Continuing professional development

Effective management of lower respiratory tract infections in childhood

NCYP27 Paul SP et al (2011) Effective management of lower respiratory tract infections in childhood. Nursing Children and Young People. 23, 9, 27-34. Date of acceptance: September 1 2011.
Siba Paul is ST4 paediatrics, Great Western Hospital, Swindon and honorary paediatric registrar at St Richards Hospital, Chichester, Claire OCallaghan is paediatric ward manager and Nicola McKee is paediatric deputy sister at St Richards Hospital, Chichester Correspondence siba_prosad@yahoo.co.uk Conflict of interest None declared

Abstract
This article summarises the five most common lower respiratory tract infections seen in acute care, guiding the nurse in assessment and early recognition of signs of deterioration. A discussion on each condition is provided along with guidance on prevention, advice for parents and on managing patients. This article is intended for students or newly qualified childrens nurses, however, it can also serve as a refresher for all professionals working with children.

Aims and intended learning outcomes

This article aims to take the reader through the presentations, assessment, investigations and management of the common lower respiratory tract infections. Each condition is accompanied by an illustrative case study to give an idea of what nurses may encounter while assessing a child. After reading this article and completing the time out activities you should be able to: Identify the signs and symptoms of lower respiratory tract infections. Apply the paediatric early warning score towards recognition of a potentially unwell child presenting with a respiratory illness. Identify and manage a child who may deteriorate during hospital admission. Describe the importance of working in a team when caring for children.

Keywords
Assessment, bronchiolitis, pneumonia, lower respiratory tract infections, paediatric respiratory care
These keywords are based on the subject headings from the British Nursing Index This article has been subject to open peer review and checked using antiplagiarism software. For related articles visit our online archive and search using the keywords

or lower airways. The upper airway ends in the larynx and the lower airway starts with the trachea (NHS Choices 2011). Cough and wheeze are primary signs of lower RTI while stridor is seen in upper respiratory tract pathology (Gill and OBrien 2007). RTIs are common during winter because of close contact between people staying indoors (NHS Choices 2011). Box 1 (page 28) highlights why younger children may be vulnerable to RTIs. Box 2 (page 28) highlights the most common lower respiratory tract ailments encountered in acute childrens settings. Children are a diverse population who have different physiological parameters. Respiratory rate varies with age this will vary with the state of arousal, health and physical wellbeing of the child (Marks et al 1993). Table 1 (page 29) will serve as an aide-memoire of the respiratory rate for children. Now do time out 1. Risk factors for child respiratory illness Some children may be more vulnerable than their peers and knowledge about such risk factors is helpful while assessing RTI. Box 3 (page 28) highlights some important ones.

Introduction
Respiratory tract infections (RTIs) are common in children. They are one of the most common reasons for consultation with a health professional in developed countries (Schaad 2005, National Institute for Health and Clinical Excellence 2008, Blacklock et al 2011). Acute RTIs are among the leading causes of childhood mortality; statistics for England and Wales revealed that they accounted for 4 per cent of deaths in children aged zero to 14 years (Office for National Statistics 2009). For the purpose of clinical description, the airways may be described as upper

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Risk factors
In your experience what do you consider to be the risk factors for respiratory tract infections in children? How would these risk factors influence your assessment and approach for further management?

