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How to manage bronchiolitis during the COVID-19 pandemic: preparing for a winter surge

Guidance is available to help deal with the annual rise in infant bronchiolitis while coping with COVID-19

Guidance is available to help deal with the annual rise in infant bronchiolitis while coping with COVID-19

  • Bronchiolitis, a significant contributor to ED workloads in winter, affects one in three infants in the UK in the first year of life
  • Robust infection control measures must be maintained in emergency departments during the winter
  • Parents should be told how to spot red flag symptoms, with safety net advice for those who dont need to be admitted to hospital

Bronchiolitis brings a surge of emergency department (ED) presentations every autumn and winter. Around one in three infants in the UK develop the illness, mainly caused by the respiratory syncytial virus, during

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Guidance is available to help deal with the annual rise in infant bronchiolitis while coping with COVID-19

  • Bronchiolitis, a significant contributor to ED workloads in winter, affects one in three infants in the UK in the first year of life
  • Robust infection control measures must be maintained in emergency departments during the winter
  • Parents should be told how to spot red flag symptoms, with safety net advice for those who don’t need to be admitted to hospital
Bronchi of a child
Bronchi of a child Picture: Alamy

Bronchiolitis brings a surge of emergency department (ED) presentations every autumn and winter. Around one in three infants in the UK develop the illness, mainly caused by the respiratory syncytial virus, during their first year of life.

Bronchiolitis is always a significant contributor to ED workloads in colder months, with infants and children experiencing symptoms including wheezing, dry cough and a slight temperature.

This winter is likely to be similar, but with the added complications to care and services caused by the COVID-19 pandemic.

New guidance for healthcare staff on managing bronchiolitis in hospitals in light of COVID-19

To give an idea of the scale of care required for children with bronchiolitis, in England in 2014-15 there were almost 40,000 hospital admissions related to the condition, according to the National Institute for Health and Care Excellence (NICE). Many more will have sought emergency care but not been admitted.

New guidance on managing bronchiolitis in hospitals in light of COVID-19 has been published for healthcare staff by the Royal College of Paediatrics and Child Health (RCPCH).

This warns ED staff to be prepared for the annual surge in bronchiolitis cases, while maintaining COVID-19 secure facilities.

University Hospital Southampton NHS Foundation Trust consultant in paediatric infectious diseases Sanjay Patel
Sanjay Patel

University Hospital Southampton NHS Foundation Trust consultant in paediatric infectious diseases Sanjay Patel says robust infection control measures must be maintained in EDs during the winter.

Onset of bronchiolitis and respiratory virus season will place services under pressure

‘It is also necessary to ensure that the flow of patients through the hospital is maintained during the winter period, when it is predicted that demand for paediatric services will increase significantly and the onset of the bronchiolitis and respiratory virus season will place services under considerable pressure,’ he says.

The RCPCH guidance sets out how patients with bronchiolitis should move through the ED.

University Hospital of Wales ED staff nurse David Riseborough says emergency nurses are used to seeing small children with signs of bronchiolitis. This generally means young children and infants with increased work to breathe, decreased oxygen saturation and decreased feeding as their nose is blocked, meaning they are often dehydrated.

Young children with respiratory problems can deteriorate very quickly

The triage systems will generally push these children to the front of the queue, as young children and infants with respiratory problems can deteriorate very quickly. Mr Riseborough says: ‘95% of arrests in children are respiratory and caused by things like bronchiolitis, croup and exacerbations of asthma. We always see children with shortness of breath first because of this.’

Emergency nurses and the RCPCH are clear that the current pandemic doesn’t change how a child is assessed.

‘The biggest question is how the child is presenting,’ says Mr Riseborough. ‘If they have symptoms of bronchiolitis we treat it as bronchiolitis, with necessary personal protective equipment (PPE) until we know otherwise.’

It is likely that the red and blue zones to separate patients with COVID-19 symptoms and those without will remain throughout the winter, the RCPCH guidance says.

