This article will focus on the assessment and management of bronchiolitis and critically reflect on the practice of an advanced nurse practitioner (ANP), working in an urgent care out of hours (UCOOH) service. The pathophysiology and epidemiology of bronchiolitis will be briefly outlined, and the process of assessment, diagnosis and management of this condition will be critiqued, based on the existing evidence. Dilemmas associated with differing treatments will also be discussed and recommendations provided for the development of future practice.
Bronchiolitis
Bronchiolitis is an acute inflammation of the bronchioles that predominately affects children under the age of two years, but most common in the first 12 months of life. Respiratory syncytial virus remains (RSV) the most frequent cause (National Institute for Health and Care Excellence [NICE], 2015). Epithelial cells within the bronchial tree become infected: mucus and slough from cell death, partially or completely obstruct the small airways resulting in diminished gas exchange, breathlessness, and hypoxia (DeVincenzo, 2007).
Viral bronchiolitis is the principal cause of admission in children under a year old in England and Wales with numbers exceeding 30 000 annually (Green et al, 2016). Occurrence is seasonal, in winter months incidence is typically at epidemic proportions for approximately six weeks, however this can differ from year to year (Public Health England, 2015a). Bronchiolitis is usually a self-limiting lower respiratory viral illness lasting 3−7 days, however in cases were comorbidities exist it can trigger severe illness (NICE, 2015).
Treatment of bronchiolitis varies in practice and there is a lack of consensus regarding management (Carande et al, 2018). Health Education England ([HEE], 2017) indicate that nurses in advanced practice should use clinical reasoning, expertise, and evidence-based practice (EBP) to diagnose safely and appropriately. It is therefore imperative that guidelines are utilised, ensuring EBP to holistically assess, diagnose and manage patients on a personalised basis.
Assessment of an unwell child
The assessment of an unwell child is challenging and to prevent further deterioration it is important to focus on spotting the sick child at an early stage (Snelson, 2011). It is imperative to perform an initial assessment prior to taking a history and a full examination, this ensures that risk is managed to ensure patient safety (HEE, 2017). The paediatric triangle is utilised as a triage tool that allows rapid assessment of a child's appearance, work of breathing and circulation by means of auditory and visual clues to determine the level of illness (Clayden and Lissauer, 2012). Initial features such as a child appearing very unwell, drowsy or with altered consciousness, grunting, nasal flaring, tachypnoea, cyanosis or mottling of the skin can suggest that the child is very unwell and detection provides crucial early warning signs of deterioration (Snelson, 2011). In these cases, the nurse should seek urgent medical 999 assistance and arrange hospital admission (NICE, 2015). Children under the age of one year are at a higher risk of developing sepsis (Plunkett and Tong, 2015), to ensure detection, the NICE (2017b) risk stratification tool is valuable in the assessment of risk in these children.
Presentation of bronchiolitis
Bronchiolitis presents initially with coryza and a persistent cough; as the RSV infection progresses, tachypnoea, chest recession or both may be present alongside wheeze or crackles (NICE, 2015). Other common symptoms include poor feeding due to increase work of breathing (Snelson, 2011) and a pyrexia of up to 39 °C (NICE, 2017a). At 3−5 days the infection peaks, during which symptoms worsen; in conjunction with this poor feeding may occur (NICE, 2015). Questioning about history therefore includes when the symptoms of pyrexia, breathing difficulties and feeding difficulties commenced. Dehydration can develop therefore determining if the child is having wet nappies or passing urine is a crucial aspect of the history (Barratt, 2018).
Past medical history is a vital, especially in children who are at high risk of deterioration and would potentially require referral to secondary care, for example infants born prematurely, those under three months of age, and those with chronic lung or congenital heart disease, neuromuscular disorders, or immunodeficiency (NICE, 2017a). A focused history is taken including birth history, previous immuniSations, family history, social history and the development of the child (Snelson, 2011). This approach is in line with HEE (2017) who advocate that ANP's should apply a holistic approach to assessment and be able to identify risk factors.
Communication skills
It is key as an ANP nurse to have excellent communication skills, working with parents to take an in-depth history and holistic assessment (HEE, 2017). Fergusson and Lawton (2008) specify that listening to parents is central to taking a history about an unwell child, because parents know their child best, and excellent listening skills during communication are used to enable them to highlight their concerns. To maintain accuracy of history taking, it is essential to foster a trusting relationship with patients and parents is fostered by using an empathetic approach alongside being tolerant, nonjudgmental and attentive (Roland and Snelson, 2018).
Examination
Examination of an unwell child is innovative due to the individuality of each child and situation. The examination is personalised to each child as they present, but always includes a top to toe assessment (Clayden and Lissauer, 2012). Measurement of vital signs should be taken as recommended for all children presenting with pyrexia (NICE, 2013). NICE (2015) stipulate in their guidance regarding management of bronchiolitis, that oxygen saturations are measured and recommend that children with saturations of less than 92% on air, need to be transferred to secondary care immediately by 999. It is important to note that vital signs can fluctuate significantly in children and are only beneficial if they are taken in context (Snelson, 2011). It is crucial to be capable to identify what is normal or abnormal, however this can prove problematic and influences such as fear, anxiety or pain are assessed with each child.
Evidenced-based judgements
To inform decision making, multiple sources of evidence-based judgements are used; this facilitates making a working diagnosis. The NICE (2013) fever traffic light system for children under five years presenting with pyrexia (see Table 1) is used as a valuable tool to predict serious illness. Paediatric early warning scores (PEWS) are available, however there are variations, with no current single PEWS identified in practice (Lambert et al, 2017). It is understood that whilst scoring tools are useful, they should not be used in isolation to predict deterioration, therefore they are used alongside clinical reasoning to establish safe decision-making.
Table 1. Sepsis risk stratification tool: children aged under 5 years out of hospital
As a senior nurse, substantial knowledge about subject specific areas is required so that safe decisions are made, incorporating EBP whilst working autonomously within the code of conduct (HEE, 2017; Nursing and Midwifery Council [NMC], 2018). It is imperative to recognise signs such as a pyrexia above 39 °C, this is unusual in bronchiolitis and could indicate pneumonia (NICE, 2017a). Similarly, duration of pyrexia is assessed, for example a fever of over five days should be evaluated as it could indicate Kawasaki disease (NICE, 2013). A respiratory examination may reveal mild subcostal recession and a bilateral expiratory wheeze; these signs can be present in children with bronchiolitis (NICE, 2017a). Symptoms such as wheeze are not usually present in children presenting with pneumonia, where coarse crackles are predominantly heard (NICE, 2017a). Children with an upper respiratory tract infection (URTI) normally have crepitations on auscultation, usually due to transmitted sounds or excess secretions, however this will include normal breath sounds. Efficacy and work of breathing are assessed, signs of deterioration may include a low oxygen saturation, floppiness, drowsiness, reduced or increased respiratory rate, tachycardia, pallor, tracheal tug, grunting, and nasal flaring (Snelson, 2011). Presence of any, indicate urgent referral.
On examination, it is essential to observe the child for any rashes. A non-blanching rash is an indication of sepsis (NICE, 2017b), other rashes may suggest an alternative diagnosis such as scarlet fever or chicken pox. A systematic examination of the ear nose and throat can rule out tonsillitis and reveals moist or dry mucus membranes as a sign of hydration status (NICE, 2018). NICE (2015) suggest a fluid intake of at least 50−75% of the child's normal fluid intake is required to maintain hydration, if below this, admission is indicated, however risk factors are also taken into consideration when assessing hydration. Signs of dehydration may include depression of the fontanelle in babies, reduced skin turgor, dry lips, sunken eyes, or sunken temples (Snelson, 2011).
Patient safety
The safety of patients is recognised as a key NHS principle (Department of Health [DOH], 2013; NHS, 2018; NMC, 2018). Fundamental to advanced practice is the processes of clinical reasoning; to increase the safety of patients it is vital as an ANP to think critically, apply knowledge and make accurate decisions to establish a correct diagnosis (Cockram and Hicks, 2011; HEE, 2017).
Diagnosis in acute paediatrics is not solely reliant on decision tools or investigations (Roland and Snelson, 2018), guidelines such as NICE (2015) are useful, but various approaches can be utilised to aid the diagnostic process. The hypothetico-deductive model is used to formulate a hypothesis from observable data for example, history of patients, vital signs and clinical findings (Barratt, 2018). An alternative approach, pattern recognition or inductive reasoning, is used to incorporate the retrieval of clinical information and knowledge base built from several years of previous experience prior to commencing development as an ANP (Hughes and Nimmo, 2016). This method is intuitive and applies recollection of prior consultations subconsciously, and with development of a senior clinical nursing role has raised consciousness about personal use of this process and facilitated the ability to draw on it effectively (Barrett, 2018).
In conjunction with these approaches sits the innate denotation that a certain diagnosis or management pathway is appropriate and therefore utilisation of gut feeling is core practice of the advanced nurse ANP. In practice, a combined approach is frequently used to establish a patient centered, safe and accurate assessment and diagnosis (Hughes and Nimmo, 2016).
Differential diagnoses
Within the management of bronchiolitis several differentials require consideration; these include, pneumonia, asthma, foreign body inhalation, virally induced wheeze, croup, gastroesophageal reflux, and congenital heart disease (NICE, 2015). There may be apprehension that the child presenting with a wheeze is an early presentation of asthma (Bourke and McNaughten, 2015). The most up to date guidance, from the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) on the diagnosis and management of asthma indicates that the history of wheeze is dependent on age at first presentation, so when preschool children present with ongoing episodes of wheeze it is important to consider asthma, especially if there is a strong family history of atopy, however when the wheeze is recurring with URTI, and no persisting symptoms, it is unlikely to be the cause (BTS, SIGN, 2019).
In the UCOOH, children that are at risk, or present with moderate, severe respiratory distress, low oxygen saturation levels, or poor feeding are directly referred for further assessment and management to secondary care (NICE, 2015), either by referral to the paediatrician on call where the parents would take the child directly if deemed safe, or when oxygen therapy is required, urgent referral is via 999 phone call to emergency services. Whilst reduction in Emergency Department attendance is high on the NHS agenda (NHS, 2019), managing risk and safety of patients is paramount (HEE, 2017), and referral is necessary occasionally.
Supportive management of bronchiolitis
Bronchiolitis is usually a self-limiting illness, that requires supportive management only with treatment directed at fluid input (NICE, 2015). However, management approaches to bronchiolitis continue to be a subject of substantial debate with vast differences in practice exhibited in the UK and beyond (Farley et al, 2014). It is important to benchmark care to ensure high quality safe care (DOH, 2010). Within the latest bronchiolitis guidance, antibiotics, salbutamol or ipratropium bromide, hypertonic saline, adrenaline (nebulised), montelukast, corticosteroids are not recommended for the treatment of bronchiolitis due to their poor clinical benefit (NICE, 2015). Despite this, surveys report that they are still being used within primary care, with only a small improvement in appropriate management since the introduction of the NICE (2015) guidance (Nickless et al, 2017; Carande et al, 2018).
The variation in practice may reflect the severity of individual disease, geographical location and different care settings, (Nickless et al, 2017). However, it may also be due to opposing opinions and different clinical knowledge or beliefs amongst clinicians (Carande et al, 2018). In the UCOOH, it has been observed that there is an inclination for junior staff to want to nebulise bronchiolitis children with salbutamol to help their respiratory distress, this has also been witnessed amongst paramedic crews. This is a form of ritualistic practice. As an ANP there is a requirement to educate colleagues (HEE, 2017). It is emphasised to multidisciplinary team (MDT) colleagues that there is no benefit to treatment with bronchodilators whilst there is a risk of unpleasant adverse effects, for example increased distress, tremors and tachycardia, significantly outweigh any potential benefits (Gadomski and Scribani, 2014).
There is evidence that antibiotics are still prescribed in primary care for the treatment of bronchiolitis (Farley et al, 2014; Nickless et al, 2017), this is often observed when parents attend UCOOH due to no improvement of their child's condition since antibiotics have been prescribed. A Cochrane review found insufficient evidence to support the use of antibiotics for the treatment of bronchiolitis (Farley et al, 2014). This information should be disseminated to the MDT colleagues to ensure best practice in line with HEE (2017).
Research
For children that are considered high risk of complications of RSV a passive immunisation, Palivizumab may be given under expert supervision (Joint Formulary Committee [JFC], 2018). This is not a vaccine but a monoclonal antibody that can be given prophylactically to reduce the risk of harm, however, is only useful in short term protection of RSV (PHE, 2015b). It is licensed for the prevention of severe lower respiratory tract disease caused by RSV in children under six months of age, born at 35 weeks or less at the onset of RSV season, and children under the age of two either needing treatment for bronchopulmonary dysplasia within the preceding six months, or with haemodynamically significant congenital heart disease (JFC, 2018).
Research indicates that Palivizumab is safe and successful in reducing hospital admissions and severe complications among children at high risk (Andabaka et al, 2013). However, due to the high cost of the drug it is only cost effective in the above groups ruling out its use in the whole infant population (Wang et al, 2008). Currently there is no vaccine or effective antiviral treatment for RSV and palivizumab given prophylactically continues to be the only means in the prevention of severe infection in high risk infants.
Leadership
Leadership and education are paramount and integral to the role of the senior nurse and involves promoting consistent practice in line with the evidence base (DOH, 2010; HEE, 2017; NHS, 2019). This can be challenging; on a personal note, confidence as an ANP has grown having assessed the available evidence and guidelines, and the use of leadership skills is being adopted to advise colleagues who may become uncertain when observing inconsistent clinical decision making. This is especially important in the UCOOH environment where many primary care centres are currently nurse-led, but where MDT colleagues such as physiotherapists and paramedics are increasingly taking up employment.
