RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE

BANGALORE, KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1 / Name of the candidate and address / Ms Shiny Joy
1st year M.Sc(N)
Sy. No.31/1, Hennur-Bagalur road,
Kadusonnappanahalli,
Kannur post, Bangalore.
2 / Name of the institution / Koshys College of Nursing
3 / Course of the study and subject / 1st Year M.Sc Nursing
Child Health Nursing
4 / Date of admission to course / 05/07/2011
5 / Title of the topic / “A study to assess the effectiveness of structured teaching programme for knowledge and practice of hypertonic saline nebulisation for bronchiolitis among mothers of under five children."

BRIEF RESUME ON INTENDED WORK

INTRODUCTION

“Listen, are you breathing just a little and calling it a life?”-Mary Oliver

Bronchiolitis is a common illness of the respiratory tract due to inflammation of the tiny airways, called the bronchioles. Bronchiolitis is swelling and mucus build up in the smallest air passages in the lungs (bronchioles), usually due to a viral infection. As these airways become inflamed, they swell and fill with mucus, making breathing difficult.1

Bronchiolitis usually occurs in children less than two years of age. Bronchiolitis most often affects infants and young children because their small airways can become blocked more easily than those of older kids or adults and typically occurs during the first two years of life, with peak occurrence at about three to six months of age. It is more common in males. Children who have not been breastfed, those who live in crowded conditions, and exposure to cigarette smoke can increase the likelihood that an infant will develop bronchiolitis.1

Acute viral bronchiolitis is a common disease in infancy. This is most commonly caused by respiratory syncytical virus (RSV, also known as human pneumovirus). Other viruses which may cause this illness include metapneumovirus, influenza, parainfluenza, coronavirus, adenovirus, and rhinovirus. Bronchiolitis is seasonal and appears more often in the fall and winter months. It is a very common reason for infants to be hospitalized during winter and early spring.2

One of the greatest risk factors for getting bronchiolitis is being younger than six months old, because their lungs and immune system are not yet fully developed. Boys tend to get bronchiolitis more frequently than girls do. Risk factors for bronchiolitis include being around cigarette smoke, age younger than 6 months old, not being breastfed and prematurity (being born before 37 weeks gestation). Other factors that have been associated with an increased risk of bronchiolitis in children include, never having been breast-fed (breast-fed babies receive immune benefits from the mother), an underlying heart or lung condition, a depressed immune system, exposure to tobacco smoke, contact with multiple children, such as in a child care setting, living in a crowded environment and having siblings who attend school or child care and bring home the infection.3

Bronchiolitis begins as a mild upper respiratory infection. Over a period of two to three days, the child develops more breathing problems, including wheezing and a "tight" wheezy cough. Other

*RSV : respiratory syncytical virus

symptoms include, bluish skin due to lack of oxygen (cyanosis), breathing difficulty including wheezing and shortness of breath, cough, fatigue, fever, muscles around the ribs sink in as the child tries to breathe in (called intercostal retractions), nasal flaring in infants, rapid breathing (tachypnea), stuffiness, running nose and poor feeding.1

Typical examination is performed by physical examination. On auscultation, wheezing and crackling sound is heard through stethoscope. Other tests include, blood gases, chest x-ray, culture of a sample of nasal fluid to determine the virus causing the disease and mucus sample test using a pharyngeal swab or a suction catheter that is gently inserted into the nose.3

The best treatment for most kids is time to recover and plenty of fluids. Making sure a child drinks enough fluids can be a tricky task, however, because infants with bronchiolitis may not feel like drinking. They should be offered fluids in small amounts at more frequent intervals than usual.1

Hypertonic saline (HS) nebulisation is given to children with bronchiolitis as a therapy. Any solution of sodium chloride (NaCl) in water with a concentration of NaCl higher than that found in physiological saline (0.9%) is called hypertonic saline.4

Hypertonic (3% to 7%) saline has been used to promote mucus clearance in various inflammatory respiratory diseases by drawing water from the airway epithelium to rehydrate the periciliary layer.5

Seven percentage NaCl solutions are considered mucoactive agents and as such are used to hydrate thick secretions (mucous) in order to make it easier to cough up and out (expectorate). Hypertonic saline solution, by absorbing water from the submucosa, can theoretically reverse some of the submucosal and adventitial edema and decrease the thickness and dryness of the mucous plaques inside the bronchiolar lumen. Nebulized hypertonic saline solution reduces pathological changes and decrease airway obstruction and edema. The nebulized hypertonic saline regimens consistently decreases length of hospital stay (LOS) by 0.9 to 1.6 days.6

