A 14-month-old male came to clinic during the winter with a 2 day history of low grade fever to 100.6°F and rhinitis. The evening before he began to have more coughing that was not episodic nor barky and his parent noticed that he seemed to be breathing fast. He was drinking about half of his normal amounts and was still urinating. His parent denied cyanosis. The past medical history showed a healthy male who was fully immunized. He had never wheezed in the past nor had atopic dermatitis. The family history was positive for his mother who had asthma. The review of systems was otherwise normal.
The pertinent physical exam showed a mildly ill appearing male with a respiratory rate of 35/minute, heart rate of 98 beats/minute and temperature of 99.4°. Pulse oximeter was 93%. His capillary refill was brisk and he had moderate secretions from his mouth and nose that were clear. HEENT was otherwise unremarkable. His lung examination had mild rhonchi that cleared with coughing. He also had some mild end-expiratory wheezing at both bases. He had no nasal flaring, intercostal retractions, abdominal breathing or trachael tugging.
The diagnosis of bronchiolitis was made. The pediatrician discussed the etiology and natural disease course with the family emphasizing that currently he was well-hydrated and was not having any increased work of breathing. She educated the parents on signs to call the clinic for and also had the nursing staff show the parents how to use nasal saline and suctioning at home. She also discussed other symptomatic treatment which could make the patient more comfortable such as antipyretics and/or humidified air.
Bronchiolitis is a clinical disease with following features: begins usually with rhinitis and cough that may progress to also having tachypnea, rales, wheezing and increased work of breathing shown by nasal flaring and/or accessory muscle use. The increased work of breathing may cause problems with feeding and hydration and also with mental status changes. It is usually seen in infants and children < 2 years of age. It is also usually seasonal (winter in upper North America) with 60-70% of cases being caused by respiratory syncytial virus but also human rhinorvirus, human metapneumovirus, influenza, adenovirus, coronavirus and human and parainfluenza viruses. Co-infections also are relatively common.
Diagnosis is clinical. Treatment includes secretion removal from the nose, oxygen therapy if needed, maintenance of hydration and monitoring.
Specifically, new guidelines from the American Academy of Pediatrics for infants < 23 months of age, also in accordance with the National Health Service in the United Kingdom (with minor variations), state that the following should or should not occur:
- Diagnose bronchiolitis clinically
- Assess risk factors for severe disease
- Assess exposure to tobacco smoke and encourage smoking cessation in family members
- May consider administration of
- Hypertonic saline in hospitalized infants
- Oxygen if saturations are < 90%
- Should administer
- Fluids by nasogastric tube or intravenously for hydration if needed
- Palivizumab prophylaxis for premature infants < 29 weeks and for infants with chronic lung disease or hemodynamically significant heart disease who require supplemental oxygen for at least the first 28 days of life.
- Prevent viral spread by rigorous attention to hand hygiene with alcohol-based rubs being preferred
- Encourage breastfeeding
- No/Should not
- Obtain routine chest radiographs
- Hypertonic saline in an emergency room
- Systemic corticosteroids
- Antibiotics unless there is a strong suspicion for or presence of concomitant bacterial infection
- May consider not using continuous pulse oximetry
- Chest physiotherapy
Increased risk of progress to severe disease or mortality in patients with bronchiolitis includes:
- Congenital anomalies
- Congenital heart disease that is hemodynamically significant
- Chronic lung disease, i.e. bronchopulmonary dysplasia
- In utero smoke exposure
- Immunocompromised state
- Genetic abnormalities – more severe presentation
Questions for Further Discussion
1. How should palivizumab prophylaxis be administered?
2. What is the theoretical basis that hypertonic saline should improve bronchiolitis symptoms?
- Specialty:Allergy / Pulmonary Diseases
- Age: Toddler
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Scottish Intercollegiate Guidelines Network (SIGN). Bronchiolitis in children. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2006 Nov. 41 p. (rev. 2009, cited 11/14/14).
Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S 3rd, Hernandez-Cancio S.
Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014 Nov;134(5):e1474-502.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital