Updated: 12/25/2021

Bronchiolitis

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Questions
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Evidence
6
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  • Snapshot
    • A 6-month old infant is seen in the emergency room for wheezing. His breathing has become increasingly difficult over the past 2-3 days. He has also had a worsening cough, subjective fevers, and rhinitis. Today, his parents took him to the pediatrician’s office, where his oxygen saturation was 80% on room air. He was sent immediately from the clinic to the emergency room via ambulance, where he was given supplemental oxygen. On physical exam, he has increased work of breath with nasal flaring, grunting, and intercostal retractions. He also has bilateral wheezes. His parents are counseled on the possibility of further interventions if his oxygen saturation does not improve.
  • Introduction
    • Clinical definition
      • a viral respiratory infection that causes wheezing and increased respiratory effort in children and infants
    • Prevention
      • palivizumab
        • mechanism
          • monoclonal antibody against F protein, a key protein that RSV utilizes to infect patients
        • indication
          • premature infants
          • babies at risk of severe infection (i.e., immunocompromised status)
  • Epidemiology
    • Incidence
      • more common in the winter
    • Demographics
      • children < 2 years of age
    • Risk factors
      • asthma
      • day care centers
      • exposure to air pollutants such as cigarette smoke
      • cardiopulmonary disease
      • immunodeficiency
      • congenital heart disease
      • premature infants
  • Etiology
    • Respiratory syncytial virus (RSV)
      • most common
      • an enveloped, linear, single-stranded, negative-sense paramyxovirus with a helical capsid
    • Rhinovirus
    • Parainfluenza virus
    • Influenza virus
    • Coronavirus
    • Pathogenesis
      • the virus initially infects the upper respiratory tract and travels to the lower respiratory tract within a few days
      • edema of submucosa causes an obstructive pathology in the lungs, causing wheezing and respiratory distress
  • Presentation
    • Symptoms
      • low-grade fever
      • congestion
      • cough
      • poor feeding
      • grunting
    • Physical exam
      • tachypnea
      • bilateral wheezing
      • prolonged expiratory phase
      • increased work of breath
        • nasal flaring
        • intercostal retractions
  • Studies
    • Labs
      • rapid antigen test
  • Differential
    • Asthma
      • distinguishing factors
        • typically recurrent episodes with identifiable triggers
        • history of atopy in the patient or family
    • Foreign body aspiration
      • distinguishing factor
        • unilateral wheezing
  • DIAGNOSIS
    • Making the diagnosis
      • most cases are clinically diagnosed
  • Treatment
    • Conservative
      • supportive care
        • indication
          • all patients
        • modalities
          • hydration
          • supplemental oxygen
  • Complications
    • Hypoxemic respiratory failure
      • treatments
        • oxygen
        • mechanical ventilation
  • Prognosis
    • Typically self-limited
    • More severe in infants < 6 months of age

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Questions (5)

(M3.PD.16.49) A 7-month-old male child is brought into your office for recent rhinorrhea and cough. The mother states that the child has had mild fevers of up to 100.7 F over the last three days along with clear nasal discharge, and a nonproductive cough, but the child has been working harder to breathe over the last day. The mother states the child was vaccinated for the flu one month ago. His vitals are significant for a temperature of 100.9F and his physical exam is significant for intercostal retractions along with expiratory wheezing. What is the most likely organism responsible?

QID: 103340

Parainfluenza virus

6%

(1/17)

Adenovirus

0%

(0/17)

Influenza A virus

0%

(0/17)

Respiratory syncytial virus

94%

(16/17)

Echovirus

0%

(0/17)

M 6 D

Select Answer to see Preferred Response

(M3.PD.16.45) A 16-month-old male patient, with no significant past medical history, is brought into the emergency department for the second time in 5 days with tachypnea, expiratory wheezes and hypoxia. The patient presented to the emergency department initially due to rhinorrhea, fever and cough. He was treated with nasal suctioning and discharged home. The mother states that, over the past 5 days, the patient has started breathing faster with chest retractions. His vital signs are significant for a temperature of 100.7 F, respiratory rate of 45 and oxygen saturation of 90%. What is the most appropriate treatment for this patient?

QID: 103336

Humidified oxygen, racemic epinephrine and intravenous (IV) dexamethasone

88%

(15/17)

Albuterol, ipratropium and IV methylprednisolone

0%

(0/17)

Intubation and IV cefuroxime

0%

(0/17)

IV cefotaxime and IV vancomycin

6%

(1/17)

Nasal suctioning, oxygen therapy and IV fluids

6%

(1/17)

M 11 D

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(M2.PD.15.5) A mother brings her 6-month-old boy to the emergency department. She reports that her son has been breathing faster than usual for the past 2 days, and she has noted occasional wheezing. She states that prior to the difficulty breathing, she noticed some clear nasal discharge for several days. The infant was born full-term, with no complications, and no significant medical history. His temperature is 100°F (37.8°C), blood pressure is 60/30 mmHg, pulse is 120/min, respirations are 40/min, and oxygen saturation is 95% on room air. Physical exam reveals expiratory wheezing, crackles diffusely, and intercostal retractions. The child is currently playing with toys. Which of the following is the most appropriate next step in management?

QID: 102584

Albuterol

11%

(2/18)

Azithromycin and ceftriaxone

6%

(1/18)

Chest radiograph

33%

(6/18)

Intubation

0%

(0/18)

Monitoring

50%

(9/18)

M 7 E

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(M2.PD.15.7) A 6-month-old male presents for a routine visit to his pediatrician. Two months ago, the patient was seen for tachypnea and wheezing, and diagnosed with severe respiratory syncytial virus (RSV) bronchiolitis. After admission to the hospital and supportive care, the patient recovered and currently is not experiencing any trouble breathing. Regarding the possibility of future reactive airway disease, which of the following statements is most accurate?

QID: 102586

“Your child’s risk of asthma is the same as the general population.”

20%

(20/99)

“There is no clear relationship between RSV and the development of asthma.”

36%

(36/99)

“Your child has a less than 5% chance of developing asthma”

9%

(9/99)

“Your child has a greater than 20% chance of developing asthma”

32%

(32/99)

“Your child’s risk of asthma is less than the general population.”

1%

(1/99)

M 8 E

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(M2.PD.14.6) A 3-month-old boy is brought to the emergency room by his mother for 2 days of difficulty breathing. He was born at 35 weeks gestation but has otherwise been healthy. She noticed a cough and some trouble breathing in the setting of a runny nose. His temperature is 100°F (37.8°C), blood pressure is 64/34 mmHg, pulse is 140/min, respirations are 39/min, and oxygen saturation is 93% on room air. Pulmonary exam is notable for expiratory wheezing and crackles throughout and intercostal retractions. Oral mucosa is noted to be dry. Which of the following is the most appropriate diagnostic test?

QID: 102585

Chest radiograph

25%

(17/69)

No further testing needed

29%

(20/69)

Polymerase chain reaction

9%

(6/69)

Sputum culture

33%

(23/69)

Viral culture

3%

(2/69)

M 6 E

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Evidence (6)
VIDEOS & PODCASTS (1)
EXPERT COMMENTS (10)
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