Case 31 Increasing respiratory distress
Adam, a 4-week-old boy born at term, is admitted having had a 20 second ‘blue’ episode in the GP’s evening surgery. He has been breast fed since birth and is gaining weight. Adam’s 3-year-old sister has recently had a cold. The day before admission Adam had a runny nose, reduced feeds and fewer wet nappies. The history is otherwise unremarkable. Examination shows a miserable boy with a temperature of 37.4°C, a pulse rate of 160/minute and an oxygen saturation of 89% in air. He has a cough, copious clear secretions and a respiratory rate of 40/minute with mild subcostal and intercostal recession. On auscultation there are widespread fine crackles and expiratory wheezes. The cardiovascular and abdominal examinations are normal.
What is the likeliest diagnosis? What test(s) would you request?
A clinical diagnosis of bronchiolitis is made and a nasopharyngeal aspirate subsequently confirms the cause to be the Respiratory Syncytial Virus (RSV). A CXR is unnecessary at this stage. Adam is administered oxygen via nasal prongs and admitted to the ward for nasogastric feeding and nursing care. Over the next 12 hours his respiratory distress gradually worsens with tracheal tug and increased intercostal and subcostal recession. By the time of the consultant morning ward round Adam is in a headbox requiring 40% oxygen to maintain saturations ≥92% and feeds have been stopped due to large gastric aspirates. He has been commenced on iv fluids at 100 mls/kg/day and at the time of the cannula insertion, 2 hours previously, a venous gas had shown a pH 7.28 (normal 7.35–7.45), pCO2 7.1 kPa (4–6.5 kPa), bicarbonate 23 mmol/L (20–26 mmol/L) and base excess –2 mmol/L (-2.5 to 2.5 mmol/L). A CXR requested due to his clinical deterioration shows patchy atelectasis.
How would you rate the severity of his illness – mild, moderate or severe?
The consultant transfers Adam to the High Dependency Unit, requests 1:1 nursing and close and frequent reviews by the FY2 and ST4 trainees. The possible future need for CPAP is discussed with both staff and parents. Four hours later, Carol, the nurse looking after Adam, asks the FY2 to review the patient because Adam has had several apnoeas and bradycardias lasting up to 30 seconds. His pulse has risen to 190/minute and his oxygen requirement to 60%. The FY2 phones the ST4, Dr Burns, for advice and Dr Burns suggests an ipratropium bromide nebulizer.
Was this a reasonable course of action by the ST4 doctor?
An hour later the nurse, Carol, bleeps Dr Burns to request her to come and review Adam. Carol reports two episodes of apnoea requiring stimulation lasting 90 seconds and that Adam’s pulse is now 220/minute. His oxygen saturation cannot be maintained at >87%. Dr. Burns gives a verbal prescription for an adrenaline nebulizer and says that she will attend in about an hour to assess the response.
What would you have done?
Half an hour later the nurse in charge bleeps Dr Burns asking her to attend urgently because the adrenaline has been ineffective and Adam has had two further prolonged apnoeas, desaturating to 54% and requiring intermittent positive pressure ventilation (IPPV) via bag and mask. By the time Dr Burns arrives, the consultant, called by the senior nurse, is already present and bagging the baby. An urgent capillary gas shows a pH 7.08, pCO2 16.2 kPa, bicarbonate 17 mmol/L and base excess – 5 mmol/L. Adam is immediately intubated, ventilated and transferred to a PICU. His course there is complicated by two pneumothoraces and he requires high frequency oscillation. He is an inpatient for a total of 6 weeks and eventually makes a good recovery.
Adam’s parents refuse to return to the referring hospital and write a letter of complaint stating that their son had not received appropriate and timely medical care.
Expert opinion
Bronchiolitis is a common usually self-limiting illness of infancy; 2–3% of infants with RSV positive bronchiolitis are admitted annually with most being managed at home. Typically there is a clinical deterioration over the first 48–72 hrs and babies <2 months may become exhausted and apnoeic. A small proportion of infants need high dependency or intensive care – most respond well to CPAP avoiding the need for intubation. Ventilating such babies has a high complication rate.
There is no evidence that bronchodilators, oral or inhaled steroids have any effect on the clinical course or any important outcomes although they are often tried. There is emerging evidence that adrenaline may be useful. However, the cornerstones of management during a hospital admission are close observation, frequent clinical review and early intervention – all requested by the consultant. This already sick baby’s observations showed a continued steady deterioration and the ST4 trainee, Dr Burns, should have gone to see him at the first report of apnoeas and bradycardias. There is a strong possibility that Adam would have responded favourably if CPAP had been started then and avoided the need for intubation. By the time the consultant was called Adam was too sick for this option.
Nursing staff are extremely experienced in caring for children with bronchiolitis and often progress management without medical input. Their request to attend to review such a baby should have been dealt with promptly. They should also be empowered to bypass the trainees and summon the consultant if they have concerns that are not being addressed. Such occasions should be rare.
Legal comment
Luckily, Adam appears to have made a good recovery. But there were failings in his treatment.
The consultant had requested that the nurses place the child under 1:1 observation and that the FY2 and ST4 trainees should frequently review him. The nurses appear to have performed their duties. It is the trainees who have been the weak link. As a result, there was a failure to start CPAP.
The expert comments that the trainee should have attended promptly when asked to review Adam. There appears to be a systems failure here. The trainees should appreciate the experience of the nurses and listen to their concerns. In the General Points below, it is suggested that senior nurses should be able to bypass the trainees and contact the consultant, if the trainees do not give adequate attention to their concerns. The fact that the nurses did not do this until a very late stage may indicate that the department is over-hierarchical to the detriment of patient care.
This incident should spark a review of how the trainees, nurses and consultants all interact.
