Pediatrics · Year 3 · from Pediatrics

Case 2: Bronchiolitis

Patient Demographics

  • Age: 6-month-old male
  • Sex: Male

Chief Complaint

"He's been wheezing and having trouble breathing."

History of Present Illness

A 6-month-old male born at 36 weeks gestation presents with 3 days of nasal congestion and cough, now with increased work of breathing and decreased feeding over the past 24 hours. He initially had clear rhinorrhea and sneezing, followed by worsening cough that sounds "wet." Parents noticed fast breathing and a "whistling" sound when he breathes. He is taking only half his usual bottle volumes and has had fewer wet diapers. No fever initially, but temperature was 38.0C this morning. His 4-year-old sister had a cold last week. He has no history of wheezing or respiratory problems.

Growth Parameters

  • Weight: 7.5 kg (40th percentile)
  • Length: 66 cm (35th percentile)
  • Head circumference: 43 cm (50th percentile)

Physical Examination

  • General: Tired-appearing infant, mild-moderate respiratory distress
  • Vital signs: T 38.0C, HR 160, RR 56, SpO2 91% on room air
  • HEENT: Copious clear nasal discharge, mild nasal flaring, pharynx clear
  • Cardiovascular: Tachycardia, no murmur
  • Respiratory:
  • Tachypnea with subcostal and intercostal retractions
  • Nasal flaring
  • Audible wheezing and crackles
  • Scattered expiratory wheezes and fine crackles bilaterally
  • Prolonged expiratory phase
  • No grunting
  • Abdomen: Soft
  • Skin: No cyanosis, mild perioral pallor
  • Neurologic: Alert but less interactive than usual per parents

Workup

  • SpO2: 91% on room air (improves to 95% on 1 L NC)
  • Nasal swab RSV PCR: Positive
  • Chest X-ray (if obtained): Hyperinflation, peribronchial thickening, patchy atelectasis (not routinely recommended)
  • CBC, CMP: Not indicated for typical bronchiolitis

Diagnosis

RSV bronchiolitis, moderate severity

Clinical Reasoning

This is a classic presentation of bronchiolitis: an infant <12 months with URI prodrome followed by lower respiratory symptoms (wheezing, crackles, tachypnea, retractions) during RSV season. The combination of prematurity (36 weeks), age <12 months, hypoxemia (SpO2 <92%), moderate respiratory distress, and decreased oral intake indicates moderate severity requiring hospitalization. RSV is confirmed by PCR, though testing is not required for clinical diagnosis.

Management

  1. Hospitalization indicated for:
  • Hypoxemia (SpO2 <92% on room air)
  • Moderate-severe respiratory distress
  • Decreased oral intake with dehydration risk
  • Age <6 months with RSV
  1. Supportive care (mainstay of treatment):
  • Supplemental oxygen via nasal cannula to maintain SpO2 >90-92%
  • Nasal suctioning (gentle, before feeds and as needed)
  • IV or NG fluids if unable to maintain oral intake
  • Cardiorespiratory monitoring
  1. NOT recommended (per AAP guidelines):
  • Bronchodilators (albuterol) - no proven benefit
  • Corticosteroids - no proven benefit
  • Antibiotics - unless secondary bacterial infection suspected
  • Routine chest X-ray
  1. Escalation criteria:
  • High-flow nasal cannula if escalating oxygen needs
  • CPAP/BiPAP if progressive distress
  • ICU for impending respiratory failure, apnea
  1. Discharge criteria:
  • SpO2 >90% on room air for 12-24 hours
  • Adequate oral intake
  • Decreased work of breathing
  1. Prevention: Palivizumab for high-risk infants (preterm <29 weeks, CHD, CLD)

Clinical Image

Image Description: Chest radiograph demonstrating hyperinflation, peribronchial thickening, and patchy atelectasis characteristic of bronchiolitis.

Source: Radiopaedia URL: https://radiopaedia.org/cases/bronchiolitis-3 License: CC BY-NC-SA 3.0

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