Allow for adequate physical distancing, respiratory hygiene and hand hygiene

Waiting areas should be organised to minimise the risk of infection spreading, by allowing adequate physical distancing, respiratory hygiene and hand hygiene.

Assessment of signs and symptoms will as usual guide healthcare professionals on whether a child has bronchiolitis. Oxygen saturation should be measured in every child presenting with suspected bronchiolitis, NICE guidance states.

Signs and symptoms

NICE says to diagnose bronchiolitis if a child has a coryzal prodrome (cold symptoms, including acute inflammation of the mucous membrane of the nasal cavities) lasting one to three days, followed by:

  • Persistent cough and
  • Either tachypnoea or chest recession (or both) and
  • Either wheeze or crackles on chest auscultation (or both)

Healthcare professionals should take into account that fever (normally below 39°C) is a common symptom in about 30% of cases, and poor feeding.

Illustration of lungs
Picture: iStock

When diagnosing bronchiolitis, consider that young infants, particularly those under six weeks of age, may present with apnoea without other clinical signs.

Healthcare professionals should consider a diagnosis of pneumonia if the child has high fever (over 39°C) and/or persistently focal crackles.

Source: NICE (2015)

Nurses should be alert for signs of impending respiratory failure, which NICE says should be suspected if there are signs of exhaustion. These include listlessness or decreased respiratory effort, recurrent apnoea or failure to maintain adequate oxygen saturation despite oxygen supplementation.

Oxygen supplementation should be given to children with bronchiolitis if their oxygen saturation is persistently less than 92%, NICE states.

For emergency nurses, this can provide the most significant change when it comes to the management of children who require additional oxygen through the pandemic.

Nurses will often not know whether a patient has COVID-19 when assessing them

Oxygen treatment including high-flow nasal cannula oxygenation, continuous positive airway pressure (CPAP) and Optiflow are aerosol generating procedures (AGPs), which can result in the release of airborne particles from the respiratory tract. If the patient has COVID-19 there is an increased risk of transmission to healthcare staff and others.

Six risk factors for severe bronchiolitis

  1. Chronic lung disease (including bronchopulmonary dysplasia)
  2. Haemodynamically significant congenital heart disease
  3. Age in young infants (under three months)
  4. Premature birth, particularly under 32 weeks
  5. Neuromuscular disorders
  6. Immunodeficiency

Source: NICE (2015)

With people currently attending EDs only tested for COVID-19 if they are admitted, nurses will often not know whether a patient is infected when assessing them.

These oxygen treatments should only be performed or initiated when clinically indicated and a senior decision-maker should be involved if they are being considered, the RCPCH states.

A point of care test result may be useful, if available

In addition, the infection control implications of transferring a child on oxygen treatment needs to be considered. It is preferable for patients to be admitted before these are begun, but if starting such treatment is unavoidable before transfer to an inpatient setting, a point of care test result may be useful, if available.

If this is not available, testing for a child who is going to be admitted should be carried out in the ED. Staff should not wait for a result before admitting the patient, though, as this will slow the flow of patients too much.

The child must be managed in an appropriate isolation area in the ED by staff wearing the correct PPE. For children with confirmed COVID-19 or symptoms of it who are receiving AGPs this means gloves, gown, visor and FFP3 mask or suitable hood.

Procedures with no good evidence supporting their use should be minimised, according to the RCPCH, including administering nebulisers or hypertonic saline to infants.

Sick child in hospital bed
Picture: iStock

Lorrie Lawton, consultant nurse in emergency care at King’s College Hospital NHS Foundation Trust in London, says a lot of trusts are considering admitting children for high-flow or Optiflow oxygen for infants with bronchiolitis at an earlier stage than they did pre-pandemic.