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Box 1 Reasons for increased vulnerability of young children Increased exposure to respiratory pathogens from siblings and other children when in childcare. Environmental risk factors, such as passive smoking, exposure to pollutants and absence of breastfeeding. Inability to report symptoms and dependency on parental interpretation. Young children usually have three to eight episodes of respiratory illness per year. In some instances, their immune system may not have had previous exposure to the pathogens. Activities such as attending nursery or school will suddenly increase their exposure. This helps to build up immunity against the pathogens in the long term. Defects in the immune system and familial predisposition. Shorter respiratory tract compared with adults. Lack of interconnectivity in the lower airways and a lower functional reserve in children causing quick compromise of the airway (Colley 1975, Schaad 2005, NHS Choices 2011). Criteria for admission Nursing staff can provide valuable input in guiding the medical team in deciding how best to manage cases of lower RTIs. The following should prompt towards managing the child in the hospital (British Thoracic Society (BTS) 2002, Scottish Intercollegiate Guidelines Network (SIGN) 2006): Oxygen saturation below or equal to 92 per cent, cyanosis. Rapid respiratory rate (Table 1). Difficulty in breathing, recessions of the chest wall. Intermittent apnoea (brief pauses in breathing) or grunting (abnormal, short, deep, hoarse sounds caused by a forced expiration against a closed glottis). Children with risk factors (Box 3). Not feeding 50 per cent of daily requirement or dehydrated. Family unable to observe or supervise adequately. Now do time out 2. five years old, while Mycoplasma pneumoniae and Chlamydophilia pneumoniae are more common in children over five years of age. Clinical presentation CAP presents with fever, cyanosis and signs of respiratory distress such as tachypnoea, cough, recessions, decreased breath sounds and crackles (abnormal discontinuous bubbling noises heard on chest auscultation during inspiration) (Dirlewanger et al 2002, Ostapchuk et al 2004). Bacterial pneumonia is more likely in children older than three years of age with a temperature higher than 38.5C. Viral pneumonia is more common in infants and young children with wheeze, low-grade pyrexia (<38.5C), hyperinflation and marked recession for example, chest wall retraction, indrawing of the chest wall muscles because of pliable chest wall in very young children (BTS 2002). Paediatric early warning score A child who looks clinically unwell, or has pre-existing risk factors, may benefit from an early chest X-ray and review by a senior paediatrician. It should be remembered that respiratory deterioration and arrest is mainly seen in children with respiratory cardiac arrest occurring secondary to this. In adults cardiac arrest leads to respiratory arrest. Box 2 Most common childhood lower respiratory ailments Pneumonia. Bronchiolitis (viral respiratory tract infection affecting the bronchioles). Viral-induced wheeze (previously termed wheezy bronchitis). Laryngotracheobronchitis (croup). Premature babies with chronic lung disease presenting with a respiratory illness. Box 3 Risk factors for respiratory tract infections Absence of breastfeeding. Age below 12 weeks at presentation. Chronic lung disease: cystic fibrosis, chronic lung disease of prematurity, underlying lung anomalies. Congenital heart disease. Congenital or acquired immune deficiencies. Gastroesophageal reflux disease. Needs supplemental oxygen at home. Neuromuscular disorders: associated with depressed consciousness. Older siblings in the nursery or school. Passive smoking, especially maternal.
(Adapted from British Thoracic Society 2002, Stephenson 2002, Meates-Dennis 2005, Kelly 2006, Yanney and Vyas 2008, Bhakta et al 2009, Barson et al 2011)

Pneumonia
Community-acquired pneumonia (CAP) is defined as a pneumonia acquired by a healthy child outside the hospital; it usually presents with cough and fever. It has an annual incidence of 34 to 40 per 1,000 in children under five years of age in Europe and the United States (BTS 2002, Ostapchuk et al 2004, Paul and Warren 2010, Barson et al 2011). Streptococcus pneumoniae is the most common bacteria seen in children under

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Assessment priorities
When initially assessing a child with pneumonia, which of the risk factors in the list you compiled for time out 1 or those in Box 3 are especially important?

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The paediatric early warning score (PEWS) is now an established tool of standard nursing observation in children in most UK hospitals and can provide a forewarning time of more than 11 hours. The PEWS will alert the team to intervene early and possibly avert a respiratory arrest (Akre M et al 2010). Case study one and Figure 1 (page 30) show how a severe CAP may present and the management strategies that may be necessary. Now do time out 3.

