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Hello, My name is Joe Read on the Clinical Practice Educator on the Pediatric Medical Unit on my Name's Jack Emails. I'm also practice Educator and we both work within South Hampton Children's Hospital. The aim of our session today on Bronculitis is to give you a greater understanding with the nursing care management of uninfected and child with bronchiolitis in preparation for the anticipated RSP surge that we think will start earlier this year. In the months of best. The presentation is based around guidelines which are available from the Pier network I either Pediatric Innovation Education Research Network. We are also following thought guidelines the CPAP on oxygen Trayvon team on. But also the guidelines from West six healthier together on these will be referenced throughout the presentation. Thank y'all Itis is an acute inflammatory disease of the lower respiratory tract resulting from obstruction of small airways. It's initiated by infection of the upper respiratory tract by a number of seasonal virus is more commonly, respiratory syncytial virus, or RSV. Bronchiolitis is the most common reason for hospitalization of Children less than two years of age, and it's the most frequent cause of admissions. Teo Pediatrics and Intensive care units with the king. Respiratory distress. So commonly are spears responsible for 50 to 90% of all cases of bronchiolitis, and it can result in 20,000 hospital admissions annually estimated by the age of two years old. 70% of Children have been exposed to R S be. This year is going to be an exceptional year, we believe, because, obviously with social distancing, the Children from last year haven't been exposed. And so there is a lack of heard immunity within the community. Typical bronculitis and infants is a south limiting disease. The average duration of the illness for Children less than 12 months is 12 days. Most infants to contact contract RSV infection recover completely. The basic management of bronchiolitis is to ensure that the child is well oxygenated. Well hydrated oxygen still remains the one measure of undoubted benefit, so typically, infections in the UK occur between October and February. But there was predicted, shown that this year they will start much early, potentially in August, And those babies that we think you're going to be a particular risk of those premature on the ones under six weeks off a judge, Other babies that will be a particular risk will be those with congenital heart disease on those babies that are immuno deficient. Bronchiolitis is a clinical diagnosis characterized by fever, nasal discharge, a dry, wheezy cough and poor feeding. Tack it near tachycardia, hyperinflated chest and fine inspiratory crackles. You can see a normal bronchitis picture on the left of the slide. On the right hand side of that slide, you can see an inflamed bronchial cheap with extra mucus secretion. This can often lead to our mucous plugs, which may cause airway obstruction. Hyperinflated lungs increased, um, attention off garden dioxide, which would result in my pocket. Senior infants have smaller airways on D r block a tree nasal breathers. So if you can imagine their airways of filled with mucus, it makes it makes it very difficult for them. Teo breathe and feed at the same time on often results in poor feeding. This bronculitis pathway can be found on the West six healthier together websites. It's a clinical assessment and management. All the Children younger, the one year old was suspected bronculitis. It's a traffic light system for clinicians toe aids with decision making in the acute setting, they are able to assess severity of symptoms from green being low risk through toe amber and then read high risk cohort ing of infants with bronchiolitis. The decision to cohort is based on symptoms, regardless of whether the infant has RSV or not. We generally in Southampton Children's Hospital we cohort nurse bronch it in a bronchiolitis bay rather than individual cubicles. And they see infant requires protective isolation, strict adherence the hand hygiene and use off pee pee. As directed by your local trust policy, it's really important that hands must be washed and gloves and eighth and changed between each patients. F F P three masks should be considered for your own protection during high rates of influenza and adenovirus again, as per your local trust myself, a shin policy because situation of mask and I protection is important. Aerosol generating procedures such as the collection of an M P. A are undertaken. These in interventions were Jesus spread of RSP within the hospital staff. Being vaccinated with the seasonal flu vaccine will reduce the risk of start acquiring influenza. So historically you would have taken and there's a phone gyn aspart to determine what was spiritually bias is causing the bronchial itis within set up in Children's hospital. This year, we will actually be doing the typical vowel swaps we believe, which we've been doing for covert, and that will not only give you a cove. It result also will tell you what the iris is causing. The symptoms provided you've actually tick, told the test for viruses on the swab form. The mention about isolation being a longer required