Pediatrics

6 month old with respiratory distress

Morgen Govindan on Dec 15, 2013

A 6-month-old male is brought to the ED by his parents because they are concerned about his breathing.  He has had rhinorrhea and a cough for the past three days.  His mother states that his breathing has become “noisier” today, and he now appears to be “struggling to breathe.”  She thinks he might feel warmer than usual, but they have not measured his temperature.  She reports that he has been eating and drinking less than usual for the past day.  He has had only one wet diaper today.  He has no vomiting or diarrhea.

The patient has no other active medical problems and his only medication is vitamin D supplementation.  He is breastfed and recently started on solids, which he has been taking well up until yesterday.  His past medical history is significant for prematurity, born at 36 weeks gestation.  He was briefly intubated in the NICU for respiratory distress, but was quickly weaned off oxygen.  He has done well since without any chronic respiratory problems. 

He lives at home with his parents, 5-year-old brother, and dog.  There is no smoking in the household.  He attends daycare, but the parents are unaware of any sick contacts there.  He has met all of his developmental milestones and his immunizations are up to date.  His family history is only notable for mild seasonal allergies in his mother and exercise-induced asthma in his older brother.

  • Temp  38 C
  • HR  142
  • BP  75/55
  • RR  52
  • O2  89% on Room Air

General: Well-developed male infant in respiratory distress.

HEENT: Anterior fontanelle open and flat.  Clear rhinorrhea present.  Bilateral tympanic membranes clear without erythema.  Tacky mucous membranes.

Respiratory: Moderate subcostal and intercostals retractions, nasal flaring. Scattered crackles and biphasic wheezing appreciated on auscultation.

Cardiac: Tachycardic with regular rhythm. No murmur noted. Symmetric pulses, cap refill 4 seconds.

Abdominal: Soft, non-tender, non-distended. Normoactive bowel sounds. No organomegaly. 

GU: Circumcised Tanner 1 male genitalia. Bilaterally descended testes. Patent anus.

Skin: No rashes or jaundice. Decreased skin turgor.

Neuro: Age-appropriate muscle bulk and tone.

What tests would you perform in the ED? Click all that apply.

Expand all answers
CBC and electrolytes
No, laboratory tests should not routinely be ordered for the diagnosis of bronchiolitis (1).


Chest x-ray
No, radiological studies should not routinely be ordered for the diagnosis of bronchiolitis (1).


Full sepsis evaluation
No. This patient is older than 60 days and therefore has a low risk of having a serious bacterial illness (SBI). Patients less than 60 days with a fever and clinical diagnosis of bronchiolitis often are admitted to the hospital and receive a full sepsis evaluation for a low but potential risk of concurrent SBI (2).


Viral panel
No, viral studies are not recommended for the diagnosis of bronchiolitis (2).


No tests are necessary. This is a clinical diagnosis based on the history and physical findings.
This is the correct answer. The diagnosis of bronchiolitis is based on the clinical history and physical exam. Diagnostic criteria include a history of preceding URI, rhinorrhea, cough and potential exposure to those with a viral URI. Physical findings of bronchiolitis include tachypnea, increased work of breathing as evidenced by retractions, nasal flaring and/or grunting, color change, wheezing, and decreased oxygen saturation (3). The most important physical parameters in assessing the severity of bronchiolitis are respiratory rate, work of breathing, and level of oxygen saturation (2).


What risk factors for severe progression of bronchiolitis should be assessed? Click all that apply.

Select all that apply
Expand all answers
Age <12 weeks
Yes, younger children (less than 6-12 weeks) have an increased risk of more severe disease from bronchiolitis (1,3,4). Are there other risk factors?


Prematurity
Yes, prematurity (<37 weeks gestation) is associated with increased morbidity and mortality from bronchiolitis (4,5). Are there other risk factors?


Chronic lung disease
Yes, chronic lung disease is associated with more severe disease (1,5). Are there other risk factors?


Tobacco exposure
Exposure to cigarette smoke may increase the risk of RSV infection (1,6). However, the data regarding tobacco exposure are less robust, and this is not considered one of the primary risk factors for severe disease (1,3).


Congenital heart disease
Yes, congenital heart disease is associated with higher RSV-related morbidity and mortality (5). Are there other risk factors?


What treatment(s) should be included in the management of this patient? Click all that apply.

Select all that apply
Expand all answers
Hydration and oxygen
Correct! The mainstays of bronchiolitis treatment are supportive, including hydration, oxygenation, and nutritional support (1,3). The patient’s hydration status and ability to take fluids orally should be assessed. This patient has not been drinking well and exhibits signs of dehydration, including tachycardia, tacky mucous membranes, prolonged capillary refill and decreased skin turgor. Supplemental oxygen is indicated to maintain the SpO2 at or above 90% (1). Does this patient require any other interventions?


Bronchodilators
Possibly. This continues to be a controversial issue. The AAP recommends against routine use of bronchodilators in the management of bronchiolitis. However, a single trial of inhaled alpha- or beta-adrenergic medication (epinephrine or albuterol) may be administered with careful monitoring. Inhaled bronchodilators should only be continued if there is documented improvement with the treatment (1,3).