As a senior nurse there is professional responsibility to execute knowledge, support and empower junior staff through supervision in clinical practice, peer review and clinical supervision (HEE, 2017). This is particularly rewarding when observing increased confidence in diagnosing and managing bronchiolitis and reductions in requests for prescriptions or authorisation for inappropriate treatments and unnecessary referrals. This gives opportunities to benchmark practice and ensure high standards of care and is promoted in senior practitioner meetings.
Importance of personalised care
For children who are adequately hydrated, mild distress, no other worrying findings in the history or examination, then discharge home is realistic (Snelson, 2011). However, personalised care is assured by ascertaining factors such as parents' ability to take adequate care of the child, observe worsening symptoms and assess the social circumstances of the family (NICE, 2015), which ensures optimum safety of the child. Throughout the consultation an assessment of the parents' cognitive skills is made in managing the child's condition, this is essential in order to tailor health education and health promotion to their individual ability. If it is judged they are not able to cope, referral to secondary care is required (NICE, 2015).
Pivotal to the role of the ANP nurse is excellent communication skills (DOH, 2010; HEE, 2017). Prior to discharge, time needs to be taken to discuss the management and care of the child, empowering parents, involving them in the decision making and provide them with the correct information that is required for self management of bronchiolitis, which may then reduce inappropriate further attendance.
Important aspects include the duration of the illness, in association with the day 3−5 peak, it is explained that the symptoms may worsen before they improve (NICE, 2015). An accurate history of when the symptoms commenced is taken to provide parents with the relevant information regarding the expected course of illness and the associated red flag signs that must prompt parents to obtain a clinical review. A child worsening after 5−7 days would be unusual and could need referral (Snelson, 2011).
NICE specify certain red flags in their guidance, these include, dry nappies or poor feeding, reduced fluid intake of less than 75% of usual intake in 24 hours, increased lethargy, fast breathing, or a history of apnoea, increased recession, grunting and nasal flaring (NICE, 2015). Time is always given to discuss red flags at a level that parents and carers can understand, this include who to contact if worsening symptoms occur including 999/111 or their own GP for review. To reduced anxiety of parents and avoid unnecessary concern it is vital to reassure them that bronchiolitis is generally a self-limiting viral illness with breathing and feeding improving within five days, however the cough may be prolonged for up to three weeks (Snelson, 2011).
Further information should be given regarding fluids, during bronchiolitis it is normal for babies to reduce feeding and parents should frequently offer small quantity of fluids (Snelson, 2011; NICE, 2015). Antipyretics such as Paracetamol or ibuprofen may be given, discussion with parents is given to advice on their use, only recommending in the presence of fever and distress and not just as the sole aim of reducing pyrexia; as per the ‘NICE fever in the under fives' guideline (NICE, 2013).
From a strategic perspective, education and leadership is essential in the UCOOH setting, where disparity in practice has been identified, which is not in line with contemporary guidelines and the requirement for EBP. To aid this, it has been proposed in a senior clinical meeting that to develop a training package to aid role facilitation of learning in clinical practice. This was considered advantageous and development has commenced.
Conclusion
Appropriate management of children presenting to an OOH service with bronchiolitis is challenging and can be overwhelming for nurses. Moreover, bronchiolitis can have a large impact on the patient, family, and the health care system. Nurses must be aware of the pathophysiology, presentation, diagnosis and management of children presenting to UCOOH with bronchiolitis, to manage patients safely which is central to the concept of advanced practice (HEE, 2017).
The scope of the ANP extends beyond the application of knowledge and expertise in managing individual patients. The evidence clearly advocates non-pharmacological supportive management for children that do not require admission (NICE, 2015). Despite national guidelines, a disturbing lack of consistency in application has been observed amongst MDT colleagues. Recognition of this is imperative to clinical practice and exhibits a necessity to apply, education, excellent communication and leadership skills to educate the MDT, parents and carers. This is challenging, yet essential developmental requirement of advanced practice. Sequentially, attention to these crucial aspects of the ANP role will benchmark practice and ensure high quality care.
Key Points:
- For the diagnosis and management of bronchiolitis taking a full history and examination is essential
- Bronchiolitis is usually self-limiting but good communication is vitally important to reduce the anxiety of parents and to highlight potential red flags
- Red flags: less than 75% of a child's fluid intake in 24 hours; dry nappies; poor feeding; increased lethargy; fast breathing; history of apnoea increased recession; grunting; and nasal flaring