Case Study Assignment Bronchiolitis in Children
HPI: A 14-month-old Native American boy brought in by his mom due to cough, low grade fever and runny nose for the past 2 days. This morning, the mother noted that her son was breathing quickly and “it sounds like he has rice cereal popping in his throat.” Mom is worried because her son seems to have a lot of “bouts of colds”. Per mom, his oral intake is decreased. He didn’t want to eat this morning.
PE: Smiling, alert Native American boy.
VS: Temp of 99.9, pulse 112, respiratory rate is 58, Pulse ox 96%
HEENT: There is moderate, thick, clear rhinorrhea and postnasal drip. CV: His capillary refill is less than 3 seconds
PULM: lung sounds are diminished in the bases, he has pronounced intercostal and subcostal retractions, expiratory wheezes are heard in all lung fields.
Diagnosis Is Bronchiolitis
To prepare:
Review “Respiratory Disorders,” “Cardiovascular Disorders,” and “Genetic Disorders” in the Burns et al. text.
Review and select one of the six provided case studies. Analyze the patient information. Consider a differential diagnosis for the patient in the case study you selected. Think about the most likely diagnosis for the patient.
Think about a treatment and management plan for the patient. Be sure to consider appropriate dosages for any recommended pharmacologic and/or non-pharmacologic treatments.
Consider strategies for educating patients and families on the treatment and management of the respiratory disorder.
Post an analysis of your assigned case by using the following: What additional questions will you ask?
Has the case addressed the LOCATES mnemonic? If not, what else do you need to ask? What additional history will you need? (Think FMH, allergies, meds, and so forth that might be pertinent in arriving to your differential diagnoses) Bronchiolitis in children case study
What additional examinations or diagnostic tests, if any, will you conduct? What are your differential diagnoses? What historical and physical exam features support your rationales? Provide at least 3 differentials.
What is your most likely diagnosis and why? How will you treat this child?
Provide medication treatment and symptomatic care.
Provide correct medication dosage. Use the knowledge you learned from this week\’s and previous weeks\’ readings as well as what you have learned from pharmacology to help you with this area.
Patient Education, Health Promotion & Anticipatory guidance:
Explain strategies for educating parents on their child’s disorder and reducing any concerns/fears presented in the case study.
Include any socio-cultural barriers that might impact the treatment and management plans.
Health Promotion:
What immunizations should this child have had? Based on the child’s age, when is the next well visited?
At the next well visit, what are the next set of immunizations? What additional anticipatory guidance should be provided today?
Background : Acute bronchiolitis is one of the most frequent causes of emergency department visits and hospitalization in children. There is no specific treatment for bronchiolitis except for supportive treatment, which includes ensuring adequate hydration and oxygen supplementation. Continuous positive airway pressure (CPAP)
aims to widen the lungs’ peripheral airways, enabling deflation of overdistended lungs in bronchiolitis.
Increased airway pressure also prevents the collapse of poorly supported peripheral small airways during expiration. Observational studies report that CPAP is beneficial for children with acute bronchiolitis. This is an update of a review first published in 2015.
Objectives : To assess the efficacy and safety of CPAP compared to no CPAP or sham CPAP in infants and children up to three years of age with acute bronchiolitis. Search methods :
We conducted searches of CENTRAL (2017, Issue 12), which includes the Cochrane Acute Respiratory Infections Group’s Specialized Register, MEDLINE (1946 to December,2017), Embase (1974 to December 2017), CINAHL (1981 to December 2017), and LILACS (1982 to December 2017) in January 2018. Selection criteria : We considered randomized controlled trials (RCTs), quasi‐RCTs, cross‐over RCTs, and cluster‐RCTs evaluating the effect of CPAP in children with acute bronchiolitis. Data collection and analysis
Two review authors independently assessed study eligibility, extracted data using a structured pro forma, analyzed data, and performed meta‐analyses. Main results : We included three studies with a total of 122 children (62/60 in intervention/control arms) aged up to 12 months that investigated nasal CPAP compared with supportive (or “standard”) therapy. We included one new trial (72 children) that contributed data to the assessment of respiratory rate and need for mechanical ventilation for this update.