Table 1

Respiratory rate according to age Respiratory rate per minute 3050 2030 2030 1520 Consider as rapid (respiration/minute) >60 >50 >40 >30

Age in years Newborn Infant (<1 year) Toddler (one to three years) Child (from four years of age)
(Adapted from Gill and OBrien 2007)

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Community-acquired pneumonia
Children with community-acquired pneumonia (CAP) can suffer short-term morbidity. What do you think will be the role of a chest X-ray in CAP? In your experience why would the child need fluid restriction?

retention and dilution of the sodium in the blood, which needs fluid restriction (BTS 2002). Prognosis and prevention The mortality rate is low (less than one per 1,000 per year), however, CAP still causes significant morbidity (Barson et al 2011). Pneumococcal and Haemophilus influenzae type b (Hib) immunisation have decreased hospitalisation rates, morbidity and, possibly, mortality rates in younger children (Barson et al 2011). It is possible that some children with CAP have not completed the childhood immunisation, which has long-standing benefits for the child. It may be useful for the parents to be told about the benefits and you may be able to encourage them to immunise the child. A clear follow-up plan should be given to the parents at discharge. Children who have suffered complications, such as pleural effusion or significant consolidation, should be followed up in the outpatient department with a repeat chest X-ray. Now do time out 4.

Management Children who are well can be managed at home and their parents advised on measures for fever management, adequate fluid administration, antibiotics and deterioration needs reassessment (BTS 2002). The childrens nurse plays an important role in addressing parents anxieties and may be able to offer reassurance when a child is discharged home after an initial assessment, along with a plan of what features to look out for if the child deteriorates. In the hospital setting a child may need supplemental oxygen, intravenous fluids and other supportive measures. A chest X-ray is done to substantiate or confirm the clinical suspicion of pneumonia but may not be able to differentiate between a bacterial and viral aetiology (BTS 2002, Murahovschi 2004, Finn 2008). There is no clear guidance available, but raised inflammatory markers such as white cell count, erythrocyte sedimentation rate and C-reactive protein may help further management because a raised inflammatory marker will be expected in a bacterial pneumonia (Virkki et al 2002, Murahovschi 2004, Summah and Qu 2009, Paul and Linney 2011). Children with CAP admitted to hospital are generally treated with antibiotics which one is largely dependent on unit policy. Amoxicillin is the preferred antibiotic in children under five years of age because Streptococcus pneumoniae is the common pathogen in this age group. For children older than five years of age, a macrolide antibiotic such as erythromycin or azithromycin is preferred because Mycoplasma pneumoniae is more common in this age group (BTS 2002). A course of antibiotics for CAP of seven to ten days is advisable (BTS 2002, Ostapchuk et al 2004). Syndrome of inappropriate antidiuretic hormone may be seen with CAP, as was evident in case study one, causing fluid
NURSING CHILDREN AND YOUNG PEOPLE

Bronchiolitis
This is commonly seen in infants and young children (Meates-Dennis 2005). Respiratory syncitial virus (RSV) is responsible for about 50-90 per cent of all cases, resulting in about 20,000 hospital admissions per year in the UK (Meates-Dennis 2005, Yanney and Vyas 2008). RSV affects almost all infants and young children in the first three years of life, with a peak incidence of hospitalised patients at two to six months of age (Meates-Dennis 2005). Bronchiolitis can also be caused by other viruses, such as adenovirus, bocavirus, influenza,

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Differential diagnosis
Consider your experience of children with bronchiolitis. When you compare this illness with that of a child presenting with pneumonia, what are the main differences? If you have not come across a child with this condition, what do you imagine might be the presenting features?

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parainfluenza, coronavirus and enterovirus (Yanney and Vyas 2008). Clinical presentation In the UK, the term bronchiolitis describes an illness that begins as an upper respiratory tract infection (URTI) followed by signs of respiratory distress, a hacking cough, bilateral crepitations (rattling noises in the chest), air trapping and wheezing (Yanney and Vyas 2008). The typical clinical features, age of the child and presence of findings on both sides of the chest, such as crepitations, will help in differentiating this condition from pneumonia. However, there is no clear-cut distinction between the two and management depends on the overall clinical situation. RSV is spread by respiratory secretions from close contact with infected persons or contact with contaminated surfaces or objects (Meates-Dennis 2005). The underlying pathophysiology is inflammation of the small airways (bronchioles) (Meates-Dennis 2005, McDougall 2011). Apnoea may occur in up to 20 per cent of cases, particularly in premature infants. Although infants born pre-term outgrow the tendency to have spontaneous apnoeas by the time their age is equivalent to the normal 40 weeks gestation, periods of additional stress caused by infections, such as bronchiolitis, apnoea and desaturations are known to recur (Ramesh and Samuels 2005). Clinical examination findings include fever, increased respiratory effort, tachypnoea, low saturations, wheezing and fine crackles on auscultation, and dehydration (SIGN 2006, McDougall 2011). Now do time out 5.

