Nebuliser Therapies in the Treatment of Bronchiolitis
Introduction
Bronchiolitis is a mostly seasonal disease, with the majority of cases being caused by the respiratory syncytial virus. Around 2 -3 percent (30 per 1000) of all children under 1 year old are likely to be admitted to hospital with this disease (Smyth and Openshaw, 2006).
Using a modified version of the Gibbs Reflective cycle (1988) this assignment will evaluate the assessment and treatment of an unwell infant bought in to the children’s ward, and in particular will focus on the efficacy of nebuliser therapies in the treatment of bronchiolitis. Consent was gained prior to questioning and examination and confidentiality maintained throughout (HCPC, 2012).
Description
A 4 week old baby was bought in to the children’s ward by ambulance suffering from severe respiratory distress. He had been seen by a doctor and diagnosed with bronchiolitis two days earlier at which time his symptoms were less severe. The Scottish Intercollegiate Guidelines Network note that some infants with bronchiolitis may deteriorate within the first 72 hours (SIGN, 2006), a fact perhaps supported by the article published by Woollard and Jewkes (2004) recognising that children can compensate extremely well to significant illness, but when these compensatory mechanisms fail they can do so “rapidly, catastrophically and irreversibly”. On gaining a history from the parents (Thomas and Monaghan, 2010 pp. 522-523), this baby was previously fit and well, meeting his developmental milestones (Parker, 2012), and would, according to Ormrod (2008), have reached sub-stage 2 of the Piaget’s Sensorimotor stage “Primary Circular Reactions”. A Heel Prick or “Guthrie” test (Willacy, 2013) at 5 days revealed no abnormalities.
He initially presented to his G.P. with the classic symptoms of bronchiolitis: coryzal symptoms leading to irritable cough; tachypnoea, tachycardia, widespread crepitations and a low grade temperature (Simon,Everitt and Kendrick, 2007 pp.851), but unfortunately had since deteriorated and was now showing signs of severe disease: severe chest wall recession, nasal flaring, grunting, an oxygen saturation (SPO2) reading of less than 94%, feeding less than half his normal amount (SIGN, 2006) and was at risk of respiratory failure (Dieckmann, 2006 pp.66 -67). Widespread wheezes and crackles were noted on auscultation (Pattemore, 2008). Please see Appendix 1 for the full assessment.
Analysis
As part of their treatment regime the ambulance crew had administered nebulised salbutamol en route to the hospital, which had had little effect on the baby’s condition. Following a later discussion with a doctor it became evident that salbutamol may not be effective in relieving the symptoms of bronchiolitis, a fact I was unaware of at the time.
Dieckmann et al (2006 pp.66-67) advocate the use of both nebulised salbutamol and epinephrine in severe bronchiolitis as it may “prevent the need for assisted ventilation”. Some studies have felt that salbutamol had benefits over epinephrine, particularly in relation to successfully discharging patients (Walsh, Caldwell and Rothenburg, 2008), although a later paper (DeNicola et al, 2013) found that epinephrine showed greater efficacy in improving clinical signs than salbutamol, a finding also supported by Hartling et al (2011). The question as to whether salbutamol could provide either an immediate or longer term clinical improvement was researched by Godomski and Brower (2010) by way of a Cochrane review, who concluded that bronchodilators had no marked benefits in the treatment of bronchiolitis, and noted that where their study may have shown small improvements to outpatient groups, this may be due to earlier inclusion of asthma patients in some studies. It also noted that salbutamol was responsible for adverse effects such as tachycardia, tremors and even decreased oxygen saturation, the latter being a key factor in the decision by some doctors to admit a child to hospital, despite the lack of evidence supporting the usefulness of pulse oximetry in bronchiolitis (Smyth and Openshaw, 2006).
Whilst showing benefits to children suffering from asthma and croup (Hvizdos and Jarvis, 2000), inhaled steroids are not routinely indicated in those suffering from bronchiolitis (DeNIcola et al, 2013) although Hartling et al ( 2011) feel there may be justification for a trial using combined adrenaline and steroid therapy.
Perhaps the limited effectiveness of inhaled drugs could be explained by Amirav et al (2002), who, by way of y-scintigraphy, demonstrated a poor aerosol deposition of nebulised bronchodilators in the lungs of infants suffering from bronchiolitis, a finding which they attributed to the infant’s already small conducting airways becoming further narrowed or blocked by mucus. Interestingly, the most promising nebuliser therapy is perhaps the safest and least expensive. Anil et al (2009), found that nebulised normal saline at 30 minute intervals had a positive clinical effect with no adverse effects, while Eber (2011), Ansari et al (2011) and Zhang et al (2013) all advocate the use of hypertonic saline, as it can improve airway hygiene by its effect on the mucus plugs often associated with bronchiolitis, again, without demonstrating any adverse effects.
Action
In regard to management of the disease, Johnson and Hill-Smith (2012) recommend maintaining fluid intake, while Smyth and Openshaw (2006) conclude that in the absence of specific, proven therapies clinical treatment is limited to supportive care, which although lacking validation from large controlled trials includes oxygen and fluid therapy. Thus, a nasogastric tube was inserted (Durai, Venkatraman and Philip, 2009) (although Eber (2011) notes that there is a split in practice between nasogastric and intravenous hydration) and a head box utilised (Gater, Norman and Nabney, 2012) in order to administer humidified oxygen (Chandler, 2001). He was closely monitored by staff from that point on, eventually being transferred to a 24 hour unit in a nearby town following an “SBAR” (situation, background, assessment, recommendation) telephone update (Way et al, 2013).
Implication on practice I now realise that a comprehensive history and thorough assessment is imperative in the diagnosis of bronchiolitis, as other potentially serious conditions can have similar presentations (SIGN, 2006). From the evidence above, I would certainly now consider nebulising with normal or hypertonic saline when dealing with suspected bronchiolitis, whereas previously I would have only perhaps considered salbutamol.
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References
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