broncholitis/RSV Flashcards
what is bronchiolitis?
inflammation of the fine bronchioles and small bronchi
- lower resp tract infection
- usually due to viruses (particularly respiratory syncytial virus (RSV))
- under 2 years old, peak at 6 months
RSV?
most frequent cause of hospitalization in children less than 2 years of age
- higher rates in indigenous populations in Northern Canada
- 1% mortality rate, 3% in underlying conditions
- RSV to asthma link
- can live on surfaces for several hours, hands for 30 minutes
increased risk of RSV
- if born in november, december, january
- siblings in day care
- more than 6 individuals
- low birth weight
- male
- formula fed (immune system isnt as good)
- eczema family history
initial manifestations of RSV
- rhinorrhea
- pharyngitis
- coughing
- wheezing
- ear/eye drainage
- intermittent fever
with progression the symptoms of RSV…
- increased coughing and wheezing
- tachypnea and retractions
- cyanosis
severe RSV?
- tachypnea (over 70 breaths/min)
- listlessness
- apnea
- poor air exchange
- decreased breath sounds
assessment for RSV?
- color
- movements (headbob)
- work of breathing
- auscultation (stridor, wheezing)
- secretions
- circulation and hydration
- caregivers
work of breathing findings?
- resp rate
- nasal flare
- tracheal tug
- in drawing, retractions
- seesaw breathing
- sounds: grunting
- coughing
- crying
circulation and hydration findings?
- mucous membranes (color, moisture)
- peripheral and central color mottling normal
- Ins and outs (IV hydration if nothing by mouth)
- weight: not only for intake and output, medications are weight based!!
- nutritional status: at a nutritional risk, if baby cannot coordinate movement for sucking at risk
- assess sucking reflex!
- RR greater than 55??/
diagnostics for RSV?
o Nasopharyngeal swab- RSV antigen o Chest x-ray: hyperinflation o Arterial blood gases o CBC, electrolytes Any other associated infections?
therapeutic management of RSV?
- treat symptoms
- cool humidified oxygen
- adequate fluids
- airway maintenance
- antipyretics (whether to treat or not??see how child is doing, may be a physiologic response, only treat if over 38.5…)
- home vs hospital (only children with resp distress and who are at risk (have other comorbidities) stay
- tachypnea
- supplemental humidified oxygen
- brochodilator (assess for response, not every child will be ordered them, only stay on if helpful)
- epinephrine nebs (hypertonic nebs, stimulate alpha and beta 2 receptors, relaxes smooth muscles of bronchial tree, relieving bronchial spasm)
- 3% NS nebs (improves mucociliary clearance- like a mucolytic)
nursing diagnosis for RSV (common…)
- ineffective breathing pattern
- potential fluid volume deficit
- potential fluid and electrolyte imbalance
- potential alteration in nutritional status
- potential discomfort
- potential anxiety
- potential knowledge deficit
nursing interventions for RSV?
- VS routine and PRN
- oxygen above 96%
- blow by (nasal prologns too big)
- NS drops prn
- cardiac sling
- sat probe change q4h (burns)
- stirct ins and outs
- daily weight
- NPO if RR over 55 bpm
- hydrate the mother if BF, small frequent feeds
- group care (everyone assessing the child)
- tylenol
- droplet precautions
- grouping with other RSV positive patients
- nursing assignment to limit contact with non-RSV patients
- encourage breastfeeding
- management of secretions
- provide meds (small masks, syringe meds)
- oral and IV hydration
- frequent monitoring
- health promotion opportunities
goal of pharmacology care?
prevent and control symptoms
- reduce freq and severity of exacerbations, improve health status, improve exercise tolerance
- nursing considerations: pre/post resp assess, pt teaching, life span considerations
drugs by inhalation: MDI
metered-dose inhaler
- pressured devices
- 1 minute in between
- teaching is important
- spacers
drugs by inhalation: respimats
- fine mist
- less drug in mouth and oropharynx
dry-powder inhalers (DPI)
micronized powder
breath activated
spacers not used
nebulizers?
mist
for some this may be more effective
with spacer….