was when we typically put babies with honesty into cubicle. I would imagine this year when you're going to be particularly busy, you become watching your Children anyway. A viral throat swelled may be more appropriate for the older, infinitely child if doing a rapid covert swap by adding all other viruses, this will test for relevant viruses, including RSV, So treatment for bronchiolitis is mostly supportive on largely led by the Nessen team. Information is to be provided two families regular intervals to ensure that they are updated, and this will minimize their anxiety. Infants could be given oxygen on. We would discuss this in more detail later. There's a suction can also be used to clear secretions. However, this shouldn't be routine because over section and can cause further invitation, leading to forever inflammation and question of secretions. When you're using non humidified oxygen, it may be beneficial to consider sailor nebulizers to actually loosen the secretions. We would recommend Cluster Cares with minimal handling, ensuring that the baby is not made any further has any further disturbances and close monitoring of our pews. Observations of essential and this is highlighted in the care plan. Apnea monitors are recommended with infants under the age of six weeks. Do two apneas potential being a side effect off RSV a bronchiolitis, and you could also need to consider how your nest in your baby potentially the younger ones without knees, mattresses. What new monitor is connected could be nest prone on did. It's usually beneficial to have the head of the cots raised with all ages. Capillary blood gas is an objective measurement in Children with worsening with spoke with distress. And it's also beneficial to do this when you've actually changed your treatment to actually see where it's made. Any improvement just physio is not recommended for babies with standard bronculitis, and a chest X ray is not a routine diagnostic procedure. Your treatment aimed is to keep your baby hydrated with oxygen saturations at 92% or above, oxygen can be delivered up to two liters by a nasal form cannula. However, if this isn't sufficient, you will need to consider heat it humidified high flow nasal prongs, oxygen and each hospital will have a different delivery system. Potentially examples are up to flow ever, though, or bathe with them. We will talk about delivering oxygen, and this method for everyone in the presentation, once it's hard, is improving on nasal prongs oxygen. The medical team may suggest hourly as opposed to continuous oxygen saturation monitoring. This is particularly beneficial if you're trying to normalize your baby, and this should be assessed on an individual basis. The majority of Children will not benefit from nebulized albuterol if oh on high flow. Oxygen attached to this slide is a link for the regional care plan, so you're aimed with nutritional support is to ensure that your baby is adequately hydrated without actually compromising on their respiratory effort. Babies under the age of six months typically nasal breathers on. So, typically with the extra secretions blocking up the airways, feeding will become difficult or so large amounts of feed in the stomach will tend to split the diaphragm, compromising their respiratory effort and causing them to be a risk of vomiting. Your plan should be to consider a small amount of formula or breast filled breast milk more frequently, and this could needs to be calculated on 80 to 100 mils per kilo per day. Feeding 123 are dependent on that condition. If a baby isn't tolerating all feeds swapped a nasogastric feeds with the same amount calculated. If you need to feed the baby moving too early, I eat a really you're probably going to be more likely to want to feed them, whether continuous speed so they disturbed less clear fluids only aren't recommended because there's no calories. Pick failure from this. Do you know what her severe with nasogastric feed in Children with more severe symptoms? Consider intravenous fluids, if any of the following or not relieved by nasal suctioning. For example, persistent respiratory rate greater than 80 respiration it if the infant is persistently vomiting if their oxygen saturations are falling below 92% despite supplementary nasal problem oxygen during feeding marked increase in work of breathing with poor coordination of sucking, swollen and breathing limit fluid requirements in intravenous unless we said earlier, tube fed babies to two thirds off the recommended daily allowance some infants will recommend will benefit from having suction part being fed. This isn't something that you would be doing, Boutin Lee. But if their clinical situation indicates it's in regards to discharge, it's important to make for make sure the infant Charles respiratory rate is less than 60 per minute. The child is in room air with saturations great family called to 92%. It's really important if you can try to get the child to have a sleep while stay still in a hospital and monitor their saturations during that time because it's often during their sleep that they're saturations are compromised. It's also important that Child's on adequate or beads recorder's of their normal amounts on the family is closely involved