Antibiotics
No, antibiotics should only be used to treat patients who have evidence of a concurrent bacterial infection (1).


Corticosteroids
No, corticosteroids should not routinely be used in bronchiolitis (1,3). There has been insufficient evidence to demonstrate a clear benefit to the use of steroids in decreasing hospitalization or post-bronchiolitic wheezing (7,8).


Hospital admission
There are no discrete criteria for admission in either the AAP or Cincinnati Children’s guidelines, and admission to the hospital should be based on clinical judgment (1,3). This patient is dehydrated and hypoxic, and may need to be hospitalized depending on his response to treatment.


  1. American Academy of Pediatrics Subcommittee on D, Management of B. Diagnosis and management of bronchiolitis. Pediatrics. Oct 2006;118(4):1774-1793.
  2. Wagner T. Bronchiolitis. Pediatrics in review / American Academy of Pediatrics. Oct 2009;30(10):386-395; quiz 395.
  3. National Guideline C. Evidence-based care guideline for management of first time episode bronchiolitis in infants less than 1 year of age. http://www.guideline.gov/content.aspx?id=34411&search=respiratory+syncytial+virus+and+bronchiolitis. Accessed 12/14/2013.
  4. Wang EE, Law BJ, Stephens D. Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) prospective study of risk factors and outcomes in patients hospitalized with respiratory syncytial viral lower respiratory tract infection. The Journal of pediatrics. Feb 1995;126(2):212-219.
  5. Shay DK, Holman RC, Roosevelt GE, Clarke MJ, Anderson LJ. Bronchiolitis-associated mortality and estimates of respiratory syncytial virus-associated deaths among US children, 1979-1997. The Journal of infectious diseases. Jan 1 2001;183(1):16-22.
  6. Bradley JP, Bacharier LB, Bonfiglio J, et al. Severity of respiratory syncytial virus bronchiolitis is affected by cigarette smoke exposure and atopy. Pediatrics. Jan 2005;115(1):e7-14.
  7. King VJ, Viswanathan M, Bordley WC, et al. Pharmacologic treatment of bronchiolitis in infants and children: a systematic review. Archives of pediatrics & adolescent medicine. Feb 2004;158(2):127-137.
  8. Blom D, Ermers M, Bont L, van Aalderen WM, van Woensel JB. Inhaled corticosteroids during acute bronchiolitis in the prevention of post-bronchiolitic wheezing. The Cochrane database of systematic reviews. 2007(1):CD004881.

A 6-month-old male is brought to the ED by his parents because they are concerned about his breathing.  He has had rhinorrhea and a cough for the past three days.  His mother states that his breathing has become “noisier” today, and he now appears to be “struggling to breathe.”  She thinks he might feel warmer than usual, but they have not measured his temperature.  She reports that he has been eating and drinking less than usual for the past day.  He has had only one wet diaper today.  He has no vomiting or diarrhea.

The patient has no other active medical problems and his only medication is vitamin D supplementation.  He is breastfed and recently started on solids, which he has been taking well up until yesterday.  His past medical history is significant for prematurity, born at 36 weeks gestation.  He was briefly intubated in the NICU for respiratory distress, but was quickly weaned off oxygen.  He has done well since without any chronic respiratory problems. 

He lives at home with his parents, 5-year-old brother, and dog.  There is no smoking in the household.  He attends daycare, but the parents are unaware of any sick contacts there.  He has met all of his developmental milestones and his immunizations are up to date.  His family history is only notable for mild seasonal allergies in his mother and exercise-induced asthma in his older brother.

  • Temp  38 C
  • HR  142
  • BP  75/55
  • RR  52
  • O2  89% on Room Air

General: Well-developed male infant in respiratory distress.

HEENT: Anterior fontanelle open and flat.  Clear rhinorrhea present.  Bilateral tympanic membranes clear without erythema.  Tacky mucous membranes.

Respiratory: Moderate subcostal and intercostals retractions, nasal flaring. Scattered crackles and biphasic wheezing appreciated on auscultation.

Cardiac: Tachycardic with regular rhythm. No murmur noted. Symmetric pulses, cap refill 4 seconds.

Abdominal: Soft, non-tender, non-distended. Normoactive bowel sounds. No organomegaly. 

GU: Circumcised Tanner 1 male genitalia. Bilaterally descended testes. Patent anus.

Skin: No rashes or jaundice. Decreased skin turgor.

Neuro: Age-appropriate muscle bulk and tone.

What tests would you perform in the ED? Click all that apply.

Expand all answers
CBC and electrolytes
No, laboratory tests should not routinely be ordered for the diagnosis of bronchiolitis (1).


Chest x-ray
No, radiological studies should not routinely be ordered for the diagnosis of bronchiolitis (1).


Full sepsis evaluation
No. This patient is older than 60 days and therefore has a low risk of having a serious bacterial illness (SBI). Patients less than 60 days with a fever and clinical diagnosis of bronchiolitis often are admitted to the hospital and receive a full sepsis evaluation for a low but potential risk of concurrent SBI (2).


