Inpatient BRONCHIOLITIS - WordPress.comInpatient BRONCHIOLITIS PATHWAY INCLUSION Criteria for...
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Initial Assessment Order placed in EPIC for RT Eval/Tx Per Respiratory Protocol Page RT RT to eval and score patient at least Q shift and PRN. RN (or RT) perform nasal suctioning and then assign a post-suction St. Mary’s Bronchiolitis score Continuous pulse oximetry if patient requires supplemental oxygen Spot check SpO2 Q4H and prn if not on oxygen Place on Droplet Precautions until discharge St. Mary’s Bronchiolitis Score ≤ 6 Initiate O2 by LFNC starting at 0.5L NC if sats < 90% on RA Titrate up PRN to keep O2 sats >88% RT (or RN) to continue oral and nasopharyngeal suctioning as needed Assess and rescore with vital signs if still stable on current support Consider Transfer to outside facility/PICU Criteria • Worsening after HHNC trial • 100% FiO2 for greater than 2 hours • Flow > 6 L/min (30 days -12 months) or > 8 L/min (13 months-24 months) for greater than 2 hours • CO2 >55 or pH <7.3 • Apnea >20sec requiring intervention • AMS, poor perfusion St. Mary’s Bronchiolitis Score > 6 Obtain CBG for baseline (iStat) Call RT to initiate Heated Humidified Nasal Cannula (HHNC) and notify physician if not present Initial HHNC FiO2 SETTINGS - Completed by RT 100% FiO2 Age 30 -90 days: Flow 4 L/min Age 91 days – 24 months: Flow 6 L/min Notify MD if FiO2 is 100% >2hours OR if flow > 8 L/min Assess and score Q15min x2 • Goal is to wean FiO2 to < 70% and optimize flow (decrease by 1 L/min or increase no more than 2 L/min at a time) If stable: Assess and score Q 30 min x 2 THEN Assess and score Q 2 hrs (alternate scoring between RT and RN) Reassess , suction and document score Q 2 hrs the ENITRE TIME patient is on HHNC (Can be done by RN or RT) Assess and score Q 30 min following any flow changes or if increased O2 support required Notify provider if FiO2 increased to 100%, if flow >8 L/min on HHNC, or if severity score increasing HYDRATION/NUTRITION – (Physician discretion) IVF if dehydrated IVF if on HHNC NPO IF score > 6 and/or RR > 60 (30 days– 12 months old) OR RR > 40 (13 months – 24 months) Initial feeding should be observed by the RN STOP IMMEDIATELY if any choking, coughing or respiratory distress Inpatient BRONCHIOLITIS PATHWAY INCLUSION Criteria for Protocol • Age 30 days – 24 months • Diagnosis of bronchiolitis and/or RSV EXCLUSION Criteria for Protocol • Hx of prematurity, BPD, underlying cardiopulmonary disease, immune deficiency, recurrent wheeze or asthma, cystic fibrosis, neuromuscular disease WEANING HHNC RN/RT to wean FiO2 for improving or stable Bronchiolitis score and to maintain O2 sats >88% Wean flow by 1 L/min when following criteria met: • FiO2 35%, Score < 6 after nasal suctioning, and clinically improving Reassess and score 30 minutes after adjusting flow If patient worsens after wean increase to prior settings When HHNC is stable at 2 L/min for 4 hours, trial on low flow NC at 2L or trial RA with VS Q1H ≤ 6 > 6 Updated 10/18/16
Transcript of Inpatient BRONCHIOLITIS - WordPress.comInpatient BRONCHIOLITIS PATHWAY INCLUSION Criteria for...
Initial Assessment Order placed in EPIC for RT Eval/Tx Per
Respiratory Protocol Page RT
RT to eval and score patient at least Q shift and PRN.
