An 18-month-old boy is brought to the emergency department by his parents due to worsening cough and fever. The patient developed the cough 6 days ago; it increased in frequency over the past day and caused him to wake frequently overnight. He has had fever to 38.3 C (100.9 F) for 3 days. The child takes no medications and has no significant medical history. Temperature is 38.8 C (101.8 F), and respirations are 45/min. Oxygen saturation is 96%. Physical examination shows an active, alert, and playful toddler with mild tachypnea and intermittent suprasternal retractions. Auscultation reveals scattered wheezing and crackles over bilateral lung fields. The remainder of the physical examination is unremarkable. Chest x-ray is shown in the exhibit. Which of the following is the best next step in the care of this patient?
Bronchiolitis | |
Epidemiology |
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Clinical presentation |
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Treatment |
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Complications |
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Prevention | Palivizumab for selected infants:
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RSV = respiratory syncytial virus. | |
This patient has viral bronchiolitis, a lower respiratory tract infection in children age <2 years that is most commonly caused by respiratory syncytial virus. Symptoms of bronchiolitis typically begin with cough and nasal congestion and peak on day 3-5 of illness with worsening cough and increased work of breathing (eg, tachypnea, retractions). Hypoxia is common, and examination typically reveals diffuse wheezing and/or crackles.
Bronchiolitis is usually diagnosed clinically. However, chest x-ray to exclude other causes (eg, pneumonia) may be warranted for patients with severe symptoms (eg, cyanosis, apnea) or atypical progression, such as this child who has fever and worsening symptoms after day 5 of illness. Chest x-ray findings may include increased interstitial markings and peribronchal cuffing (haziness around the bronchial wall, reflecting airway inflammation), as seen in this patient. Hyperinflation and atelectasis may also be present, and the absence of a focal consolidation is typical.
Treatment for bronchiolitis is supportive (eg, nasal suctioning, adequate hydration). Most patients can be treated as outpatients with close follow-up to ensure improvement of symptoms. A minority of patients, particularly those who are premature or young (age <2 months), may require hospitalization for dehydration or severe respiratory symptoms. These patients may require respiratory support, such as supplemental oxygen or continuous positive airway pressure.
(Choices A and D) Antibiotics are indicated to treat bacterial pneumonia in patients with cough, fever, and focal pulmonary findings on examination or chest x-ray. This patient has scattered, bilateral wheezing and rales with no focal consolidation on chest x-ray. In addition, this patient is well-appearing with normal oxygenation and only mild tachypnea and retractions, findings that make blood cultures to assess for bacteremia and hospitalization unnecessary.
(Choice B) CT scan of the chest may be warranted in children with prolonged or unexplained respiratory failure. This patient in mild respiratory distress has chest x-ray findings consistent with a self-limited illness, and no additional imaging is indicated.
(Choice E) Bronchodilators (eg, albuterol) and glucocorticoids are not typically used in bronchiolitis management because they do not decrease hospitalization rates or length of illness.
Educational objective:
Viral bronchiolitis typically presents in children age <2 years with cough and increased work of breathing (eg, tachypnea, retractions). Diagnosis is typically clinical, but chest x-ray findings include peribronchial cuffing, increased interstitial markings, and the absence of a focal consolidation.