PANCE Blueprint Pulmonary (10%)

Acute bronchiolitis (ReelDx)

REEL-DX-ENHANCED-PAID-MEMBERS-ONLY

2-year-old with difficulty breathing

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

  • Chest X Ray will show hyperinflation and peribronchial cuffing

Treatment is supportive with nasal suctioning, humidified O2, and antipyretics

  • The only treatment demonstrated to improve bronchiolitis is oxygen
  • Trial of inhaled bronchodilators, nebulized racemic epinephrine, corticosteroids if h/o underlying reactive airway disease - all are commonly used but do not have proof of efficacy
  • Ribavirin if severe lung or heart disease and in immunocompromised patients
  • Palivizumab prophylaxis (once per month for five months beginning in November) for special populations (immunocompromised, premature infants, neuromuscular disorders)

Indications for hospitalization

  • 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

A 4-month-old infant presents to the emergency department with cough and fever. The infant has been sick for 3 days, but symptoms worsened in severity during the past 24 hours. Past medical history is otherwise negative. He was born preterm at 35 weeks but was discharged home after 3 days. Birth weight was 7 pounds, and maternal group B strep was negative. Immunizations are current.

Vital signs include a rectal temperature of 100.8° F, pulse of 120 beats/minute, blood pressure within normal limits, and respiratory rate of 60 breaths/minute. The infant is well hydrated but appears ill. Grunting, nasal flaring, intracostal retractions, and increased respiratory effort are evident. Wheezing and crackles are noted on physical examination. Chest radiographs show patchy atelectasis and hyperinflation of the lungs.

The most common cause of this condition is:
A
human metapneumovirus
Hint:
This is not the most common cause
B
adenovirus
Hint:
This is not the most common cause
C
parainfluenza virus
Hint:
This is not the most common cause
D
respiratory syncytial virus (RSV)
E
influenza virus
Hint:
This is not the most common cause
Question 1 Explanation: 
RSV is the most common agent in bronchiolitis. Other viruses that cause bronchiolitis are adenoviruses, influenza virus, parainfluenza virus, and human metapneumovirus. A less common agent is Mycoplasma pneumoniae, which occurs sporadically.
Question 2
Which statement regarding management of this condition is true?
A
bronchodilators provide a consistent benefit for this illness
Hint:
Bronchodilator use is controversial. Current recommendations do not support routine bronchodilator use in the treatment of bronchiolitis. A Cochrane review examined eight RCTs of inhaled bronchodilator therapy in bronchiolitis (N = 394). One in four children who were treated with bronchodilators showed transient improvement, although it was of unclear significance. Both albuterol (salbutamol) and epinephrine are available options. Although a Cochrane review found insufficient evidence to support epinephrine use, it was believed to be favorable to salbutamol. Little supporting evidence exists from RCTs, but clinical practice suggests that a nebulized bronchodilator trial is appropriate in select infants. When good clinical response is noted, therapy is continued.
B
corticosteroids are routinely indicated for initial management
Hint:
Corticosteroid treatment is also not routinely recommended, although almost 60% of admitted infants receive these medications. A Cochrane review of glucocorticoid use in acute bronchiolitis did not show a benefit.
C
ribavirin should not be used routinely in this condition
D
intravenous fluids are required for infants younger than year
Hint:
Infants with mild disease may not require intravenous fluids. If feeding is not compromised and the respiratory rate is below 60 to 70 breaths/minute, a trial of oral feeds is appropriate. Infants with cough, retractions, or nasal flaring may be at increased risk for aspiration. Intravenous fluids are appropriate in this subset of patients until respiratory status improves.
E
chest physiotherapy provides proven benefit for this condition
Hint:
Chest physiotherapy is not routinely recommended in the treatment of bronchiolitis. A Cochrane review of three RCTs did not show benefit for either vibration or percussion physiotherapy, although nasal suctioning provides some temporary benefits.
Question 2 Explanation: 
Inhaled ribavirin is an antiviral medication used to treat bronchiolitis. Some studies document improvement in the respiratory score and decreased hospital length of stay with ribavirin. Indications for its use are controversial. It may be considered for treatment of patients predisposed to development of severe RSV-related morbidity because of underlying health problems.
Question 3
Which of the following is not considered an indication for hospitalization in an infant diagnosed with bronchiolitis?
A
< 95% by pulse ox on RA
B
Age < 3 months
C
Temperature > 100.5
D
Respiratory rate > 70 breaths per minute
E
Atelectasis on chest radiograph
Question 3 Explanation: 
Patients with bronchiolitis will commonly present with a fever. Fever alone is not an indication for admission although you must be sure to rule out pneumonia based on your physical exam findings. All the rest of the options are reasons to hospitalize patients with bronchiolitis.
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Lesson Intro Video

Brian Wallace PA-C Podcast: Pulmonary Infections (Prev Lesson)
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