejias & Ramillo, 2015).
RSV bronchiolitis should be considered in any infant presenting with acute symptoms of lower respiratory tract infections, especially during the winter months (Pickles & DiVincenzo, 2015). A conclusive diagnosis is made by taking a posterior nasopharyngeal wash or swab specimen and conducting an enzyme-linked immunoabsorbent assay (ELISA) or a immunofluorescent assay to identify the specific virus causing the symptoms (Ball et al., 2017). Additionally, a chest radiograph should be obtained. A child with bronchiolitis will have a chest x-ray showing hyperinflation, patchy atelectasis, and signs of inflammation (Ball et al., 2017). Clinical manifestations can also support a diagnosis of RSV. Children with an RSV infection will present with nasal congestion, cough, intermittent low-grade fever, wheezing, tachypnea, and poor feeding, with possible vomiting or diarrhea (Ball et al., 2017; Pickles & DiVincenzo, 2015). A child with a more significant infection will present with increased tachypnea, significant wheezing and coughing, poor fluid intake, and a distended abdomen, related to hyperexpansion in the lungs (Ball et al., 2017; Pickles & DiVincenzo, 2015).
The most important areas to assess in a young child presenting with RSV bronchiolitis are the child’s airway and respiratory function. This can be done using good observation skills noting how quickly the infant is breathing and if retractions are noted, and by using pulse oximetry to determine oxygenation (Ball et al., 2017). Infants with RSV bronchiolitis can progress into severe disease quite easily, but identifying which patients will exhibit a progressively worse disease is difficult (Mejias & Ramillo, 2015), making the need for close observation of subtle changes in patients’ status important. Parental and caregiver education also becomes very important, as many children with an RSV infection can be managed at home. The families need to help their child by encouraging rest, proper fluid intake and comfort, while being able to recognize when the patient’s status may be declining (Potts & Mandleco, 2012). Children who are showing signs of respiratory distress and/or dehydration may require hospitalization. A hospitalized infant with RSV bronchiolitis may require humidified oxygen, nasal suctioning, intravenous (IV) fluids, input and output (I&O) monitoring, and daily weights (Ball et al., 2017).
As previously mentioned, treatments for RSV are mostly supportive therapies. At this time, there is no specific treatment for RSV, and medications are 28generally not prescribed for RSV infections (Ball et al., 2017). Palivizumab (Synagis) is a medication given to protects infants from RSV, but it is reserved for only high-risk infants who meet criteria outlined by the American Academy of Pediatrics (Walsh, 2017). This medication is given monthly, up to five times, during an infant’s first winter, and it provides a passive immunity protection (Ball et al., 2017; Walsh, 2017).
NURSING INTERVENTIONS, MANAGEMENT, AND IMPLICATIONS
One of the most important nursing-related problems surrounding RSV of the hospitalized infant is being careful to not spread this contagious disease from one patient to another. Proper handwashing and isolation precautions for the RSV patient are crucial. These patients require contact precautions, which include gloves and gowns (Walsh, 2017). It is also important to continually promote adequate respiratory status, fluid balance, nutrition, rest, and comfort (Ball, Bindler, Cowen, & Shaw, 2017). Finally, nursing professionals must educate the parents and caregivers about the disease and its normal progression. Parents will need guidance in understanding bronchiolitis and respiratory distress, and recognizing signs and symptoms their infant’s disease is getting more severe or improving. Additionally, parents and family may need emotional support due to the stress of the child’s hospitalization and caring for a sick infant (Ball & Bindler, 2017).
The expected outcome of nursing care for an infant infected with RSV is complete recovery without further complications. Within 24 to 72 hours, the production of mucus will begin to decrease, aiding in improved respiratory function (Ball & Bindler, 2017). Once the virus runs its course, most infants and young children return to their pre-RSV health. Their breathing and feeding patterns should return to normal, and any weight lost because of poor feeding should be regained quickly. The incidence of reinfection can occur, but as the child grows, the severity of the disease will lessen. As noted before, there is a higher incidence of children who were severely infected with RSV and required hospitalization, acquiring asthma later in life (Meijias & Ramilo, 2015), making an RSV infection an important component of the patient’s medical history.
A RSV infection in infants and young children can differ in its severity, making it vital for health care professionals to recognize subtle changes in the patients’ status, especially related to respiratory function. Early recognition, supportive nursing interventions and thorough parent/caregiver teaching are crucial in managing patients infected with RSV.