Case study one

A three-year-old healthy girl presented with two weeks history of high fever up to 39C, cough and recent onset difficulty in breathing. Air entry was decreased in the right side of the chest and harsh bronchial breath sounds were detected. A chest X-ray showed right-sided pneumonia (Figure 1). Blood investigations showed raised inflammatory markers and a low serum sodium of 132mmol/L, indicating inappropriate secretion of anti-diuretic hormones. As a result, fluid restriction was monitored. The child was started on intravenous (IV) cefuroxime and, initially, needed supplemental oxygen. As she continued to spike high temperatures of 39C and higher; an ultrasound scan was done which showed a pleural effusion. She was transferred to the regional unit for a chest drain and received ten days on IV antibiotics and a three-day course of oral azithromycin. Figure 1 Chest X-ray of right, middle and lower lobe opacification/consolidation

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Bronchiolitis admission
Most infants experience bronchiolitis early in life and are managed at home. From your experience and considering the risk factors already mentioned can you think when such children might need admission to hospital?

Management Bronchiolitis is a clinical diagnosis and is suspected when an infant less than one year presents with classical features. While assessing infants with possible acute bronchiolitis, general wellness, respiratory rate, oxygen saturation recording, and asking parents about feeding and activity, will aid decisions about subsequent management. In hospitals, investigations should be carried out, such as blood gas analysis, chest X-ray, nasopharyngeal aspirate and blood tests (SIGN 2006). Case study two describes the case of a young infant with bronchiolitis who needed admission to hospital and required respiratory and feeding support during the course of the illness. Children judged well enough may be managed at home with parental reassurance, combined with an explanation about the disease process condition peaks on days three and four, then gradually settles, cough will continue for weeks. Advice about giving smaller volumes of feed more frequently may help to ease the breathing effort and support a better tolerance of feeds (Sethi and Nagar 2004). This is because a large feed is likely to fill the stomach and cause pressure on the diaphragm making breathing difficult for the infant with bronchiolitis.
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During a hospital admission supportive therapy, such as nasogastric tube (NGT) feeds, supplemental oxygen and continuous positive airway pressure (CPAP), may be required. CPAP works by keeping small airways open throughout the respiratory cycle, thus decreasing the effort of breathing (McDougall 2011). Evidence about the use of bronchodilators such as salbutamol remains inconclusive (Yanney and Vyas 2008).

Case study two

A seven-week-old girl, born at term and breastfed, presented with a 24-hour history of coryza (inflammation of the lining of the mucous membranes of the nose), difficulty in breathing and reduced feeding. Saturations were 88 to 91 per cent in air. Examination revealed head bobbing, subcostal recessions and widespread wheeze and basal crackles, consistent with a clinical diagnosis of bronchiolitis. She was commenced on 0.5L oxygen and nasogastric tube feeding. Nasopharyngeal aspirate confirmed the presence of respiratory syncytical virus. Continuous positive airway pressure and intravenous fluids were needed after 24 hours because of clinical deterioration and respiratory acidosis. The chest X-ray showed changes consistent with bronchiolitis (Figure 2). The symptoms improved and she was discharged after five days. This case study highlights a common scenario with classical signs in a young infant where hospital admission may be necessary as the respiratory reserve is less and often needs respiratory support. Figure 2 Chest X-ray of mild hyperinflation, increased bronchovascular markings, nasogastric tube in situ, electrocardiogram leads for monitoring

Prognosis and prevention Handwashing between touching patients will limit the spread of bronchiolitis in the healthcare setting (Meates-Dennis 2005, SIGN 2006). The recovery of pulmonary epithelial cells occurs three to four days after the onset of bronchiolitis, but cilia do not regenerate for approximately two weeks. This explains the prolonged cough and wheeze and it is helpful to let parents know this during discharge (Meates-Dennis 2005). Mortality remains as high as 0.5-1.5 per cent in hospitalised patients, increasing to 3-4 per cent in those with underlying cardiac or pulmonary disease, namely premature infants (Handforth et al 2000, Meates-Dennis 2005). No immunisation is available for RSV infections. A humanised monoclonal antibody preparation (palivizumab) is used in high-risk groups. It does not prevent infection, however, it reduces RSV hospitalisation in infants with specific comorbidities, such as premature infants on home oxygen therapy or with complex congenital heart disease (SIGN 2006, ODonnell and Roe 2009).