in the discharge decision making process. It's an expectation that are clinicians give parents safety net advice so they will give some criterias to when to bring their child back into hospital or seek medical advice if their child is deteriorating. There's a bronchiolitis parents advice sheet on their house here together website, which is really useful on. I would recommend that this is printed off on given to the parents before discharge. Generally speaking, we don't follow up Children with bronchiolitis, and it's important to inform the parents that some of the symptoms of bronchiolitis such a zone, increased work of breathing, decreased feeding and a cough can ask for up to four weeks after discharge. This Concor um slide shows the sort guideline for hospital admission and initial management of uninfected child with bronchial itis. It's a step two step guide that could be followed through, and you are would be able to find this on the sort website. If you're in front requires more than two liters of high flow oxygen, you may well consider starting humid to heat it, um unified high flow nasal cannula oxygen. It's a non invasive system used to deliver high flow oxygen on. It's the mainstay of the treatment that we tend to use within the trust Now. Obviously, every trust uses a different system, but we've actually uploaded videos of how to set up both airboat on optic low onto the pier website, and you will be have to find this under the education's tab and then under resources on this. This This is a step two step guide on how to set these up. If you click on each of the pictures, that will take you straight to the guide. This slide actually, um, list the advantages of the humidified hated high flow oxygen. Um, and it's fairly self explanatory. Basically, the whole idea is that the war and humidity of the oxygen makes the treatment much better tolerated. It will reduce, see excessive work of breathing, and so hence, improve it babies condition. And it allows parents greater access access to their child by reducing the potential for further until a tree support, which may well be required if the child hasn't had enough oxygen. Listed on this slide are the suggested indications for heated to meet applied high flow nasal cannula oxygen on. But you can see the respiratory conditions at the top part of slide that the ones that suggested to use it. It's for with the contraindications, which is fairly self explanatory. Listed below the decision to start heated humidified, high flow oxygen needs to be made in conjunction with the nursing and the medical teams. It's useful to have a blood gas prior to this treatment changes. This is an objective method of assessing the benefit of your treatment. Didn't careful about the size of your chosen problems. They need to fit comfortably was in the airway. It's important that they're not too large as they may cause, and there's two flare. This could lead to a closed circuit and the potential delivery of CPAP. Be mindful that the size of the cannula dictates your flow rate. I eat the neonatal. Yellow nasal cannula can only deliver a maximum flow of eight liters, even if you set your machine at a higher rate, the table shows a starting flow rate, and this has taken from the pier website. As you can see the liters per minute, I'll set by kilograms in weight. So with regard to monitoring your child with bronchial itis, you need to make sure you haven't emergency supply of oxygen readily available and very easily accessible at the bedside, you need to follow your trust observation protocol with guards to how often you did your child's observations and recording in on the appropriate peers Charts on the little tip is to be very aware that your nasal cannula can block. And so if your settings change on your high flow machine, make sure you check your circuit so weaning could be considered when your baby's symptoms have improved on listed on the slide of the things that you need to consider, you may have noticed that the process of weaning from high flow oxygen has changed slightly this year. It follows the same principles. The oxygen levels must be weaned before flow rates. The flow rate should be maintained until the auction level is a down to 30% and then your flow rate could be weaned as per P A guidelines. So basically it's suggested that you have your flow rates. If your baby has no deterioration within the next hour, you then can discontinue your treatment. In the event of any deterioration, you need to resume back to your previous level of flow on oxygen and reassess. 30 minute observations are suggested Uring weaning to assess work of breathing. Once your baby is improved and you decided to end that therapy, you need to ensure that the machine is safely removed on cleaned on decontaminated. Every trust will have their own way of doing this. This is the way that we need to do it. In September 2 Children saw stool, so please refer to your own infection control policies to make sure that you dispose of your circuits and clean your machine appropriately. Once your baby's improved and you decided to end the therapy, you need to ensure that thank you for working for instances presentation the reconcile that we have. You have any listed on page way of doing.