The included studies were single‐center trials conducted in France, the UK, and India.
Two studies were parallel‐group RCTs and one was a crossover RCT. The evidence provided by the included studies was low quality; we assessed high risk of bias for blinding, incomplete outcome data, and selective reporting, and confidence intervals were wide.
The effect of CPAP on the need for mechanical ventilation in children with acute bronchiolitis was uncertain due to imprecision around the effect estimate (3 RCTs, 122 children; risk ratio (RR) 0.69, 95% confidence interval (CI) 0.14 to 3.36; low‐quality evidence). None of the trials measured time to recovery.
Limited, low‐quality evidence indicated that CPAP decreased respiratory rate (2 RCTs, 91 children; mean difference (MD) −3.81, 95% CI ‐5.78 to ‐1.84). Only one trial measured change in arterial oxygen saturation, and the results were imprecise (19 children; MD ‐1.70%, 95% CI ‐3.76 to 0.36).
The effect of CPAP on change in arterial partial carbon dioxide pressure (pCO₂) was imprecise (2 RCTs, 50 children; MD ‐2.62 mmHg, 95% CI ‐5.29 to 0.05; low‐quality evidence). Duration of hospital stay was similar in both CPAP and supportive care groups (2 RCTs, 50 children; MD 0.07 days, 95% CI ‐0.36 to 0.50; low‐quality evidence). Two studies did not report about pneumothorax, but pneumothorax did not occur in one study.
No studies reported occurrences of deaths. Several outcomes (change in partial oxygen pressure, hospital admission rate (from emergency department to hospital), duration of emergency department stay, and need for intensive care unit admission) were not reported in the included studies.
Authors’ conclusions : Limited, low‐quality evidence suggests that breathing improved (a decreased respiratory rate) in children with bronchiolitis who received CPAP; this finding is unchanged from the 2015 review. Further evidence for this outcome was provided by the inclusion of a low‐quality study for the 2018 update. Due to the limited available evidence, the effect of CPAP in children with acute bronchiolitis is uncertain for other outcomes. Larger, adequately powered trials are needed to evaluate the effect of CPAP for children with acute bronchiolitis.
Week 5 Discussion
Name
Institution
The case study selected is about a 14-month-old Native American boy with a runny nose, low grade fever and cough. The additional questions that I would ask the patient’s mother are listed below.
● Does the patient have any known allergies? If yes, how does it affect the baby’s breathing?
● Do you have a personal or family history of asthma, bronchitis, emphysema, tuberculosis, lung cancer, cystic fibrosis, or any other lung disease?
● Does the patient cough throughout the day or at certain specific periods?
● The case has it addresses the LOCATES mnemonic. For instance, the allergies of the patient have not been identified. Thus I would ask the patient’s mother about the allergies of the baby. I will also ask the mother whether there are any alleviating factors that have been applied to reduce the patient’s symptoms including medications which are not mentioned in the case.
Moreover, I will ask about the time when the symptoms occur considering their pattern, frequency and the duration they last. I will also ask about the circumstances or environment under which the symptoms occur and ask the mother to rate the client’s symptoms using a scale of 1 to 10.
Additional examinations or diagnostic tests for the patient would include a pulse oximeter test to measure the oxygen levels in the blood. Notably, a mucus sample test is conducted to test for viruses from nose swab samples. Blood tests can also be conducted to check the child’s white blood cell count and oxygen levels which indicate the presence and absence of infections. Differential diagnosis is also important in determining the exact infection ailing the child.
In this case, bronchiolitis, pneumonia and asthma are the possible differential diagnoses. Bronchiolitis is characterized by fast breathing, difficulties in eating wheezing, sounds heard in the lungs, cough, sunken ribs during inhalation, runny nose and low grade fever (Meissner, 2016). Bronchiolitis in children case study.