Viral-induced wheeze
This wheeze was previously described as wheezy bronchitis and can be defined as an intermittent airway obstruction, manifested by bouts of coughing and wheezing (Silverman et al 2003, Gern 2004). Approximately 3 per cent of all children less than one year need admission to hospital with moderate or severe viral lower RTI every year (van Woensel et al 2003). Several major studies have reported wheeze being common in preschool children, with an indicated prevalence of the condition at between 25 per cent and 38 per cent (Frank et al 2008). It is important to remember that these children get intermittently wheezy with a viral RTI and remain well without any symptoms, unlike a child with asthma who will have interval symptoms of night coughs and exercise intolerance when not on treatment. RSV remains the most common aetiological factor, however, other viruses are also found, for example, influenza viruses, parainfluenza viruses, rhinovirus, adenovirus and human metapneumovirus (van Woensel et al 2003). Clinical presentation The child who is usually of preschool age presents with cough and wheezing. This results from reversible airway obstruction and manifests as a whistling, puffing or squeaking sound made by air passing through narrow tracheal and bronchial airways (Skoner 2007). Case study three (page 32) shows how a child with virus-induced wheeze may present and the inpatient management. There may be associated fever, coryzal symptoms, mild dehydration and parents often describe their child being sick this is actually phlegm or mucus brought
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Time out
Wheeze
Children with virus-induced wheeze suffer intermittent short-term symptoms. In your experience when do you think such a child may benefit from hospital admission? When should the child be considered as having asthma? inflammation with exudate and oedema of the subglottic area causes narrowing of the airway (King 2011). It is mostly viral in nature, however, if the child looks unwell bacterial tracheitis needs to be considered. Some common viruses responsible are parainfluenzae 1, parainfluenzae 2 and 3, measles, paramyxovirus and influenza A. The peak incidence is seen in the second year of life, with five cases per 100 children per year (Draper 2010, King 2011). Clinical presentation Preceded by a few days of mild URTI, low-grade fever, runny nose, mild cough, croup typically presents in the night with noisy breathing, hoarse voice and a seal-like barking cough. Initial assessment might reveal mild fever, absence of drooling, well child, restlessness, low saturations, inspiratory stridor (caused by air flow through the narrowed wind pipe due to swelling) and wheeze. However, if drooling is present or the child has a high temperature or looks unwell, bacterial tracheitis or epiglottitis needs to be considered and urgent medical attention (include ear, nose and throat, and anaesthetic team) should be sought (Draper 2010, King 2011). This is because the child is at risk of acute airway obstruction from the laryngeal oedema and spasm if he or she becomes distressed or scared by interventions such as trying to site an intravenous cannula, inserting a tongue depressor to examine the throat or trying to do some observations such as taking temperature or sticking ECG leads to the chest wall. Therefore these medical and nursing interventions should be avoided at this stage. Now do time out 7. Management A child with just a barking cough may be managed at home with reassurance from the childrens team. Some units use a croup score chart to determine illness severity. Any child with a stridor needs careful observation as there may be a potential for deterioration. Parents and healthcare professionals need to adopt a calm approach, not examine the throat with a spatula and keep the child comfortable. Oral dexamethasone or nebulised budesonide have been shown to provide symptomatic relief (Draper 2010, King 2011). Nebulised adrenaline (epinephrine) (1:1,000) should be reserved for severe cases and children receiving it should be observed in hospital (Draper 2010, King 2011).

