Kids Do the Strangest Things: Bronchiolitis and the Wheezing Infant
Chris Merritt, MD, and Gita Pensa, MD
- 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.
- 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:
- 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.
- 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
Key Topics in Urgent Care: State of the Art Management of Bronchiolitis
Ian L. - January 10, 2023 12:36 PM
Some contend that for wheeze over the age of 12 months salbutamol (albuterol ) is worth trialling .Suzanne Schuh BRONCHIOLITIS EM CASES episode 177 with Anton Helman December 2022 .
Christopher M. - January 10, 2023 1:29 PM
It's true - and there are some of these older toddlers who respond to these beta agonists. As with most conditions, there is a spectrum of illness, from "pure" bronchiolitis in the younger infants who do not respond reliably to salbutamol/albuterol to older kids with asthma with reversible bronchospasm. The large majority of infants and young toddlers with clinical bronchiolitis fall in this first camp.
Mary C. - February 8, 2023 1:35 PM
Any role for nebulized saline?
Christopher M. - February 9, 2023 2:51 PM
The evidence for this is not strong - there is weak evidence that nebulized hypertonic saline may shorten stays (while increasing adverse events) in admitted patients with viral bronchiolitis, but its use in the acute setting is not well supported.