On the other hand, pneumonia symptoms include cough, fever and sweating and loss of appetite while asthma is manifested through shortness of breath, wheezing, coughing and chest tightness. From the above differentials, bronchiolitis symptoms match most of the diagnostic criteria symptoms and the child suffers from this condition.
Treatment
The treatment of bronchiolitis in children is influenced by age and general wellness. This patient can be treated using 1.875 ml of the Ibuprofen Infant Drops (50 mg/1.25 ml), the recommended dosage for children between the age of 12 to 23 months (Oswald & Clarke, 2016). This will help in reducing the fever and increase the comfortability of the patient. The intake of fluids will also help in alleviating the symptoms.
However, antibiotics are ineffective since most cases are caused by viruses. A bulb syringe and saline nose drops can also be used to clear nasal congestion. Home care of symptoms involves keeping the child upright, drinking plenty of fluids, keeping the air moist and provision of a smoke free environment (Tomar & Yadav, 2019)
Patient Education, Health Promotion & Anticipatory Guidance:one of the strategy that can be used in educating the parents of the child to eliminate fear is through individual communication whereby the nurse will explain the concepts of the disease, symptoms, remedies and risks as well as prevention noting that bronchiolitis can get away on its own without treatment and hence no need for worry.
Creation of public awareness through the media and health fairs and programs will impart the parents with necessary knowledge regarding the infection. The socio-cultural barriers that might impact the treatment include the linguistic diversity, emotional reactions, mistrust of the healthcare system, religious beliefs and traditions of the Native American community. Bronchiolitis in children case study.
Health Promotion:
Immunizations assist in the prevention of diseases. Airborne infections spread faster especially in children due to their underdeveloped immune systems and thus vaccines help protect them. In this case, there is no vaccine currently available for bronchiolitis. However, annual flu shots are recommended for the patient. Palivizumab should also have been given to the patient to protect the lungs from infection by respiratory syncytial virus (RSV) (Blanco et al., 2019). This is injected intramuscularly every month for five months prior to the RSV season.
During winter, passive immunization of the child is crucial every month. Before receiving the immunizations, the child will be expected to meet particular criteria to prevent adverse health impacts. Influenza vaccination is also recommended for the patient once in every 12 months Bronchiolitis in children case study. The patient will be expected to visit the hospital after two weeks for wellness checkup and monitoring. This is because; the infection often goes away after 13 days without active treatment. Another visit will take place after three weeks or in the event that the symptoms worsen during treatment.
The additional anticipatory guidance that should be provided today includes the prevention strategies that can be employed to prevent the occurrence of the infection in the future. These include immunization and the frequency, avoidance of respiratory disease patients, hand hygiene and homecare. This includes monitoring and fever management as well as when to visit the doctor Bronchiolitis in children case study. The parent will also be educated on respiratory disorders common in children to prevent fear in such cases.
References
● Blanco, J. C., Pletneva, L. M., McGinnes-Cullen, L., Otoa, R. O., Patel, M. C.,
Fernando, L. R., … & Morrison, T. G. (2018). Efficacy of a respiratory syncytial virus vaccine candidate in a maternal immunization model. Nature communications,
9(1), 1904 Bronchiolitis in children case study.
● Meissner, H. C. (2016). Viral bronchiolitis in children. New England Journal of Medicine, 374(1), 62-72.
● Osvald, E. C., & Clarke, J. R. (2016). NICE clinical guideline: bronchiolitis in children. Archives of Disease in Childhood-Education and Practice, 101(1), 46-48.
● Tomar, P., & Yadav, N. K. (2019). PARENTERAL SMOKING AN IMPORTANT RISK FACTOR FOR BRONCHIOLITIS IN CHILDREN. Indian Journal of Applied Research, 9(2). https://doi.org/10.1002/14651858.CD010473.pub3