up after a bout of coughing (Stephenson 2002). Nowdo time out 6. Management Most children can be managed with parental reassurance, adequate hydration and symptomatic management. A trial of bronchodilator therapy, such as salbutamol or ipratropium bromide, is sometimes tried, although well designed trials showed minimal benefit (van Woensel et al 2003). A short course of steroid is often prescribed, however, no clear clinical benefit to young children with mild-to-moderate wheeze primarily triggered by colds has been demonstrated (Stephenson 2002, van Woensel et al 2003, Renouf 2009). Prognosis and prevention Most children do well in the long term. In a study of 628 children with preschool wheeze in Manchester, it was found that the absence of baseline exercise-induced wheeze and a history of atopic disorders reduced the likelihood of subsequent asthma by a factor of five (Frank et al 2008). Avoidance of parental smoking and uptake of childhood vaccinations, such as pneumococcal vaccination, has been reported to decrease the occurrence of viral respiratory infections (Madhi et al 2004).

Laryngotracheobronchitis (croup)
This may also be considered as an upper airway condition and is often referred to as croup. Diffuse

Case study three

A 19-month-old boy born at 31 weeks gestation, and with a previous history of pneumonia, presented with a two-day history of cough and coryza. He was dyspnoeic and was administered salbutamol bronchodilator. His respiratory rate was 40/ minute with saturations of 95 per cent in air. On examination moderate tracheal tug with subcostal and intercostal recessions were noted with wheeze. He was admitted with a diagnosis of viral-induced wheeze and commenced on hourly salbutamol and oral prednisolone. Chest X-ray showed normal lung shadow. He showed signs of clinical improvement and was discharged home the next day. 32 November 2011 | Volume 23 | Number 9

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Croup
This common condition is often an acute presentation in children. When in your experience would you seek immediate help from medical colleagues?

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Case study four

A female infant born at 23 weeks gestation needed ventilator support and continuous positive airway pressure for the first 13 weeks of life. The patent ductus arteriosus (channel by which blood is supplied to the fetus inside the womb) was surgically ligated. She was discharged at a corrected gestational age of 40 weeks, on home oxygen and on bottle feeds. Her mother continued to be a smoker. She presented with acute respiratory illness four times in her first year of life and needed management in the paediatric intensive care unit on three of these occasions. She remains under follow up with a respiratory paediatrician. She also received five doses of palivizumab. The recurrent episodes of respiratory illness are explained by her chronic lung disease (Figure 3), her immature immune system and possibly passive exposure to smoking. This case highlights the problems faced by an extremely premature baby who should be admitted early as there is a risk for deterioration with any respiratory tract infection. Prevention Childhood immunisations with Hib vaccination have reduced the occurrence of epiglottitis. Any child who may not have been vaccinated or who has missed vaccines should be encouraged to complete the schedule.

of antenatal steroids, which help in the production of pulmonary surfactant, survival for the most premature infants has improved (Kelly 2006). CLD is most commonly seen in very low birthweight babies (less than 1.5kg) with a prolonged period of mechanical ventilation and respiratory support (Bhakta et al 2009). The overall incidence of CLD is 23 per cent and increases with decreasing birthweight and lower gestational age at delivery (Bhakta et al 2009). Clinical presentation A working definition of CLD is the need for supplemental oxygen at 28 days of life or at 36 weeks of corrected gestational age, whichever is earliest (Primhak 2003, Kelly 2006, Bhakta et al 2009). These infants are often on home oxygen therapy with an aim to keep oxygen saturations at or above 93-95 per cent (Primhak 2003, Kelly 2006). They most often are given open access to childrens wards and frequently present at the start of respiratory illness. Case study four describes an infant with CLD of prematurity and the respiratory disabilities suffered by such infants during their early life. Children may present with wheeze, cough, cold, pneumonia, bronchiolitis, dehydration and so on. A detailed assessment and discussion with the childs parents is necessary to decide on further management. Now do time out 8.

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Admission criteria
Children with chronic lung disease are more prone to respiratory infections. From your experience can you think why this group of children should be admitted early when presenting with a respiratory illness?

