Kids Do the Strangest Things: Bronchiolitis and the Wheezing Infant

Kids Do the Strangest Things: Bronchiolitis and the Wheezing Infant

Chris Merritt, MD, and Gita Pensa, MD

Bronchiolitis Basics

• Bronchiolitis is an acute inflammatory condition of the bronchioles, usually triggered by a virus.
  • Respiratory syncytial virus (RSV) is the most common cause.
• It typically occurs in infants under the age of 2 years.
• Viral infection causes swelling and congestion of the small airways.
  • Older patients get the same viruses, but their larger airway means less wheezing and dyspnea.
• It is most commonly seen in the winter months.

Typical presentation

• Child under 2 years
• Upper respiratory infection symptoms for 2-3 days, often with fever, and then development of wheezing, increased tight cough, and dyspnea
• Fine wheezes and rales on lung exam
• Intercostal retractions, tachypnea, and visibly increased work of breathing may be present
• Viral otitis media may be present
• Hypoxia and significant tachypnea = more severe disease

Bronchiolitis is a clinical diagnosis.

• Typical history and exam are all that are needed for diagnosis in most cases.
• Treatment is largely guided by current American Academy of Pediatrics (AAP) guidelines.
• There is little utility in additional testing:
  • Swabs for virus identification are not routinely recommended.
  • COVID testing may be an exception when indicated.
• Chest X-ray is not routinely recommended.
  • It will often show focal areas of atelectasis that can be confused with focal consolidation. This can lead to unwarranted treatment with antibiotics.
  • Consider X-ray in patients with significant symptoms after an atypical time course.
    • If symptoms worsen considerably after an initial improvement or there are focal findings on exam, consider secondary bacterial pneumonia, which would warrant an X-ray.

Bronchiolitis risk red flags:

• History of prematurity
• Young infants (<3 months)
  • Apnea risk in young infants and in history of prematurity
• History of cardiac or pulmonary disease

Consider transferring these children to the ED for evaluation, even in the setting of reassuring vital signs.

Transfer to ED:

• Hypoxia
• Severe tachypnea or tachycardia
• Respiratory distress or significant work of breathing
• History of prematurity or significant comorbidities
• Evidence of dehydration
• Lethargy or listlessness

Treatment is limited in typical bronchiolitis:

• Nasal suctioning is the mainstay of treatment.
• Antipyretics are often helpful.
  • Reduce oxygen demand, which can reduce work of breathing.
• Oxygen, if the patient is consistently hypoxic.
  • Warrants transfer to ED
• Albuterol or racemic epinephrine is not routinely recommended.
  • The primary problem is mucus, not bronchospasm.
  • Consider albuterol in older infants and young children with history of atopy, family history of asthma, or frequent previous presentations.
• Steroids are not recommended except in an older child with a likely history of asthma.
• There is no role for cough suppressants.
• Educate parents on home care, suctioning, and reasons for return to Urgent Care or the ED.
• Commercial nasal aspirators are helpful for home use.
  • Dr. Merritt recommends commercial aspirators that use parental suction (eg, NoseFrida).

AAP Bronchiolitis Guidelines: https://publications.aap.org/pediatrics/article/134/5/e1474/75848/Clinical-Practice-Guideline-The-Diagnosis?autologincheck=redirected

Related Content:

CorePendium: Bronchiolotis

Key Topics in Urgent Care: State of the Art Management of Bronchiolitis