Page 714 - ACCCN's Critical Care Nursing

Paediatric Considerations in Critical Care 691

Clinical Manifestations In temperate regions of Australia and New Zealand, most
Sudden onset of coughing, gagging and an audible stridor cases occur between late autumn and early spring, with
in a previously-well infant or child is suggestive of an sporadic cases throughout the year. There is a paradoxical
83
inhaled foreign body. However, an accurate history – relationship between the incidence of RSV and other viral
such as a recent coughing or choking episode – is the pathogens causing bronchiolitis. RSV epidemics occur
most sensitive factor in making a diagnosis of inhaled when other respiratory pathogen epidemics are diminish-
foreign body. ing, and vice versa. Although there are limited data on
the actual incidence of bronchiolitis, laboratory isolation
Management data in New South Wales estimate that about 1000 infants
are hospitalised with bronchiolitis each year. The major-
Management will depend on the location and level of ity of these are under six months old. There is also a
110
the aspirated foreign body, as it may have lodged in the higher incidence of bronchiolitis in the Indigenous popu-
pharynx, oesophagus, larynx, trachea or bronchial tree. lation of Australia 111,112 and more severe illness when
104
Coughing is encouraged for mild airway obstruction. compared to non-Indigenous. Younger children with
113
Up to five back blows may be successful in dislodging the one or more comorbidities were at higher risk of compli-
foreign body, which may be followed by up to five chest cations. RSV infection occurs throughout the year, with
111
thrusts and back blows. Direct laryngoscopy and removal an annual peak during the winter months. 111,114
of a foreign body using Magill forceps may be required
for an acute episode when back blows and chest thrusts When bronchiolitis occurs, the highest risk for hospita-
have been unsuccessful. When the foreign body has lisation is infants under six months of age, those with
lodged below the carina, for the majority of children exposure to tobacco smoke and underlying conditions
diagnosis and definitive treatment will consist of removal such as congenital heart disease, prematurity and low
20,102,115
of the foreign body via a bronchoscopy under general socioeconomic group. Severe disease, requiring
anaesthesia. 83 admission to a paediatric ICU, is associated with prema-
turity, particularly in infants with chronic lung disease
or a history of ventilation in the newborn period and
THE CHILD EXPERIENCING LOWER congenital heart disease.
AIRWAY DISEASE
Clinical manifestations
Lower airway disease in children is a common reason Bronchiolitis is a clinical diagnosis; non-isolation of a
for admission to ICU. Infants under 12 months usually causative viral agent does not exclude the diagnosis. The
present with bronchiolitis or pneumonia. Asthma is more clinical features of bronchiolitis are variable, and may
common in older children, but infants nearing 12 months include URTI symptoms such as rhinorrhoea (runny
of age may develop asthma and there is often confu- nose) and an irritating cough. Within three days the
105
sion between bronchiolitis and asthma at this age. 106
infant develops tachypnoea and respiratory distress,
which may be mild, moderate or severe. An expiratory
SPECIFIC CONDITIONS wheeze is often present and auscultation usually reveals
Bronchiolitis and asthma are commonly seen in children, fine to coarse crackles. Fever is present in approximately
and the management of each condition is discussed 50% of infants. In very young, premature or low-
below. National and worldwide clinical guidelines for birthweight infants, apnoea is often the presenting
these conditions have been developed and are continu- symptom, which then develops into severe respiratory
ally updated. 107,108 distress. The clinical course of bronchiolitis is usually
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7–10 days; however, the effects of severe illness may last
Bronchiolitis much longer. Respiratory distress is present. Indications
Viral bronchiolitis in infancy is characterised by obstruc- for intensive care admission include frequent and/or pro-
tion of the small airways, resulting in air trapping and longed apnoeas; hypoxaemia despite administration of
respiratory distress in infants less than 12 months of age. oxygen; haemodynamic instability; an obviously tiring
It is the most common severe respiratory infection in infant or decreased level of consciousness. 20,117
infancy, although the course is usually mild to moderate
and is self-limiting, usually requiring no treatment. Severe Management
infection represents less than 5% of all cases and is A thorough history and assessment are important to
usually associated with prematurity or congenital heart provide a foundation for management of bronchiolitis.
95
disease. Respiratory syncytial virus (RSV) causes 90% of The infant with acute bronchiolitis requires continuous
109
bronchiolitis cases. Other causative agents are parain- cardiorespiratory monitoring and oxygen saturation
fluenza virus types 1, 2 and 3, influenza B, adenovirus monitoring. Treatment and management of infants pre-
types 1, 2 and 5 and Mycoplasma. RSV invades the epithe- senting with bronchiolitis is largely supportive, as most
lial cells of the bronchioles, spreading via cell fusion and pharmacological treatments are unproven. In general,
the creation of syncytia. This results in destruction of management centres on supporting hydration and nutri-
the epithelium and patches of necrosis. The debris associ- tion, oxygenation, and maintaining vigilance for signs of
ated with epithelial shedding and mucus production deterioration that may require mechanical ventilation.
lead to small airway blockage and the clinical features of Minimising the impact of procedures on the infant is also
bronchiolitis. 109 important.