Cilia from airway epithelial cells extend into a periciliary liquid that is coated with an outer mucus layer. The periciliary liquid and mucus layer are known together as the airway surface liquid. The airway surface liquid also contains antibacterial agents, migratory immune system cells, and signaling molecules that help protect against pulmonary infections. Recent evidence suggests that epithelial cell ion

*HS : hypertonic saline; *NaCl : sodium chloride

*LOS : length of hospital stay

transporters keep the periciliary liquid layer at the optimal height for ciliary beating. In normal airways, cilia beat at a height just at the interface between the periciliary liquid and the mucus layer, and mucus transport is facilitated when mucus heights are maximized. In laboratory models of the airway surface epithelium, hypertonic saline solutions increase the height of the airway surface liquid and improve mucus transport. In healthy volunteers, mucociliary transport is improved by nebulized hypertonic saline as well, even producing supranormal rates of mucociliary clearance. In other words, hypertonic saline may rehydrate the airway surface liquid and restore normal ciliary function.7

6.1 NEED FOR THE STUDY

Bronchiolitis is a common infection of the lower respiratory tract in infants in the developed countries. In our country too, it is a significant problem which is judged by the frequency of wheezing episodes among young infants. Viral bronchiolitis is the leading cause of hospitalization in infants. It is responsible for over 100,000 hospitalizations annually.6

The clinical presentation changes in relationship to the age of the child, and is usually more severe in the first year of life. This increased severity correlates with the anatomic and functional features of the airways in this age: small and more easily obstructed.7

Management, or prognosis of the disease is unclear. Given the high incidence of disease among infants and children, different treatment modalities have been in practice for some years. Some of these therapies are specific to the virus (e.g., ribavirin); others are symptomatic (e.g., bronchodilators, corticosteroids). Evidence on their efficacy is conflicting. The relative severity of the disease among vulnerable subpopulations suggests that some infants and children may benefit from prophylactic therapy, although the cost-effectiveness of available interventions needs to be explored.8

Several large, recent trials have revealed a lack of efficacy for routine use of either bronchodilators or corticosteroids for treatment of bronchiolitis. Preliminary evidence suggests a potential future role for a combination of these therapies and other novel treatments such as nebulized hypertonic saline. 9

Airway edema and mucus plugging are the predominant pathological features in infants with acute viral bronchiolitis. Commonly used therapies such as bronchodilators, steroids, antibiotics, surfactant and corticosteroids have not been more effective than placebo on clinically important outcomes; therefore current practice guidelines do not recommend routine use of these drugs. Three percent hypertonic saline has been effective in hospitalized patients with bronchiolitis, with a Cochrane review showing a decreased length of stay of 0.94 days, and statistically significant decreases in respiratory scores.10

Nebulized hypertonic saline solution may reduce the pathological changes and decrease airway obstruction. Hypertonic saline solution induces an osmotic flow of water into the mucus layer, rehydrating secretions and thereby improving mucus rheology. It breaks the ionic bonds within the mucus gel, which could reduce the degree of cross-linking and lower viscosity and elasticity. Due to less viscosity, the excretion of the secretion is easier thereby resulting in clinical improvements.7

In a Pubmed search systemic review included a detailed literature search in five electronic databases. The Cochrane systemic review comprises current best evidence. It included four methodologically acceptable randomised control trials. 254 infants less than two years old with clinical diagnosis of bronchiolitis were selected for the study. The review showed that hypertonic saline nebulisation resulted in shorter duration of hospitalization among admitted infants and better clinical score among non admitted infants. The authors concluded that hypertonic saline is clinically useful intervention in infants with bronchiolitis.6

A Cochrane review on the use of hypertonic saline in bronchiolitis included three inpatient trials with a total of 189 infants and found the use of nebulized 3% saline significantly shorten the length of hospital stay compared to those treated with nebulized 0.9% saline, with a mean difference of -0.94 days (P = 0.0006). This represents a 25.9% reduction from the mean length of hospital stay in the 0.9% saline group. The pooled results of trial demonstrate a statistically significant lower mean post-inhalation score among infants treated with 3% saline inhalation compared to those treated with 0.9% saline inhalation in the first two days of treatment. The mean difference was -0.75 for day 1, -1.18 for day 2 and -1.28 for day three. The authors concluded that nebulized 3% saline may significantly reduce the length of hospital stay and improve the clinical severity score in infants with acute viral bronchiolitis.11

