Patient Presentation
A 6 month old female, E.C., presents to the ER with her parents in January
with rhinorrhea, cough, wheezing and a low-grade fever of 37.5 degrees
Celsius. Upon initial assessment, the RN notices E.C. to have a slight
increased work of breathing, mild fussiness and pallor. E.C.’s parents
complain of her having upper respiratory tract symptoms and decreased oral
intake over the last 2-3 days. E.C.’s history is positive for prematurity
of 35 weeks. As E.C.’s stay in the ER continues, her respiratory status
starts to deteriorate. She becomes tachypneic (RR of 70 breaths per
minute) and her SaO2 drops to 90% on room air. In the ER, they put E.C. on
2 liters of oxygen via a nasal cannula, place an IV, start fluids, and
transfer her to the PICU. E.C. presents to the PICU with mild to severe
retractions, wheezing, and cyanosis. Her temperature has increased to 38.5
degrees Celsius, she is tachycardic, her BP is stable, her SaO2 has
dropped to the mid 80s even with supplemental O2, and her capillary refill
is >2seconds. She is started on IV fluids of D5 0.45 NaCl but E.C. does
not tolerate other forms of oxygen administration such as a face mask and
the decision is made to intubate the child to prevent respiratory arrest.
After a successful intubation, labs are drawn, CXR is completed and
cultures are collected. (Many times we do not collect labs prior to
intubating a child if we do not have proper access for fear of agitating
the patient more and causing a more rapid deterioration in respiratory
status).
Differential Diagnoses
Tests & Diagnosis
Treatment
The treatment for a child with RSV is mainly supportive. In E.C.’s case, a
dose of the antibiotic vancomycin was administered due to a possible
infection/sepsis but was discontinued once RSV results were positive. E.C.
continued to receive mechanical ventilation support, frequent P&PD
(percussion and postural drainage), IV hydration which was transitioned to
post-pyloric tube feedings for nutrition after 24 hours. She received
scheduled albuterol treatments (a bronchodilator – selective beta2-agonist
that causes bronchial smooth muscle relaxation) via the ventilator to help
open her airway and allow for more secretions to be suctioned. Mechanical
ventilator adjustments were made as necessary as E.C.’s respiratory status
improved. She was also on continuous sedation and pain medications to keep
her comfortable while intubated.
Outcome
E.C. remained intubated for 7 days as she received supportive therapy. Due
to her improvement in ventilator settings, she was extubated on day 8 to 2
liters nasal cannula, she was weaned off of O2 with no desaturation and
allowed to start a clear diet on day 9. On day 10, E.C. was transferred to
the pediatric acute care floor before being transferred home. E.C.’s
parents were instructed to consult with a pulmonologist regarding E.C.’s
pulmonary function due to some studies that link RSV with possible
reactive airway disease.