2 y/o with tachypnea, hypoxemia, and fever
Patient will present as → a 9-month-old infant presents with a three-day history of a mild respiratory tract infection with serous nasal discharge, fever of 38.5 C (101.4 F), and decreased appetite. Physical exam reveals a tachypneic infant with audible wheezing and a respiratory rate of 65. Flaring of the alae nasi, use of accessory muscles, and subcostal and intercostal retractions are noted. Expiratory wheezes are present.
Bronchiolitis is inflammation of the bronchioles, the smallest air passages of the lungs, which usually occurs in children less than two years of age
- Respiratory syncytial virus (RSV) is the most common cause of acute bronchiolitis
- Most common in the fall and winter months. CXR is often normal - may show air trapping and peribronchial thickening
- Diagnosed with nasal washing for RSV culture and antigen assay
- Hospitalization if O2 < 95%, age < 3 months, respiratory rate > 70 or atelectasis on chest radiograph
Diagnosed with nasal washing for RSV culture and antigen assay
- CXR findings include hyperinflation, perihilar infiltrates, increased interstitial markings, and patchy atelectasis
Treatment is supportive with nasal suctioning, humidified O2, and antipyretics
- The only treatment demonstrated to improve bronchiolitis is oxygen
- Treatment is supportive; bronchodilators sometimes relieve symptoms but probably do not shorten hospitalization, and systemic corticosteroids are not indicated in previously well infants with bronchiolitis
- Ribavirin for severe lung or heart disease and in immunocompromised patients
- Respiratory Syncytial Virus (RSV) Vaccine VIS (see current CDC guidelines)
- Monoclonal antibodies to RSV (palivizumab) prophylaxis (once per month for five months beginning in November) for special populations (immunocompromised, premature infants, neuromuscular disorders)
- If SpO2 is < 95% on room air
- Toxic appearance, poor feeding, lethargy, or dehydration
- Moderate to severe respiratory distress: nasal flaring; intercostal, subcostal, or suprasternal retractions; respiratory rate >70 breaths per minute; dyspnea; or cyanosis
- Apnea
- Parents who are unable to care for them at home
Question 1 |
Which of the following is the most common etiological agent of acute bronchiolitis in infants and young children?
Streptococcus pneumoniae Hint: This is not the most common cause | |
Mycoplasma pneumoniae Hint: This is not the most common cause | |
Parainfluenza virus Hint: This is not the most common cause | |
Respiratory syncytial virus (RSV) | |
Adenovirus Hint: This is not the most common cause |
Question 2 |
Chest X-ray Hint: May be used to rule out pneumonia but is not necessary for the initial diagnosis of bronchiolitis. | |
Nasopharyngeal swab for viral PCR | |
Complete blood count (CBC) Hint: Not specific for diagnosing bronchiolitis and typically shows nonspecific findings. | |
Pulmonary function tests Hint: Not feasible or practical in infants with acute respiratory distress. | |
Blood culture Hint: Indicated if there is a suspicion of bacterial sepsis, not for uncomplicated bronchiolitis. |
Question 3 |
Oral corticosteroids Hint: Not recommended for the treatment of bronchiolitis as they have not been shown to improve outcomes. | |
Antibiotic therapy Hint: Not indicated unless there is a clear evidence of bacterial co-infection, which is uncommon in uncomplicated bronchiolitis. | |
Supportive care, including hydration and nasal suctioning | |
Nebulized albuterol treatments Hint: May be trialed in some cases, but evidence does not consistently show benefit in bronchiolitis. | |
Hospitalization and oxygen therapy
Hint: Indicated for severe cases with significant respiratory distress or hypoxemia, not mild cases. |
Question 4 |
Respiratory rate > 70 breaths per minute Hint: A respiratory rate greater than 70 breaths per minute indicates significant respiratory distress and is a criterion for hospitalization to provide appropriate respiratory support and monitoring. | |
Temperature > 100.5°F (38°C) | |
Oxygen saturation (SpO2) < 95% on room air Hint: Infants with bronchiolitis showing an oxygen saturation less than 95% on room air may require supplemental oxygen, monitoring, and possibly further intervention, making this an indication for hospitalization. | |
Apnea Hint: Episodes of apnea in infants with bronchiolitis are a critical concern, especially in young infants or those with a history of prematurity. This condition requires immediate hospitalization for continuous monitoring and intervention. | |
Poor feeding and/or dehydration Hint: Difficulty feeding leading to dehydration is a common complication of bronchiolitis in infants that may necessitate hospitalization for fluid management and supportive care. |
List |
References: Merck Manual · UpToDate