Chronic lung disease

Chronic lung disease (CLD) was first described by Northway and colleagues in 1967 (Primhak 2003, Kelly 2006, Bhakta et al 2009). With the improvement of technology and medical advances, such as continuous positive airway pressure, and use Figure 3

Chest X-rays showing normal lung markings and chronic lung changes

Reproduced with parental consent

A: Normal lung markings

B: X-ray showing patchy chronic lung changes. The heart borders are not clear
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Management Mild bronchiolitis or pneumonia with no dehydration in an otherwise well infant may be managed at home with monitoring by community outreach nurses. Advice and guidance should be given to parents about the signs of deterioration. An infant on home oxygen therapy should be admitted and monitored in hospital if there is a need to increase the set oxygen parameters indicating worsening of the respiratory status (Primhak 2003, Kelly 2006). Case study four gives a snapshot of what happens when these infants are readmitted. Prognosis and prevention Results from the EPICure study showed that out of 4,004 births between 20 weeks and 25 weeks and six days, 811 infants were admitted to an intensive care unit and only 314 survived (39 per cent) (Costeloe et al 2000). Some infants will die in the first two years of life after being discharged from hospital. Adequate nutrition and a smoke-free environment along with routine vaccinations are helpful measures. Palavizumab prophylaxis against RSV infection is helpful (SIGN 2006, Bhakta et al 2009, ODonnell and Roe 2009).

Conclusion
Respiratory infections can present a diagnostic as well as a nursing management dilemma, especially in younger children presenting with non-classical symptoms. It is important to make a careful assessment of respiratory presentations to determine whether the problem can be managed in the home or if admission to hospital is warranted. It is hoped the case studies will help nurses managing children with respiratory illnesses to do a thorough assessment and help appropriate management and aid recognition of early deterioration. An early diagnosis and appropriate treatment are associated with a better outcome. Now do time out 9.

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Practice profile
Now that you have completed the article you might like to write a practice profile. Guidelines to help you are on page 36.