Although the admission rate is no different compared to placebo, the duration of hospitalization is less by almost one day with hypertonic saline nebulisation. Clinical severity scores show variable results for inpatients and outpatients on different days of measurement but are mostly in favour of hypertonic saline.12

Keeping in view the above information and importance of empowering the people with knowledge and practices the researcher felt that there is a need to assess the knowledge and practice of the mothers of under five children regarding hypertonic saline nebulization for bronchiolitis through a structured teaching programme.

6.2 REVIEW OF LITERATURE

The review of literature is defined as a broad, comprehensive, in depth, systematic and critical review of scholarly publications, unpublished scholarly print materials, audio visual materials and personal communications.

Researcher often undertake a literature review to familiarize them with the knowledge base. One of the major function of the research literature review is to ascertain what is already known in relation to a problem of interest.

In this study, review of literature is classified under following headings:

Based on the outcome of hypertonic saline nebulisation the review may be classified into:

Ø  Study and literature related to uses and effects of hypertonic saline solution in bronchiolitis.

Ø  Study and literature related to clinical significance of hypertonic saline nebulisation for bronchiolitis.

Ø  Study or literature related to safety profile of hypertonic saline nebulisation for bronchiolitis.

1)Study and literature related to uses and effects of hypertonic saline solution in bronchiolitis.

A prospective randomized, double-blinded, controlled, multicenter trial was conducted in United Arab Emirates, to investigate the use of nebulized 3% hypertonic saline (HS) for treating viral bronchiolitis in moderately ill hospitalized infants. A total of 96 infants admitted to the hospital for treatment of viral bronchiolitis were recruited from 3 regional pediatric centres over 3 bronchiolitis seasons. Patients were randomized to receive, in a double-blind fashion, repeated doses of nebulized 3% HS (treatment group) or 0.9% normal saline (NS) (control group), on routine therapy ordered by the attending physician. The result showed that infants in the hypertonic saline group had a clinically relevant 26% reduction in length of stay (LOS) to 2.6 +/- 1.9 days, compared with 3.5 +/- 2.9 days in the NS group. The treatment was well tolerated with hypertonic saline. It was concluded that the use of nebulized 3% HS is a safe, inexpensive, and effective treatment for infants hospitalized with moderately severe viral bronchiolitis.13

Randomized controlled trials (RCTs) and quasi-RCTs using nebulized hypertonic saline alone or in conjunction with bronchodilators were carried out as an active intervention in infants up to 24 months of age with acute bronchiolitis in India. The aim of the study was to assess the effects of nebulized hypertonic saline solution in infants with acute viral bronchiolitis. A total of 581 infants with mild to moderate acute viral bronchiolitis were treated with nebulized 3% saline and had a significantly shorter mean length of hospital stay compared to those treated with nebulized 0.9% saline. The 3% saline group also had a significantly lower post-inhalation clinical score than the 0.9% saline group in the first three days of treatment. The study concluded that the effects of improving clinical score were observed in both outpatients and inpatients. It was concluded that nebulised 3% saline significantly reduced the length of hospital stay.14

A double-blind trial was conducted in India to compare the efficacy and safety of 5%, 3%, and 0.9% saline solution for treating acute bronchiolitis in the prehospital setting was done on consecutive infants aged <18 months treated in an urban area. A total of 165 patients were randomized to receive nebulized 5%, 3%, or 0.9% (normal saline) with epinephrine every 4 hours. A total of 187 previously healthy infants diagnosed with bronchiolitis were enrolled, (mean, 56%). At 48 hours, the mean severity score for the 5% saline group was 3.69-1.09, and that for the 0.9% saline group was 4.12-1.11. The mean severity score for the 3% saline group was intermediate at 4.00-1.22. It was concluded that hypertonic saline nebulisation is an effective method in treating bronchiolitis.15

A prospective, randomized, double-blind, controlled study was done at three regional tertiary care hospitals of United States to investigate whether the addition of frequently nebulized hypertonic saline to standard therapy affects the LOS of