‘It turns children around so quickly that hospitals are keen to start it early so children are not in for long,’ she says. ‘But as it is an AGP, it is a consultant decision to start it and we have to put on full PPE. This means there is a reluctance to start it in ED as it is hard to make enough space to isolate the patient properly, so they now tend to be taken onto a ward, into a side room, where they can be properly isolated.

‘This means transferring a child who potentially has COVID-19 and could be spreading it around. Traditionally in our ED we would have started them off on Optiflow before transferring them, but that is avoided if possible at the moment.’

‘If the child is on day four already, you know they should soon start to get better’

Deciding whether a child with bronchiolitis who does not currently require oxygen treatment needs to be admitted or not depends on a number of factors, including the severity of symptoms.

Nurses say it also includes where the child is on the five-day duration that bronchiolitis typically lasts.

‘If the child is on day four already, you know they should soon start to get better,’ Ms Lawton says.

‘But if they are on day one and already unwell, it is going to get worse. So you need to be clear where the patient is on the profile.’

Other critical factors include underlying risk factors that can make an infant more likely to become severely unwell, such as premature birth.

It also depends on the ability of the parents to spot red flag symptoms, their skill and confidence in caring for a child with bronchiolitis at home, their social circumstances, and how far they are from the hospital.

Key safety information for parents

Red flagNICE recommends providing information for parents and carers to take away for reference for children who will be looked after at home. This should cover how to recognise developing 'red flag' symptoms:

  • Worsening work of breathing (for example grunting, nasal flaring, marked chest recession)
  • Fluid intake is 50%–75% of normal or there is no wet nappy for 12 hours
  • Apnoea or cyanosis
  • Exhaustion (for example, not responding normally to social cues, wakes only with prolonged stimulation)

No smoking symbolThey should be aware of arrangements for follow‑up if necessary, and should know how to get immediate help from an appropriate professional if any red flag symptoms develop.

Advise that there should be no smoking in the child’s home, because it increases the risk of more severe symptoms in bronchiolitis.

Source: NICE (2015)
Pictures: iStock

‘There are a few factors that we need to take into account, and providing safety net advice for those who don’t need to be admitted is essential,’ says Ms Lawton.

She says there is the possibility that the infection control measures instilled across society this year will reduce viral illnesses such as bronchiolitis.

‘It is too soon to know the impact the second lock down will have, but we are here and ready to care for all children affected by bronchiolitis, the same as every winter.’

Ella’s story

Ella Cope was born prematurely at 34 weeks gestation and became dangerously ill after developing bronchiolitis. She developed the illness at four weeks old, after initially seeming to have a straightforward cold.

Ella Cope in hospital, she was born prematurely at 34 weeks gestation and became dangerously ill after developing bronchiolitis
Ella Cope in hospital

‘On around day six of the cold, Ella really went downhill,’ says her mum, Steph Cope. ‘She was very snotty, had a crackly chest and was miserable. It was a Sunday so I called 111 and they sent an ambulance.’

She was diagnosed with bronchiolitis, but the health team felt it was safe for her to go home. ‘She cried the whole night – and she’s not usually an unsettled baby,’ her mother recalls.

‘In the morning, while I was on the phone to my husband, she suddenly stopped crying. Then she went really grey and pale. It was like all the life went out of her. Her arms and legs went limp, her lips went blue and her head dropped back. I screamed down the phone. We thought we were going to lose her.’

Ella was taken by ambulance to the Evelina London Children’s Hospital. She developed pneumonia, her right lung collapsed and she needed life support in intensive care. Ella’s recovery was long and complex, says her mother, who is speaking about her family’s experience to support Action Medical Research’s study into bronchiolitis.

The project aims to harness the body’s natural immune defences to fight the infection.

Ella is now two years old. Her mother says: ‘I’m so glad she won’t have any memory of it but her father and I will be haunted by it for life.’

Family picture of Ella Cope with her mother Steph, father and brother
Ella and family Picture: David Brunetti/Action Medical Research

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