57% inhaler device, 22% mouth and throat, 21% lungs
without spacer…
10% inhaler device, 81% mouth and throat, 9% lungs
short-acting beta 2 agonists?
bronchial smooth muscle relaxation causing bronchodilation through activating beta2-adrenergic receptors
- indication: prevention or relief of bronchospasm in asthma or COPD, used PRN inhaled
- side effects: may see nausea in larger doses, anxiety, palpitations, tremors, increased heart rate—> tachydysrhythmias
contraindication: BETA BLOCkers!! or taking MAOIs/other sympathomimetics r/t risk of hypertension - SALBUTAMOL
long-acting beta 2 agonists?
bronchial smooth muscle relaxation causing bronchodilation
-prevention/long term control of bronchospasm in asthma or COPD
-fixed schedule (not PRN, must be given with a glucocorticoid in asthma. inhaled)
may increase risk of death if used MONOTHERAPY
-effect may be diminished if taking beta blockers, avoid taking MAOIs other sympathomimetics r/t hypertension
anticholinergics?
blocks muscarinic receptors in the bronchi—> reduced bronchoconstriction
-indication: slower onset compared to beta agonists. used for prevention of bronchospasm. COPD “off label” for asthma
-inhaled, 1 min gap between inhalers
-SE: dry mouth, throat, nasal congestion, not readily absorbed systemic but if it does can increase intraocular pressure
-contraindications: pt with acute angle glaucoma or prostate enlargement. possible additive toxicity in use with other anticholinergic drugs
EXAMPLE: IPRATOPIUM
methylxanthines?
mech: bronchodilation by relaxing smooth muscle of the bronchi
-not firmly established, likely from blocking adenosine receptors
-indication: chronic, stable, asthma. decrease frequency and severity of attacks. no longer recommended in COPD. oral or IV
side effects: toxicity!! nausea, vomiting, diarrhea, insomnia, restlessness
contraindications: caffeine, tobacco, marijuana, many drug interactions
example: AMINOPHYLLINE, THEOPHYLLINE
bronchodilators life span considerations (children)
special delivery devices
SABA approved over 2, may be used younger
methyxanthines: all ages
anticholinergics safety not ensured under 11!!
pregnant and older adults bronchodilators
weigh benefits vs. risks
inhaled coritcosteroids???
reduces inflammation, decreases edema and results in bronchodilation. increases responsiveness to beta agonists (ex. salbutamol)
indications: persistent asthma, often used in conjunction with beta agonists. may also be used in COPD
side effects? no adrenal suppression so no serious toxicity
-oral pharyngeal candidiasis, dysphonia
-delay growth in children?
-long term bone loss
not many contraindications when inhaled
-BECLOMETHASONE, budesonide
leukotriene receptor antagonists??
suppress effects of leukotrienes (which promote smooth muscle constriction, vessel permeability, and inflammatory responses directly)
-decreases bronchoconstriction
-indication: maintenance therapy in chronic asthma, second line therapy
-adults, children 5 and above
-oral
side effects: headache and GI, arthralgia, and myalgia, neuropsychiatric effects (depression, suicidal thoughts)
interactions?? various drugs!!! aspirin, eryhtomycin, warfarin
ex. ZAFIRLUKAST
leukotriene receptor antagonists are NOT….
recommended for pts going through acute changes, will mimic signs and symptoms
opioids for RSV?
low doses of opioids very effective in decreasing perception of dyspnea (morphine sulphate)
- promote comfort, decrease RR effort to calm them and help relax
- used as adjunct but do not know how, exact mechanism unknown
antitussives?
cough suppressents, ONLY WHEN ONGOING DRY NONPRODUCTIVE COUGH
- cannot give with secretions and mucus
- opioid based (codeine)
expectorants?
reduce viscosity of secretions for easier removal
mucolytics?
break down chemical structure of mucus for easier removal by coughing
risk factors for infants developing severe RSV?
being less than 6 weeks old
- prematurity under 6 months of age
- underlying resp or cardiac conditions
- immunocompromise
RSV is transmitted from exposure to….
contaminated secretions, can live on fomites for several hours!! hands for 30 mins
pathophysiology of RSV?
affects epithelial cells of resp tract
- cilitaed cells well, protrude into lumen, lose their cilia
- fusion of infected membrane with cell membranes of adjacent epithelial cells—> forming giant cell
- bronchial mucosa swells, lumins subsequently filled with mucus and exudate
- walls of bronchi and bronchioles infiltrated with inflammatory cells
- hyperinflation, obstructive emphysema (overinflation from air trapped) resulting from partial obstruction, patchy areas of atelectasis
a single dose of bronchodilator is often prescribed and then…
if symptoms improve, it is condinued
prevention of RSV?
- palivizumab, monoclonal antibody given monthly in IM injection during RSV symptoms
- lyophilized powder form of palivizumab should be admin within 6 hrs of being reconstitued with sterile water