Viral panel
No, viral studies are not recommended for the diagnosis of bronchiolitis (2).


No tests are necessary. This is a clinical diagnosis based on the history and physical findings.
This is the correct answer. The diagnosis of bronchiolitis is based on the clinical history and physical exam. Diagnostic criteria include a history of preceding URI, rhinorrhea, cough and potential exposure to those with a viral URI. Physical findings of bronchiolitis include tachypnea, increased work of breathing as evidenced by retractions, nasal flaring and/or grunting, color change, wheezing, and decreased oxygen saturation (3). The most important physical parameters in assessing the severity of bronchiolitis are respiratory rate, work of breathing, and level of oxygen saturation (2).


What risk factors for severe progression of bronchiolitis should be assessed? Click all that apply.

Select all that apply
Expand all answers
Age <12 weeks
Yes, younger children (less than 6-12 weeks) have an increased risk of more severe disease from bronchiolitis (1,3,4). Are there other risk factors?


Prematurity
Yes, prematurity (<37 weeks gestation) is associated with increased morbidity and mortality from bronchiolitis (4,5). Are there other risk factors?


Chronic lung disease
Yes, chronic lung disease is associated with more severe disease (1,5). Are there other risk factors?


Tobacco exposure
Exposure to cigarette smoke may increase the risk of RSV infection (1,6). However, the data regarding tobacco exposure are less robust, and this is not considered one of the primary risk factors for severe disease (1,3).


Congenital heart disease
Yes, congenital heart disease is associated with higher RSV-related morbidity and mortality (5). Are there other risk factors?


What treatment(s) should be included in the management of this patient? Click all that apply.

Select all that apply
Expand all answers
Hydration and oxygen
Correct! The mainstays of bronchiolitis treatment are supportive, including hydration, oxygenation, and nutritional support (1,3). The patient’s hydration status and ability to take fluids orally should be assessed. This patient has not been drinking well and exhibits signs of dehydration, including tachycardia, tacky mucous membranes, prolonged capillary refill and decreased skin turgor. Supplemental oxygen is indicated to maintain the SpO2 at or above 90% (1). Does this patient require any other interventions?


Bronchodilators
Possibly. This continues to be a controversial issue. The AAP recommends against routine use of bronchodilators in the management of bronchiolitis. However, a single trial of inhaled alpha- or beta-adrenergic medication (epinephrine or albuterol) may be administered with careful monitoring. Inhaled bronchodilators should only be continued if there is documented improvement with the treatment (1,3).


Antibiotics
No, antibiotics should only be used to treat patients who have evidence of a concurrent bacterial infection (1).


Corticosteroids
No, corticosteroids should not routinely be used in bronchiolitis (1,3). There has been insufficient evidence to demonstrate a clear benefit to the use of steroids in decreasing hospitalization or post-bronchiolitic wheezing (7,8).


Hospital admission
There are no discrete criteria for admission in either the AAP or Cincinnati Children’s guidelines, and admission to the hospital should be based on clinical judgment (1,3). This patient is dehydrated and hypoxic, and may need to be hospitalized depending on his response to treatment.


  1. American Academy of Pediatrics Subcommittee on D, Management of B. Diagnosis and management of bronchiolitis. Pediatrics. Oct 2006;118(4):1774-1793.
  2. Wagner T. Bronchiolitis. Pediatrics in review / American Academy of Pediatrics. Oct 2009;30(10):386-395; quiz 395.
  3. National Guideline C. Evidence-based care guideline for management of first time episode bronchiolitis in infants less than 1 year of age. http://www.guideline.gov/content.aspx?id=34411&search=respiratory+syncytial+virus+and+bronchiolitis. Accessed 12/14/2013.
  4. Wang EE, Law BJ, Stephens D. Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) prospective study of risk factors and outcomes in patients hospitalized with respiratory syncytial viral lower respiratory tract infection. The Journal of pediatrics. Feb 1995;126(2):212-219.
  5. Shay DK, Holman RC, Roosevelt GE, Clarke MJ, Anderson LJ. Bronchiolitis-associated mortality and estimates of respiratory syncytial virus-associated deaths among US children, 1979-1997. The Journal of infectious diseases. Jan 1 2001;183(1):16-22.
  6. Bradley JP, Bacharier LB, Bonfiglio J, et al. Severity of respiratory syncytial virus bronchiolitis is affected by cigarette smoke exposure and atopy. Pediatrics. Jan 2005;115(1):e7-14.
  7. King VJ, Viswanathan M, Bordley WC, et al. Pharmacologic treatment of bronchiolitis in infants and children: a systematic review. Archives of pediatrics & adolescent medicine. Feb 2004;158(2):127-137.
  8. Blom D, Ermers M, Bont L, van Aalderen WM, van Woensel JB. Inhaled corticosteroids during acute bronchiolitis in the prevention of post-bronchiolitic wheezing. The Cochrane database of systematic reviews. 2007(1):CD004881.

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