What are the primary overnight concerns and physical exam findings to watch for in a 14-month-old patient with RSV (Respiratory Syncytial Virus) bronchiolitis on day 3 of hospital stay, currently on High Flow Nasal Cannula (HFNC) with 21% oxygen?

Overnight Assessment for 14-Month-Old on Day 3 of RSV Bronchiolitis on HFNC

Focus your overnight assessment on detecting clinical deterioration that would necessitate escalation of respiratory support, particularly signs of increased work of breathing, feeding intolerance, and worsening hypoxemia despite current HFNC therapy. 1

Critical Overnight History Questions

Respiratory Status

• Ask about increased work of breathing: Has the child developed new or worsening retractions (suprasternal, subcostal, intercostal), nasal flaring, or grunting? 1
• Inquire about apnea episodes: Any witnessed pauses in breathing or color changes? This is particularly important even at 14 months, though risk is lower than in younger infants 1
• Assess respiratory rate trends: Has the respiratory rate been consistently >70 breaths/minute or increasing from baseline? 1
• Document cough quality: Is the cough becoming more frequent, productive, or exhausting the child? 2, 3

Feeding and Hydration

• Quantify oral intake: How many ounces/mLs has the child taken overnight? Is this maintaining adequate hydration? 4, 5
• Ask about feeding difficulty: Is the child stopping to breathe during feeds, refusing feeds, or showing increased distress with feeding attempts? 1, 4
• Check for vomiting: Any emesis that would compromise oral intake or suggest worsening illness? 6

Mental Status and Activity Level

• Assess alertness: Is the child interactive and responding normally to parents, or becoming lethargic, irritable, or difficult to arouse? 1, 4
• Document sleep quality: Is the child able to sleep between assessments, or is respiratory distress preventing rest? 1

HFNC Tolerance

• Verify oxygen requirements: What FiO2 has been needed to maintain SpO2 >90-92%? Any escalation from the current 21%? 1, 4
• Check for interface issues: Is the child tolerating the nasal cannula, or pulling it off frequently? 1

Essential Physical Exam Findings to Monitor

Respiratory Assessment

• Work of breathing indicators: Look for suprasternal, subcostal, and intercostal retractions; nasal flaring; head bobbing; and use of accessory muscles 1
• Grunting: This is a critical sign of severe disease and impending respiratory failure requiring immediate escalation 1
• Respiratory rate: Count for a full minute; rates ≥70/minute indicate increased severity 1
• Auscultation: Listen for bilateral air entry, wheezing, crackles, and any asymmetry suggesting complications like pneumothorax or atelectasis 1

Oxygenation Status

• Pulse oximetry trends: While transient desaturations <90% can be normal, sustained hypoxemia or increasing oxygen requirements signal deterioration 1
• Cyanosis: Check for central cyanosis (lips, tongue) as a clinical sign of severe hypoxemia 1
• Note: Do not rely solely on pulse oximetry as it correlates poorly with respiratory distress; clinical assessment is paramount 1

Cardiovascular Signs

• Heart rate: Sustained tachycardia suggests increasing distress or inadequate oxygenation 1, 4
• Perfusion: Check capillary refill, skin color, and peripheral pulses 1

Hydration Status

• Mucous membranes: Assess for dryness 4, 5
• Urine output: Document frequency and volume of wet diapers 4, 5
• Skin turgor and fontanelle: Check for signs of dehydration 4, 5

General Appearance

• Activity level: Is the child playful and interactive, or listless and withdrawn? 4, 5
• Feeding behavior: Observe a feeding if possible to assess coordination and effort 1, 4

Red Flags Requiring Immediate Escalation

Transfer to ICU or higher level of care if: 1, 4

• FiO2 requirement increases to ≥50-60% to maintain SpO2 >92%
• Development of grunting respirations
• Altered mental status (lethargy, irritability, difficulty arousing)
• Recurrent apnea episodes
• Signs of respiratory exhaustion (paradoxical breathing, decreased respiratory effort despite hypoxemia)
• Sustained tachycardia or signs of cardiovascular compromise
• Rising respiratory rate and heart rate with clinical evidence of severe distress

Common Pitfalls to Avoid

• Over-reliance on pulse oximetry: Transient desaturations are common and normal; focus on overall clinical trajectory and work of breathing rather than chasing every desaturation alarm 1
• Ignoring feeding as a clinical indicator: Inability to feed is often an early sign of deterioration before oxygenation worsens 1, 4
• Missing subtle signs of fatigue: A child who appears "calmer" may actually be tiring and heading toward respiratory failure 1
• Day 3-5 is typically the peak: This child is at the expected nadir of illness, so heightened vigilance is warranted 2, 3