Clinical pathway of capillary bronchitis
(2010 Edition)
I. Standard hospitalization process of capillary bronchitis clinical pathway
(A) Applicable objects.
The first diagnosis is capillary bronchitis (ICD-10: J21).
(B) Diagnostic basis.
According to the Clinical Diagnosis and Treatment Guide-Pediatric Internal Medicine Book (edited by the Chinese Medical Association, People’s Health Publishing House).
The main diagnostic points of this disease are: small age of onset (<2 years old), obvious wheezing at the beginning of the disease, wheezing sounds and fine wet rales heard in both lungs on physical examination; chest X-ray indicating obvious emphysema and small lamellar shadows.
1. Medical history: It is most common in infants under 2 years of age, especially in infants around 6 months of age. Most of them have a history of contact with patients with respiratory tract infections.
2. Symptoms: Initial symptoms of upper respiratory tract infection, mostly low fever, runny nose, nasal congestion, cough, some may have high fever, lack of energy, loss of appetite. 2-3 days appear lower respiratory symptoms, symptoms vary in severity, cough significantly aggravated, and wheezing episodes, severe cases appear episodes of wheezing and cyanosis.
3. Signs: Most infants have fever, with varying temperatures. Breathing is accelerated, moaning and accompanied by prolonged expiration and expiratory stridor during wheezing episodes. Chest examination reveals a full thorax with a bulging sound (or overclear sound) on percussion, and croup can be heard on auscultation. When the stridor is relieved, there may be a fine wet rhotic sound or a medium wet rhotic sound. Some children may have obvious respiratory distress, irritability, nasal flapping, trigeminal signs and lip cyanosis.
4.Peripheral blood picture: peripheral blood leukocytes are low or normal, but increase when combined with bacterial infection.
5, chest X-ray: the performance is not uniform, most of the cases appear as obstructive emphysema of varying degrees in the whole lung, about half of the cases show thickened lung texture, small dotted shadows may appear, and a small proportion of cases appear pulmonary atelectasis.
6, pulmonary function: the child has obstruction of the small airways in the acute phase, and in the recovery period, the small airway obstruction is relieved.
7, respiratory pathogenic testing: the disease can be caused by different pathogens, respiratory syncytial virus (RSV) is the most common, followed by parainfluenza virus, adenovirus, etc.
8. Blood gas analysis: Blood gas analysis shows that PaO2 decreases to different degrees, PaCO2 is normal or increased, pH correlates with the severity of the disease, and children with more severe disease may have metabolic acidosis, and type I or II respiratory failure may occur.
(iii) Choice of treatment plan.
According to the Clinical Diagnosis and Treatment Guide-Pediatrics Internal Medicine Sub-volume (edited by Chinese Medical Association, People’s Health Publishing House)
1.Oxygenation: children with obvious wheezing should be given nasal catheter oxygenation and other modalities.
2.Strengthen respiratory care: increase the humidity of indoor air, reasonably apply nebulized inhalation, and promptly pat the back and aspirate sputum after nebulization to keep the respiratory tract unobstructed.
3.Treatment of wheezing: for severe wheezing, inhale bronchodilator drugs (such as salbutamol, polycarbital, ipratropium bromide, etc.) and glucocorticoids according to the condition. Short-term oral or intravenous glucocorticoids may be used for severe wheezing. Those who are irritable can be sedated as appropriate.
4, anti-infective treatment: antiviral drugs can be used ribavirin (virazole), interferon, etc.; combined with bacterial infection, the corresponding antibiotics are available (follow the method of pediatric medication).
5, symptomatic treatment: treatment of dehydration: oral or intravenous rehydration can be given, if there is metabolic acidosis, bicarbonate of soda can be given. Heart failure and respiratory failure should be treated according to the corresponding critical illness, and if necessary, tracheal intubation for mechanical ventilation.
(D) The standard hospitalization days are 7-10 days.
(E) Entry pathway criteria.
1. The first diagnosis must be in accordance with ICD-10: J21 capillary bronchitis disease code.
2.When the child also has other disease diagnoses, but does not require special treatment during hospitalization nor does it affect the implementation of the clinical pathway process for the first diagnosis, it can be entered into the pathway.
3.The following conditions do not exist.
(1) Age less than 3 months.
(2) Preterm infants with gestational age less than 34 weeks.
(3) With underlying diseases, such as congenital heart disease, bronchopulmonary dysplasia, and congenital immune function defects.
(vi) Day 1-2 after admission.
1.Required examination items.
(1) Blood routine and CRP, urinary routine, fecal routine.
(2) Cardiac enzyme profile and liver and kidney function.
(3) Respiratory virus testing.
(4) respiratory tract bacterial culture and drug sensitivity.
(5) blood mycoplasma and chlamydia testing
(6) Chest radiography.
(7) electrocardiogram.
(8) blood gas analysis test.
2. Necessary information.
Admission clinical pathway, strengthen back patting and other care, pay attention to the changes of pulmonary symptoms.
(vii) Day 3-5 after admission.
1. Optional tests according to the patient’s condition.
(1) Blood gas analysis test.
(2) Pulmonary function measurement.
(3) Electrocardiogram review.
(4) Serum allergen test.
(5) Echocardiography.
(6) review of blood for mycoplasma and chlamydia
(7) Bronchoscopy.
2. Necessary information.
If heart failure, respiratory failure and other complications should be promptly discharged from the clinical pathway of capillary bronchitis.
(H) Discharge criteria.
1.The wheezing disappears and the cough is significantly reduced.
2. Axillary temperature <37,5°C for 3 consecutive days.
3. Significant improvement in pulmonary signs.
(ix) Variation and cause analysis.
Children with capillary bronchitis hospitalized for 10 days after comprehensive treatment still have recurrent episodes of cough and wheeze that are difficult to cure, called refractory capillary bronchitis, and should be discharged from the clinical pathway of capillary bronchitis in a timely manner.