References
Akre M et al (2010) Sensitivity of the pediatric early warning score to identify patient deterioration. Pediatrics. 125, 4, e763e769. Barson WJ et al (2011) Epidemiology, Pathogenesis, and Etiology of Pneumonia in Children. www.uptodate.com/contents/ epidemiology-pathogenesis-and-etiology-ofpneumonia-in-children?view=pri (Last accessed: September 14 2011.) Bhakta KY et al (2009) Chronic lung disease of infancy. In Turcios NL, Fink RJ. Pulmonary Manifestations of Pediatric Diseases. Saunders Elsevier, Philadelphia PA. Blacklock C et al (2011) Which symptoms and clinical features correctly identify serious respiratory infection in children attending a paediatric assessment unit? Archives of Disease in Childhood. doi:10.1136/adc.2010.206243 British Thoracic Society (2002) BTS guidelines for the management of community acquired pneumonia in childhood. Thorax. 57, Suppl 1, i1-i24. Colley JRT (1975) The vulnerable child. Journal of the Royal College of General Practitioners. 25, 153, 257-262. Costeloe K et al (2000) The EPICure study: outcomes to discharge from hospital for infants born at the threshold of viability. Pediatrics. 106, 4, 659-671. Dirlewanger M et al (2002) Community-acquired pneumonia in children aged 2 months to 5 years: application of the WHO guidelines in a developed country setting (Switzerland). European Journal of Pediatrics. 161, 8, 460-461. Draper R (2010) Lower Respiratory Tract Infection in Children. www.patient.co.uk/doctor/ LRTI-in-Children.htm (Last accessed: September 14 2011.) Finn R (2008) To X-ray or not in Child with Signs of Pneumonia. http://findarticles.com/p/ articles/mi_hb4384/is_7_42/ai_n29454128/ (Last accessed: September 14 2011.) Frank PI et al (2008) Long term prognosis in preschool children with wheeze: longitudinal postal questionnaire study 1993-2004. British Medical Journal. 336, 7658, 1423-1426. Gern JE (2004) Virus-Induced Wheezing vs Asthma. www.medscape.com/ viewarticle/478312 (Last accessed: September 14 2011.) Gill D, OBrien N (Eds) (2007) Paediatric Clinical Examination Made Easy. Fifth edition. Churchill Livingstone, London. Handforth J et al (2000) Basic epidemiology and immunopathology of RSV in children. Paediatric Respiratory Reviews. 1, 3, 210-214. Kelly MM (2006) The medically complex premature infant in primary care. Journal of Pediatric Health Care. 20, 6, 367-373. King L (2011) Emergent Management of Croup (Laryngotracheobronchitis). http://emedicine. medscape.com/article/800866-overview (Last accessed: September 14 2011.) Madhi SA et al (2004) A role for Streptococcus pneumoniae in virus-associated pneumonia. Nature Medicine. 10, 8, 811-813. Marks MK et al (1993) Reference ranges for respiratory rate measured by thermistry (12-84 months). Archives of Disease in Childhood. 69, 5, 569-572. McDougall P (2011) Caring for bronchiolitic infants needing continuous positive airway pressure. Paediatric Nursing. 23, 1, 30-35. Meates-Dennis M (2005) Bronchiolitis. Archives of Disease in Childhood Education and Practice Edition. 90, 4, ep81-ep86. Murahovschi J (2004) Chest X-ray (mania) in pediatric emergency departments (Letter). Jornal de Pediatria. 80, 2, 163-166. National Institute for Health and Clinical Excellence (2008) Respiratory Tract Infections: Antibiotic Prescribing. Clinical guideline 69. NICE, London. NHS Choices (2011) Respiratory Tract Infection. www.nhs.uk/conditions/ Respiratory-tract-infection/Pages/Introduction. aspx (Last accessed: September 14 2011.) ODonnell R, Roe M (2009) Respiratory syncytial virus bronchiolitis. In Murphy PJ et al Case Studies in Pediatric Critical Care. Cambridge University Press, Cambridge. Office for National Statistics (2009) Childhood, Infant and Perinatal Mortality in England and Wales 2009. ONS, London. Ostapchuk M et al (2004) Community-acquired pneumonia in infants and children. American Family Physician. 70, 5, 899-908. Paul SP, Linney MJ (2011) Significance of very high C-reactive protein (CRP) values in the paediatric practice: a retrospective study. Clinical Biochemistry. 44, 7, 540-541. Paul SP, Warren V (2010) Community acquired pneumonia in a three year old child: dealing with a difficult case. Nursing Times. 106, 49-50, 14. Primhak RA (2003) Discharge and aftercare in chronic lung disease of the newborn. Seminars in Neonatology. 8, 2, 117-126. Ramesh P, Samuels M (2005) Are methylxanthines effective in preventing or reducing apnoeic spells in infants with bronchiolitis? Archives of Disease in Childhood. 90, 3, 321-322. Renouf P (2009) Oral prednisolone did not improve outcomes in preschool children with an attack of virus-induced wheezing. Evidence-based Nursing. 12, 3, 73. Schaad UB (2005) Prevention of paediatric respiratory tract infections: emphasis on the role of OM-85. European Respiratory Review. 14, 95, 74-77. Scottish Intercollegiate Guidelines Network (2006) Bronchiolitis in Children: A National Clinical Guideline. www.sign.ac.uk/pdf/sign91. pdf (Last accessed: September 14 2011.) Sethi GR, Nagar G (2004) Evidence based treatment of bronchiolitis. Indian Journal of Pediatrics. 71, 8, 733-737. Silverman M et al (2003) Episodic viral wheeze in preschool children: effect of topical nasal corticosteroid prophylaxis. Thorax. 58, 5, 431-434. Skoner DP (2007) Wheeze in preschool children. Consultant for Pediatricians. 6, 4. www.pediatricsconsultant360.com/content/ wheeze-preschool-children (Last accessed: October 5 2011.) Stephenson P (2002) Management of wheeze and cough in infants and pre-school children in primary care. Primary Care Respiratory Journal. 11, 2, 42-44. Summah H, Qu JM (2009) Biomarkers: a definite plus in pneumonia. Mediators of Inflammation. doi: 10.1155/2009/675753. van Woensel JB et al (2003) Viral lower respiratory tract infection in infants and young children. British Medical Journal. 327, 7405, 36-40. Virkki R et al (2002) Differentiation of bacterial and viral pneumonia in children. Thorax. 57, 5, 438-441. Yanney M, Vyas H (2008) The treatment of bronchiolitis. Archives of Disease in Childhood. 93, 9, 793-798.

34 November 2011 | Volume 23 | Number 9

NURSING CHILDREN AND YOUNG PEOPLE

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