RN (or RT) perform nasal suctioning and then assign a post-suction St. Mary’s Bronchiolitis score
Continuous pulse oximetry if patient requires supplemental oxygen
Spot check SpO2 Q4H and prn if not on oxygen
Place on Droplet Precautions until discharge
St. Mary’s Bronchiolitis Score ≤ 6 Initiate O2 by LFNC starting at 0.5L NC if sats < 90% on
RA Titrate up PRN to keep O2 sats >88% RT (or RN) to continue oral and nasopharyngeal
suctioning as needed Assess and rescore with vital signs if still stable on
current support
Consider Transfer to outside facility/PICU Criteria • Worsening after HHNC trial • 100% FiO2 for greater than 2 hours • Flow > 6 L/min (30 days -12 months) or > 8 L/min
(13 months-24 months) for greater than 2 hours • CO2 >55 or pH <7.3 • Apnea >20sec requiring intervention • AMS, poor perfusion
St. Mary’s Bronchiolitis Score > 6 Obtain CBG for baseline (iStat) Call RT to initiate Heated Humidified Nasal Cannula (HHNC)
and notify physician if not present Initial HHNC FiO2 SETTINGS - Completed by RT
100% FiO2 Age 30 -90 days: Flow 4 L/min Age 91 days – 24 months: Flow 6 L/min Notify MD if FiO2 is 100% >2hours OR if flow > 8
L/min Assess and score Q15min x2
• Goal is to wean FiO2 to < 70% and optimize flow (decrease by 1 L/min or increase no more than 2 L/min at a time)
If stable: Assess and score Q 30 min x 2 THEN Assess and score Q 2 hrs (alternate scoring between
RT and RN) Reassess , suction and document score Q 2 hrs the ENITRE
TIME patient is on HHNC (Can be done by RN or RT) Assess and score Q 30 min following any flow changes or if
increased O2 support required Notify provider if FiO2 increased to 100%, if flow >8 L/min on
HHNC, or if severity score increasing
HYDRATION/NUTRITION – (Physician discretion) IVF if dehydrated IVF if on HHNC NPO IF score > 6 and/or RR > 60 (30 days– 12
months old) OR RR > 40 (13 months – 24 months) Initial feeding should be observed by the RN
STOP IMMEDIATELY if any choking, coughing or respiratory distress
Inpatient BRONCHIOLITIS PATHWAY
INCLUSION Criteria for Protocol • Age 30 days – 24 months • Diagnosis of bronchiolitis and/or RSV EXCLUSION Criteria for Protocol • Hx of prematurity, BPD, underlying cardiopulmonary
disease, immune deficiency, recurrent wheeze or asthma, cystic fibrosis, neuromuscular disease
WEANING HHNC RN/RT to wean FiO2 for improving or stable
Bronchiolitis score and to maintain O2 sats >88% Wean flow by 1 L/min when following criteria met:
• FiO2 35%, Score < 6 after nasal suctioning, and clinically improving
Reassess and score 30 minutes after adjusting flow If patient worsens after wean increase to prior
settings When HHNC is stable at 2 L/min for 4 hours, trial
on low flow NC at 2L or trial RA with VS Q1H
≤ 6
> 6
Updated 10/18/16
Inpatient BRONCHIOLITIS PATHWAY
INCLUSION Criteria for Protocol • Age 30 days – 24 months • Diagnosis of bronchiolitis and/or RSV EXCLUSION Criteria for Protocol • Hx of prematurity, BPD, underlying cardiopulmonary disease,
immune deficiency, recurrent wheeze or asthma, cystic fibrosis, neuromuscular disease
Indications for Testing • Pertussis testing for apnea observed • RSV testing if < 2 months or IF will change clinical care • Flu testing if will change clinical care
Recommendations/Considerations • No routine radiographs or labs • No inhaled Albuterol or Epinephrine • No hypertonic saline in ED (inconsistent/weak recs for
inpatient use) • No systemic steroids • No chest physiotherapy (vibration or percussion) • No antibiotics unless concomitant bacterial infection • NG or IVF if can’t maintain oral hydration
(taken from the Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis from Pediatrics 2014)
Discharge Home Criteria • St. Mary’s Bronchiolitis score < 4 • No need for deep suction for > 4 hrs • O2 sat >88% on RA x 4H • No apnea > 48H • Feeding adequately • Parent teaching regarding respiratory distress and safe feeding • Candidate for home O2, per provider discretion- please see recs
Updated 10/18/16
